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A 48-Year-Old Woman with Nausea, Vomiting, Early Satiety, and Weight Loss

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A 48-Year-Old Woman with Nausea, Vomiting, Early Satiety, and Weight Loss A SELF-TEST IM BOARD REVIEW JAMES K. STOLLER, MD, EDITOR ON A MOHAMMED A. QADEER, MD CAROL A. BURKE, MD CLINICAL Department of General Internal Medicine, Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation The Cleveland Clinic Foundation CASE A 48-year-old woman with nausea, vomiting, early satiety, and weight loss 48-YEAR-OLD female ice-skating teacher Her abdomen has scars from her cholecys- A is seen for evaluation of progressive gas- tectomy and appendectomy incisions. There trointestinal (GI) symptoms. For 6 to 7 years, is no distension, tenderness, or organomegaly. she has had intermittent pain in the upper A bruit is audible in the upper abdomen; she and middle abdomen. The pain is dull, nonra- has no carotid or femoral bruits. diating, and worse after eating. She under- went cholecystectomy about 5 years ago Laboratory data because of this pain, but it did not provide Her chemistry panel, complete blood count, much relief. erythrocyte sedimentation rate, and C-reac- About a year and a half ago, she started to tive protein level are normal, except for low experience nausea, vomiting, early satiety, concentrations of protein (4.1 g/dL, normal and postprandial abdominal bloating. Over 6.0–8.4), albumin (2.4 g/dL, normal 4.0–5.4), this period, she developed anorexia, particu- and thyroid-stimulating hormone (0.25 larly for fatty foods, and she has lost 20 µU/mL, normal 0.4–5.5). pounds. She is also having intermittent loose The patient stools. Her pain, however, has not changed in ■ DIFFERENTIAL DIAGNOSIS has lost character or severity. She has no significant past medical histo- Which of the following is the least likely 20 pounds diagnosis? ry. She had an appendectomy 10 years ago and 1 in 1 1/2 years a partial thyroidectomy for a benign nodule. ❑ Peptic ulcer disease Her only medication is prochlorperazine, ❑ Chronic pancreatitis which she takes as needed for nausea and ❑ Irritable bowel syndrome vomiting. ❑ Gastroparesis She has smoked one pack of cigarettes per day for 25 years and denies alcohol intake. Peptic ulcers are most commonly caused Her maternal grandfather and granduncle by either Helicobacter pylori (about 70% of died of colon cancer. There is no family histo- duodenal ulcers and 50% to 60% of gastric ry of inflammatory bowel disease. Review of ulcers1) or nonsteroidal anti-inflammatory other systems is unremarkable. drugs. The common presenting symptoms include dyspepsia and abdominal pain, but Physical examination most ulcers may be asymptomatic.2 The patient appears thin but in no distress. In about 10% of cases, chronic gastroduo- Her blood pressure is 114/65 mm Hg with no denal ulcers can result in gastric outlet orthostasis, pulse 68/minute, height 5’5”, and obstruction due to fibrosis and scarring.3 The weight 102.9 pounds. Her heart and lungs are onset of obstruction is heralded by nausea, normal. vomiting, postprandial abdominal bloating, pain, and weight loss. This paper discusses therapies that are experimental or are not approved Chronic pancreatitis is characterized by by the US Food and Drug Administration for the use under discussion. abdominal pain that radiates to the back and, CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 9 SEPTEMBER 2004 693 Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. GASTROINTESTINAL SYMPTOMS QADEER AND BURKE in advanced cases, by pancreatic insufficiency. any patient who presents with symptoms of The pain may be continuous but worse after gastric outlet obstruction, as it can rule out eating. Patients intentionally eat less to avoid mechanical causes such as scarring and fibrosis the pain, which leads to severe weight loss.4 of the pylorus due to peptic ulcers and gastric Steatorrhea occurs when lipase secretion has antral neoplasia. diminished by 90%.5 Significant nausea and Duodenal obstruction is uncommon and is vomiting are not commonly observed in most often due to extrinsic causes such as chronic pancreatitis. compression from a pancreatic tumor or sur- Gastroparesis causes symptoms of gastric rounding lymph node metastases. A rare cause outlet obstruction, including nausea, vomiting, of duodenal obstruction is the superior mesen- abdominal bloating, early satiety, and weight teric artery (SMA) syndrome, in which the loss6 and should be considered in the differen- third part of the duodenum is trapped between tial diagnosis when these symptoms are present, a “calcified” or “acute-angled” SMA and the particularly in women in their 40s and 50s. aorta or spine. Its clinical significance is con- Irritable bowel syndrome is the least like- troversial, its symptoms are nonspecific, and it ly diagnosis. The Rome II criteria7 for this is difficult to diagnose. diagnosis require that the patient have experi- Upper gastrointestinal radiographic studies enced abdominal pain or discomfort for at with contrast should be avoided in patients with least 12 weeks (not necessarily consecutive) in suspected gastric outlet obstruction because the the past 12 months, and that the pain have at barium contrast in the stomach makes it impos- least two of the three following features: sible to examine the mucosa properly if an • It is relieved by defecation endoscopic study is performed soon afterward, • Its onset is associated with a change in fre- until the barium is passed or removed by naso- quency of stool gastric suction. Furthermore, endoscopy is more • Its onset is associated with a change in sensitive for detecting mucosal lesions8 and form (appearance) of stool. allows biopsy of lesions if required. On the other Certain “alarm features” preclude the hand, a series of upper gastrointestinal radi- Gastroparesis diagnosis of irritable bowel syndrome and war- ographs may provide anatomical delineation if should be rant appropriate investigation: gastrointesti- endoscopy is contraindicated or difficult owing nal bleeding, weight loss greater than 10 to a tight stricture. considered pounds, a family history of colon cancer, Dietary restriction and anticholinergic especially in recurring fever, anemia, and chronic severe agents are treatments for irritable bowel syn- diarrhea or constipation. drome and have no role here. women in their Our patient does not meet the Rome II CT of the abdomen is useful in evaluating 40s and 50s criteria, owing to her unintentional weight upper abdominal symptoms and gives informa- with loss. In addition, her abdominal bruit is worri- tion about the pancreas, liver, gallbladder, some and suggests another diagnosis. common bile duct, and retroperitoneum. appropriate A solid-phase gastric emptying test is symptoms ■ DIAGNOSTIC WORKUP warranted if no mechanical obstruction is found on EGD in a patient with symptoms of Which of the following would be the most gastric outlet obstruction. 2 appropriate first step in this patient’s diag- nostic workup? Case continued ❑ Esophagogastroduodenoscopy (EGD; The patient had undergone an extensive eval- upper GI endoscopy) uation at another hospital. ❑ Dietary restriction and anticholinergic • Thyroid function tests, the 72-hour fecal agents fat content, the serum gastrin level, and cate- ❑ Computed tomography (CT) of the cholamine levels were all normal. abdomen • An upper GI endoscopic study showed a ❑ Solid-phase gastric emptying test large amount of food residue in the stomach with chronic nonerosive gastritis but was oth- EGD should be the first investigation in erwise normal. 694 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 9 SEPTEMBER 2004 Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. GASTROINTESTINAL SYMPTOMS QADEER AND BURKE TABLE 1 •A series of small bowel radiographs showed markedly delayed transit time to the colon. The small bowel mucosa had a normal pattern. These findings—the delayed solid-phase gastric emptying, the dilated and residue-filled stomach on EGD and CT, as well as the markedly dilated stomach—confirmed the diagnosis of gastroparesis. Subsequently, antroduodenal motility studies were done to rule out chronic intestinal pseudo-obstruc- tion, and these studies were normal. Even after exhaustive investigations, no etiologic factor could be identified, and the patient’s gastroparesis was deemed idiopathic. ■ GASTROPARESIS Not available for online publication. Gastroparesis is a motility disorder of the stomach characterized by symptoms of gastric See print version of the outlet obstruction in the absence of mechani- Cleveland Clinic Journal of Medicine cal causes. Gastric motility is modulated by gastric myoelectrical activity, a part of a local neural network. It is also regulated by meal composi- tion and hormonal mechanisms.9 Fatty meals delay emptying, as do secretin and cholecys- tokinin, whereas motilin and neurotensin accelerate it. Neurologic mechanisms include parasympathetic (vagal) and sympathetic influences along with gastrointestinal reflexes. Soykan et al6 reported a series of 146 patients with gastroparesis. The most com- mon symptoms were nausea (present in 92%), vomiting (84%), abdominal bloating (75%), early satiety (60%), and abdominal pain (46%). In a series of 28 patients, Hoogerwerf et al10 reported abdominal pain in 90%, early satiety in 86%, and vomiting in 68%. Occasionally, an audible and palpable succus- sion splash may be noticed. Women are more likely than men to have impaired gastric emptying, particularly during the luteal phase of the menstrual cycle.11 In •A CT scan of the abdomen showed that the series reported by Soykan et al,6 women the stomach was dilated and filled with fluid constituted 82% of all patients. The mean age and debris and the small bowel was diffusely was 45 years and the mean age at symptom dilated without a transition point. The liver, onset was 33.7 years. pancreas, and spleen were normal. In almost 80% of the cases in these series, • On solid-phase gastric emptying testing, the cause of gastroparesis was either idiopath- the half-life of stomach emptying was 454 ic, diabetes mellitus, or prior gastric surgery minutes (normal 60–90).
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