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Endgames Picture Quiz

Nausea with a twist

BMJ 2010; 340 doi: (Published 23 June 2010) Cite this as: BMJ 2010;340:c2955
  1. Kenneth J Porter, senior house officer1,
  2. Daniel Thomas, associate specialist1,
  3. Rajab Kerwat, consultant general surgeon1,
  4. Sumantra Kumar, consultant radiologist2
  1. 1Department of General Surgery, Queen Mary’s Hospital, Sidcup, Kent DA14 6LT
  2. 2Department of Radiology, Queen Mary’s Hospital
  1. Correspondence to: K J Porter kenjporter{at}

    An 81 year old woman presented to our department with a two day history of nausea and retching but was unable to vomit. For the past three weeks she had been experiencing dysphagia with only small amounts of liquid tolerated, excessive belching, and weight loss. She had no abdominal pain and her bowels were opening normally. She had a known hiatus hernia and previous oesophagitis for which she was taking regular omeprazole.

    On examination she did not have a fever but she was dehydrated and tachycardic. Her abdomen was soft and non-tender and a cardiorespiratory examination showed no abnormalities. She underwent chest radiography and computed tomography of her chest and abdomen (figs 1 and 2 ). She was treated successfully for her condition and discharged home.


    • 1 What are the differential diagnoses for this patient?

    • 2 What is the abnormality on computed tomography?

    • 3 What is the most likely diagnosis?

    • 4 How can this condition be treated?


    1 What are the differential diagnoses for this patient?

    Short answer

    The differential diagnoses include proximal upper gastrointestinal obstruction secondary to oesophageal motility disorders, reflux oesophagitis, peptic ulcer disease, oesophageal or gastric cancer, and complicated hiatus hernia.

    Long answer

    Given the patient’s presentation with nausea, retching, and excessive belching, a diagnosis of gastric outlet obstruction is possible.1 Since the advent of proton pump inhibitors, cancer is the most common cause of such obstruction.2 Stenosis caused by a prepyloric ulcer must also be considered, but abdominal pain and vomiting are usually prominent in this setting.3 Such symptoms were not seen in our patient so this diagnosis can be excluded. An oesophageal motility disorder, such as presbyo-oesophagus, is also a possible …

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