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A 22 year old man with persistent regurgitation and vomiting
- Ahmad Abass El-Khattib El-Khattib (16 June 2006)
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Cow's milk is for calves
- Theo Fenton (16 June 2006)
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Google
- Stephen R Workman (16 June 2006)
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Persistent vomiting
- J Jeffrey Ford (16 June 2006)
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Structural problem
- Alexandra M Ames (17 June 2006)
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Is there a fixable problem?
- douglas gilroy (18 June 2006)
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PS
- douglas gilroy (18 June 2006)
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?Visceral Arterial Pathology
- Andrew Harris (18 June 2006)
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What about his brain?
- Stephen Head (18 June 2006)
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Puzzling problem
- Anthony N Glaser (19 June 2006)
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As a hospital doctor.......
- Eugene Campbell (19 June 2006)
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Physical or psychological
- alexander Williams (19 June 2006)
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Type A Personality with Functional Symptoms
- Amer I Sheikh (19 June 2006)
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Authors Response
- Mark R Fox, Angela Anggiansah, Jeremy Sanderson (19 June 2006)
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? Cannabinoid hyperemesis
- JAMES H ALLEN (19 June 2006)
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Abdominal Epilepsy ?
- Shyam Mohan Reddy Teegala (20 June 2006)
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A Genetic Disorder?
- Richard J Hunt (21 June 2006)
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22 year old with persistent regurgitation and vomiting - a psychological cause?
- Claudia E Goodman (21 June 2006)
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What about the emotions?
- Abraham H Brafman (22 June 2006)
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22 yo with persistent vomiting
- karen ross (22 June 2006)
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A 22 year old man with persistent regurgitation and vomiting: case presentation
- Alan Thomas Clarke (24 June 2006)
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Thinking outside the box..
- Daniel J Youngerwood (3 July 2006)
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Ahmad Abass El-Khattib El-Khattib, Prof. of Gastroenterology and Hepatology Ain Shams University Hospitals-Cairo-Egypt
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The differential diagnosis includes gastric neurosis or stress- induced duodenogastric effect. If I attended the meeting, I would take a thorough psychiatric history. I think there is something upsetting Mr. Neville needs elucidation. Mr. Neville needs no further investigations, as he is thoroughly investigated and proved negative for any organic cause for his illness. I will tell Mr. Neville and his mother that GI disorders are functional and organic and we did sufficient investigations to Mr. Neville to exclude organic diseases with a good confidence. "I think Mr. Neville that you have a functional GI disorder and this is a story totally different from being asthmatic. And also the GERD you have is partially related to stress." Then I will start an introductory CBT (cognitive behaviour therapy) session by explaining the meaning of functional disorder with examples. Then I will suggest drug medication and CBT sessions to deal with the cause of the trouble. The suggested medications are SSRI inhibitor or tricyclic antidepressant in addition to proton pump inhibitor. Competing interests: None declared |
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Theo Fenton, Consultant Paediatrician Mayday Hospital, Croydon CR7 7YE
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Cow's milk protein allergy could cause all these symptoms, but is difficult to prove, and investigations are often unhelpful. I'd try a two- week period off all cow's milk products to see if there's temporary resolution of symptoms. Avoiding cow's milk usually can't be done without a dietitian's input though -- it come's in too many guises (e.g. most margarines contain milk) and he needs to get calcium from somewhere. Milks from other animals (e.g. goats) shouldn't be used as substitutes, because there's often cross- sensitivity. Competing interests: None declared |
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Stephen R Workman, Assistant Professor Dalhousie University, Department of Medicine, Halifax Nova Scotia. B3H 2Y9
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1. The differential diagnosis is broad, I would use a long list from a valid source and subsequently cross off items as they are ruled out. Occam's razor: It would be nice if the asthma could be tied in to the rest of the complaints. Tracheo-esophageal fistula (TEF) comes to mind and I would look for this as an initial step. (Statistically unlikely but both elegant and possible.)CT or bronchoscopy have both been used to diagnose TEF. 2 College students should not lose weight and drop out of school without a diagnosis. He needs a diagnosis or an in patient work up. 3. Investigations: CT of chest initially. If negative: Google search revealed (http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3060&nbr=2286) Do tests below that have not already been done in order of perceived utility. Abdominal x-ray Upper gastrointestinal (GI) barium study Upper gastrointestinal and small bowel follow-through (SBFT) Enteroclysis Abdominal computed tomography (CT) with oral and intravenous contrast Ultrasonography Gastric emptying scintigraphy Esophagogastroduodenoscopy Electrogastrography (EGG) Antroduodenal manometry Evaluation for central disorders Magnetic resonance imaging for intracranial lesions Evaluation for psychogenic causes Minnesota Multiphasic Personality Inventory instrument 4. "I know how frustrating this can be, but I don't know what is wrong. It may take a few weeks and a number of different opinions before we find out. If this was a simple problem it would have been identified months ago. I promise not to send you home until there is a diagnosis and a treatment plan in place." Competing interests: None declared |
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J Jeffrey Ford, GP Clevedon BS21 7TA
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1-The differential diagnosis for me is between anorexia nervosa and anything which could cause gastric outlet obstruction. If pushed I would favour pyloric stenosis or achalasia. 2 I would have admitted him also 3 Assuming all the investigations normal,observation by the nursing staff unremarkable I would like a psychiatric assessment. 4 That I was considering allphysical possibilities but I would like to exclude psychological diagnosis. Competing interests: None declared |
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Alexandra M Ames, GP registrar West Barnes Lane Surgery KT3
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1.Pharyngeal Pouch or other structural problem 2. Admitted him for rehydration and urgent investigation 3. Gastrograffin swallow 4. Apologise for the long and difficult struggle for a diagnosis. Explain that in medicine we do not always have all the answers right away but promise too do our best. Also apologise profusely for discahrging prematurely. Competing interests: None declared |
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douglas gilroy, cons gen surg Whiteabbey hoepital, Doagh road, Belfast, BT37Have we
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1.Differential Diagnosis, not necessarily in order likelyhood in this particular presentation: i) Volume reflux leading to nutritional impairment ii) Volume reflux with as yet undiagnosed hiatus hernia sliding/rolling (on occasions prone to torsion and sometimes notoriously difficult to diagnose) iii)Dysfunctional stomach, delayed gastric emptying, (sometimes seen in diabetics), not necesarily associated with mechanical problems such as pyloric stenosis. iv)Mechanical problem leading to obstruction in duodenum/small bowel beyond reach of scope.Things to be considered specificaly would be Wilkies (SMA)syndrome, adenoma/lymhpoma etc. v) Metabolic problems associated with persistent vomiting, eg Adissons (rare in the absence of electrolyte abnormality) vi) Congenital problems such as intermittent torsion of small bowel secondary to short mesentry/ malrotation. Pancreatic anomalies. vii)Reflux with psychological overlay. 2.Admit for assessment. 3.In the first instance : i)CT scan with triple contrast. ii)Barium meal/follow through by radiologist with special interest, looking for functional assessment of stomach, in particular looking for "rebound" appearance of contrast in 3rd part and any change in drainage with change in posture, and small bowel series. 4. Offer sympathy for diffculty in diagnosis and treatment. Explain that Kenneth had either an unusual form of a common problem, or an unusual problem on lines of above. Raise the possibility that diagnosis on occasion may not be possible Outline plan of investigation. Arrange second opinion from relevant specialist. Explain concept of and methods of nutritional support in the meantime, in the absence of early diagnosis. Competing interests: None declared |
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douglas gilroy, cons gen surg Whiteabbey hoepital, Doagh road, Belfast, BT37Have we
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In addition to above, if GI tests are neg, consider "once in a working life" type presentations of brain tumour etc. Competing interests: None declared |
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Andrew Harris, Senior House Officer Heart of England Foundation NHS Trust
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1. Coeliac or superior mesenteric artery compression syndrome. 2. Referral to RMO for admission for rehydration and further investigation. 3. Aortography 4. As early responses. Apologise and explain in medicine we can't know all the answers straight away, but we will do our best to investigate this further and we will seek advice from our colleagues. Competing interests: None declared |
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Stephen Head, General Practice Perfromer Middleton Lodge, New Ollerton, Newark, Nottinghamshire, NG22 9SZ
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Agree with much said above, but suggest other causes of vomiting should be sought. Could his illness be due to neurological problems, either raised intra-cranial pressure or some problem with his Vomiting Centre? Has anyone looked at his fundi or done a thorough CNS examination? How about a CT scan? Competing interests: None declared |
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Anthony N Glaser, Family Physician Summerville, SC 29483, USA
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1 - Differential diagnosis? Superior mesenteric artery syndrome, cyclical vomiting syndrome, abdominal migraine, somatisation disorder, conversion disorder, gastric neuropathy/gastroparesis 2 - What would I have done at Christmas? Probably not admitted him - there is nothing to suggest that his investigations and treatments could not have been done in the outpatient setting (it is not clear that he needed parenteral nutrition, for example) and I would be a little wary of reinforcing his complaints by admitting him. I would try to get a much better history of the relationship between stresses (college, home, what else?) and his complaints, the secondary or even primary gains that could possible accrue from his symptoms, the role of his mother's anxieties and his childhood illnesses and asthma and his apparent frequent use of medical services, his level of anxiety or depression, other psychiatric comorbidities, role of other family members, the role of food in family dynamics 3 - Further investigations? - Better history, particularly psychosocial. Gastric emptying study. Upper GI in standing position (to look for superior mesenteric artery syndrome). Renal ultrasound during an attack of symptoms (r/o intermittent ureteropelvic junction obstruction which has been found to be a cause of some cases of cyclical vomiting syndrome) 4 - What to tell Mr Neville and his mother? - You have a puzzling and difficult problem, and we need to keep looking for an underlying cause - but even if we can't find one, we can try different treatments which should be able to help you, even it if is on a trial-and-error basis at the moment (and I would consider trials of IV erythromycin, cisapride, metoclopramide, olanzapine, aprepitant, tegaserod, triptans, antidepressants, other anti-emetics). This must be a very worrying and distressing problem for both of you, and quite often all the worry and anxiety of a serious problem like this adds to severity of the problem, and treating your anxiety might perhaps help you to cope with it while we are trying to treat the symptoms themselves. What do you think of that? Competing interests: None declared |
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Eugene Campbell, Research Fellow Gastroenterology Wolfson Digestive Diseases Centre, NG7 2 UH
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My reply mirrors my thoughts as a hospital-based doctor with no experience as a GP. To summarise: a 4 year history of nausea, reflux, vomiting,pain and now weight loss, with constipation and faecal loading seen on X-ray. Asthma as a comorbid condition. Only the upper GI tract has been investigated with manometry, pH studies and OGD. No mention is made of histology so I presume biopsies were not taken. I would like to know more history eg family history, particularly of any GI symptoms eg drug history, chronic cocaine and cannabis use have both been reported to cause recurrent vomiting. Similarly for analgesia: is his constipation caused by opiates taken for his pain? Has he taken NSAIDs which can be associated with GI ulceration, stricturing and diaphragms? So would I admit this man? Yes, if a GP rang me and requested it. My differential diagnosis? This is very broad. He does have alarm symptoms though a long history. This could still be IBD with small bowel involvement. Coeliac possible as endomysial antibodies can still miss cases. Biopsy of small bowel is gold- standard. It's probably easier to explain how and why I would investigate him. As an inpatient I could observe him as well as get the benefit of others opinions. Ward sisters and nurses often pick up things we doctors miss on our ward rounds particularly regarding family dynamics, psyche etc. I would repeat the OGD and get D2 biopsies as well as look at the rest of his small bowel with a barium study. This is to look for inflammatory/mechanical/obstructive lesions. It may also give an idea of other problems eg as seen in other rarer conditions like visceral myopathy. This could go together with the faecal loading suggestive of colonic involvement. If I had access to a gastric emptying study, I would do it. Anti-enteric nervous system antibodies have been reported in association with enteric neuropathies and would check these. Expensive tests....yes, but this young man "just isn't right" and it's worth doing the job properly to sort him out and get his life back on track. Nutrition is important and will need to involve hospital nutrition team. What would I say to patient and family. Pretty much the same as above. Doing these tests to make sure not missing an organic problem. Others have mentioned doing a neurological examination and MRI Brain to ensure not a central tumour. I'd go down this route too if I felt the GI tract was essentially normal. Competing interests: None declared |
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alexander Williams, GP St Thomas health Centre, Cowick St , Exeter
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1.As a GP for 15 years, but as someone who holds MRCP and has worked as a hospital practitioner in Hospital medicine i would like to add the perspective as seen from primary care, from somebody with an interest and understanding of general medicine I am always most keen to exclude a physical cause for any symptoms and enjoy the academic challenge of making the rare or esoteric diagnosis,however he would appear to have been investigated quite thoroughly already.I have a concern that if this illness has a non organic basis we could be fuelling the patients(and mother's) anxieties further by more and more investigations His endoscopy was in the preceding year and was shown to have GOR. It would be prudent to ensure this condition had not proceeded to lower oesophageal ulceration and partial obstruction (however no biochemical evidence of pyloric obstruction). Should we consider Zollinger -Ellison syndrome and other amine producing tumours? I was interested in history of recurrent respiratory infections in childhood and he is now thin and losing weight...could he have a mild form of cysic fibrosis or Cilial dyskinesia? However my gut feeling is that we are principally dealing with a psychological problem as the symptoms have deteriorated after a difficult meeting at college. His mother had multiple concerns about his health in childhood...has she been overly anxious about his health and this has made him anxious also. I wonder about the onset of anorexia or stess induced vomiting, either as an exclusive diagnosis or as functional overlay on an existing physical complaint.Could this be Munchausens by proxy?? 2.This may be a very difficult and sensitive consultation. Am i party to his records and how much background do i have? Clearly a full history and examination is mandatory and as it is still necessary to exclude physical causes further investigation would be appropriate.It may be appropriate to explore some pschological issues and exclude sigmificant anxiety or depression that are often co-existent with other pschiatric illness's. This again may be more sensitivly dealt with by their own practitioner. Little would happen over the festivities so a discussion with the consultant registrar inolved with a planned admission may be more appropriate. I would either liase with his own GP or pick up the batten if he is my patient 3. As suggested under question 1. a repeat endoscopy, to exclude any gastric obstruction, and biopsy to look at cilial morphology.Serum gastrin levels and 24 hr urinary 5Hydroxy Indole Acetic Acid(5HIAA) and gene analysis for Cystic fibrosis.Perhaps a more formal psychiatric assessment would be appropriate to explore the long standing background and its impact on the current symptomatology. 4. I think this would in part be determined by their expectations. Perhaps some open ended questions like "is there anything else you would like to ask," or "How do you feel about that as a plan", may open up some fertile ground for discussion. It will be difficult if you are not their family doctor to know all the background information. On the basis that honesty is the best policy i think i would suggest that i was keen to exclude physical illness's as the cause of his symptoms but would be keen to explore whether psychological problems existed as well, and may also need adressing.Close liason with their own carer and a plan for follow up would also be appropriate. Competing interests: None declared |
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Amer I Sheikh, Consultant in Family Medicine King Faisal Specialist Hospital & Research Centre, PO Box 3354, Riyadh 11211. Saudi Arabia
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1. Since common physical pathology has been excluded, the list of differential diagnoses includes rarer pathology, and psychological aetiology resulting in a functional disorder. Being a General Practitioner, I would favour the latter as it is far more common. Mr Neville is an otherwise fit and healthy young man who is an academic high achiever, and is held in high esteem by his peers. This is achievable only by being conscientious in his work and being sensitive to the needs of others. However, this is not without significant stress. A further factor suggesting an anxious and sensitive nature is his asthma which is poorly controlled desite apparently adequate physical treatment. Studies have shown that asthma is exacerbated by psychosocial factors as much as by URTI's. Further enquiry into psychosocial circumstances is warranted. 2. If I had been called to review Mr Neville in the community, the severity of his symptoms would have dictated if he was to be admitted or not. If he was not able to keep anything down including fluids and was dehydrated, that would have warranted admission. 3. As a GP, I would not order any additional investigations at this stage and would prefer referral to a Gastroenterologist. However, that would be after a trial of therapy aimed at any psychological factors. 4. I would reassure Mr Neville and his mother that investigations to date have ruled out any significant pathology, and would explain the dysfunctional nature of his condition. This would include empathy for the severity of his symptoms. Explaining the possible psychological aetiology of the problem would entail telling him of the link between stress and physical symptoms. It is not "all in his mind" nor is he imagining his symptoms, but significant stress can directly result in sometimes severe and debilitating physical symptoms. After exploring for any psychosocial stressors, I would offer him a trial of an SSRI or Cognitive Behavioural Therapy if appropriate. Competing interests: None declared |
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Mark R Fox, Clinical and Research Fellow Oesophageal Laboratory, St. Thomas' Hospital, Angela Anggiansah, Jeremy Sanderson
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The number and range of responses to this case highlight how challenging the management of patients with persistent regurgitation and vomiting can be. 1 Differential Diagnosis & 3 Investigation. Several responders suggest further investigations to exclude structural and functional pathology of the GI tract. A pharyngeal pouch can cause regurgitation; however an association with reflux is less typical. Similarly, food allergy and malabsorption are rarely associated with GORD, and tend to cause diarrhea rather than consitipation in adults. A large hiatus hernia should have been detected at endoscopy and manometry (although it is odd to find severe GORD when LOS structure and function is preserved - this should prompt consideration of alternative diagnoses!). Thus we agree with those responders that consider the problem may involve abnormal gastro-duodenal function or distal obstruction. We agree also that CNS disease needs to be excluded in patients with unexplained, intractable nausea and vomiting. Many responders propose that psychiatric review should be the next step. There is a complex interplay between GI symptoms, stress and psychiatric disease. Identification and correction of abnormal cognitions or behaviours that underlie a patients response to disease can be almost as important the diagnosis itself. 2. Ken reported recurrent regurgitation and vomiting with abdominal pain and weight loss. These are ‘alarm’ symptoms and his quality of life was severely affected. Hospital admission is often unavoidable if the patient cannot retain food or fluid and is loosing weight. 4. Whatever the cause of symptoms a clear statement of the diagnostic and therapeutic problems facing patient and doctor is likely to be helpful. Competing interests: None declared |
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JAMES H ALLEN, MEDICAL OFFICER MT.BARKER HOSPITAL,WELLINGTON RD,MT BARKER,SOUTH AUSTRALIA,5244
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[1]My differential diagnosis for Mr Neville would be [a]Acute Intermittent Porphyria [b]Addision's Disease [c]Cannabinoid Hyperemesis :Cyclical Hyperemesis in Association with Chronic Cannabis Abuse. [2]If I had been called to see Mr Neville at Christmas I would ,first and foremost, have interviewed him in the absence of his Mother.The patient should be quizzed again about drug use, with paticular reference to chronic marijuana abuse. Furthermore, any bizzare behaviour,such as a compulsive desire to bathe or shower,should be elicited. [3]In terms of investigations, a urine sample would be most helpful. It can be protected from light and sent for a porphyria screen and consented for a drug screen.A short synacthen test should also be performed on the patient. [4]I would advise Mr Neville to await the results of his Investigations before going further.I would argue patient confidentiality with respect to divulging too much information to his Mother. Competing interests: None declared |
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Shyam Mohan Reddy Teegala, Physician (currently doing MPH) 77054
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Based on the unusual history, clinical presentation and lab reults, of Mr.Neville, the differential diagnosis may be - 1. Abdominal Epilepsy 2. Cyclic Vomiting Syndrome 3. Zollinger - Ellison Syndrome 4. A cyst or tumor or a foreign body altering the stomach motility. A complete Psychiatric history and assessment of both the patient and his family is needed. Further investigations as per the differential diagnosis that may be done - 1. EEG 2. Serum Gastrin Levels. 2. Repeat Upper GI Endoscopy. 3. Gastric Emptying Studies. I would be sympathetic with Mr.Neville and his family, explaining his unusual presentation. I will do symptomatic management, while working up the right diagnosis. I would rather not discharge the patient, without a correct diagnosis. Competing interests: None declared |
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Richard J Hunt, SpR General Surgery Kingston General Hospital, KT2 7QB
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1) My differential diagnosis would include all of the above listed, and I'd like to add Hirschprung's Disease likely showing my ignorac by asking if Cystic Fibrosis could be causing his symptoms, and his childhood asthma was in fact recurrent chest infections? 2) I would have asked the on call physician to admit him for rehydration in the first instance 3) Genetic Screening for CF and a full thickness rectal biopsy to exclude Hirschprung's 4) I'd tell Mr Neville (and his mum, if he consented to it) that he has a complex set of symptoms which we have yet to find a cause for. List the management plan, and as a previous responder said, suggest that we may never get a diagnosis, but his symptoms can be ameliorated with pharmacological and possiblt surgical means. Competing interests: None declared |
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Claudia E Goodman, Teacher B.Ed New Beacon School
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Since physical causation seems to have been ruled out,my feeling is that that this particular problem has a psychological/emotional cause, possibly due to problems at College,friendship/relationship difficulties or problems at home.If I had been called to review Mr Neville at Christmas,I would have asked him about his personal cicumstances and would have tried to assess if this could be a reaction to severe stress or anxiety about College or other events/people in his life.Can the cause of the problem be eliminated quickly e.g change of course? I would also conduct a detailed questionnaire to elicit responses to reveal his state of mind.If there was an indication of anxiety/depression, I would immediately refer Mr Neville for some Cognitive Behaviour Therapy alongside person- centred counselling. I would also prescribe an appetite stimulant(eg Pizitifen) and Lorazepam. I would also supply Mr Neville with a course of nutritional drinks to help maintain fluid levels and adequate nutrition.I would be honest with Mr Neville and his mother.The more Mr Neville knows and understands about his eating problem, which is a form of self-injury,the more quickly he can address and try to overcome the problem. This may take many months however or longer .... Competing interests: None declared |
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Abraham H Brafman, Ret. Consultant Child & Adolescent Psychiatrist, Hon Sen Lect UCH W1
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The physical investigations are evidence of a most competent specialized unit and the history leaves no doubt of abnormalities in the upper digestive system of Mr Neville. However, the episodes of anxiety and panic demand exploration of this young man's emotional experiences regarding his daily life. When told that in childhood a "mother had been very concerned about his health and often took (the patient) to the doctors", I form the hypothesis that physical symptoms might have become that patient's "language of distress". It is possible that this may have occurred in Mr Neville's case and it is certainly something worth exploring. Competing interests: None declared |
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karen ross, GP pinhoe,exeter ex1 3sy
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I would include bulaemia nervosa, severe constipation, raised intracranial pressure, drug induced, in the differential. If adequate oral intake is impossible then admission seems the only option even if it is Christmas. I would suggest in addition TFTs and a CT head as well as a psychiatric assessment. I would explain to the patient that the exact cause was not yet certain and that a period of observation in addition to the above further investigations would be sensible. Competing interests: None declared |
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Alan Thomas Clarke, Specialist Registrar In Gastroenterology and General Medicine Gartnavel General Hospital, Glasgow, G12 0YN
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The history and clinical findings with manometry/impedance are suggestive of self-induced belching secondary to aerophagia provoked by meals. The sharp rise in oesophageal impedance in the distal oesophagus which migrates proximally suggests this is gastric rather than supragastric belching. It can be difficult to convince patients that such a condition is self-induced and careful explanation of the mechanism of self-induced belching (often using a demonstration by the practitioner of air-swallowing ) may help. This case report suggests that the diagnosis of non-acid reflux can be difficult using conventional manometry/pH techniques and highlights the role of intra-luminal impedance in the investigation of patients with persistent reflux symptoms despite negative investigations. The important factor that clinched the diagnosis was the careful observation of the patient's eating/vomitting pattern and highlights the value of meticulous history taking and examination. Competing interests: None declared |
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Daniel J Youngerwood, GP Principal London W1G 9TQ
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Incredibly unlikely but - could this be Churg-Strauss syndrome? This could have been either associated with his asthma or even brought on by his earlier use of leukotriene antagonists.... Competing interests: None declared |
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