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GI Grand Rounds GIGI GrandGrand RoundsRounds ““AA LifetimeLifetime ofof AbdominalAbdominal PainPain”” 12/9/200412/9/2004 TimTim EdwardsEdwards PMHPMH AugAug 25,25, 19921992 44 yearyear oldold malemale presentspresents toto aa pediatricpediatric gastroenterologistgastroenterologist forfor primaryprimary complaintcomplaint ofof anorexia,anorexia, intermittentintermittent abdominalabdominal painpain whichwhich occasionallyoccasionally awakensawakens himhim atat nightnight TheseThese problemsproblems havehave beenbeen presentpresent forfor >1>1 yearyear NegativeNegative UGIUGI studystudy EGDEGD withwith mildmild gastritisgastritis RxRx withwith tagamettagamet 40mg/kg/day40mg/kg/day andand caffeinecaffeine freefree dietdiet MayMay 19,199419,1994 SeenSeen forfor c/oc/o abdominalabdominal painpain withwith vomitingvomiting atat bedtimebedtime BeenBeen doingdoing wellwell offoff allall medicationsmedications forfor 11 yearyear WeightWeight 4444 lbs;lbs; heightheight 4343 inchesinches ExamExam withinwithin normalnormal limitslimits GESGES T1/2T1/2 prolongedprolonged atat 135135 minutesminutes RxRx withwith CisaprideCisapride 5mg5mg 20minutes20minutes QAC+HSQAC+HS forfor gastroparesis.gastroparesis. OctoberOctober 19,19, 19941994 SeenSeen inin f/uf/u forfor gastritisgastritis andand GERDGERD DoingDoing wellwell onon TagamentTagament andand PropulsidPropulsid NoNo abdominalabdominal painpain RecentlyRecently startedstarted withwith looseloose stoolsstools HeightHeight 4646 in,in, weightweight 47.547.5 lbslbs ExamExam withinwithin normalnormal limitslimits PropulsidPropulsid stoppedstopped withwith recurrencerecurrence ofof severesevere abdominalabdominal painpain withinwithin severalseveral daysdays SeptemberSeptember 21,21, 19981998 F/UF/U ofof GERDGERD andand gastroparesisgastroparesis PrilosecPrilosec 20mg/day20mg/day andand PropulsidPropulsid 10mg10mg BIDBID--TIDTID C/OC/O crampycrampy abdominalabdominal painpain NoNo vomitingvomiting 22--33 looseloose stoolsstools perper dayday withoutwithout bloodblood oror mucusmucus NoNo weightweight lossloss HeightHeight 5555 inches;inches; weightweight 9090 lbslbs FebruaryFebruary 25,25, 20032003 SeenSeen forfor recurrentrecurrent abdominalabdominal painpain associatedassociated withwith vomitingvomiting forfor threethree weeksweeks OffOff medicationsmedications forfor 22 yearsyears DailyDaily epigastric/substernalepigastric/substernal pain.pain. PainPain usuallyusually postprandial.postprandial. EmesisEmesis isis nonbiliousnonbilious,, previouslypreviously ingestedingested foodfood LostLost 66 lbslbs WeightWeight 121121 lbs;lbs; HeightHeight 6565 inin ExamExam withinwithin normalnormal limitslimits PlacedPlaced onon blandbland dietdiet andand NexiumNexium forfor recurrentrecurrent GERDGERD AugustAugust 18,18, 20032003 RecentRecent EGDEGD withinwithin normalnormal limitslimits BiopsiesBiopsies normal,normal, nono celiacceliac diseasedisease NoNo improvementimprovement withwith ZelnormZelnorm 3mg3mg BIDBID OnceOnce perper weekweek withwith severesevere crampycrampy abdominalabdominal painpain relievedrelieved withwith nonbiliousnonbilious vomitingvomiting WeightWeight 112112 lb;lb; heightheight 6666 inchesinches ExamExam withinwithin normalnormal limitslimits 4H4H GESGES withwith T1/2T1/2 161161 minutesminutes JanuaryJanuary 27,27, 20042004 F/UF/U GERDGERD andand gastroparesisgastroparesis RecurrentRecurrent abdominalabdominal painpain hashas returnedreturned ProminentProminent regurgitationregurgitation FrequentFrequent nauseanausea NoNo diarrheadiarrhea DecreasedDecreased appetite;appetite; lostlost 44 lbslbs sincesince OctoberOctober IncreasedIncreased NexiumNexium 40mg40mg BID;BID; IncreasedIncreased ReglanReglan toto 55 mgmg TIDTID FebruaryFebruary 8,8, 20042004 StillStill withwith epigastric/substernalepigastric/substernal painpain 22-- 3X/wk3X/wk WillWill vomitvomit whenwhen painpain isis severesevere ReglanReglan increasedincreased toto 7.5mg7.5mg TIDTID ReferredReferred toto DrDr WoWo forfor evaluationevaluation andand potentialpotential useuse ofof DomperidoneDomperidone AprilApril 20,20, 20042004 DoingDoing wellwell onon NexiumNexium QAMQAM andand reglanreglan BIDBID NoNo N/V/abdominalN/V/abdominal painpain RepeatedRepeated UGIUGI withwith SBFTSBFT andand CTCT abd/pelvisabd/pelvis werewere withoutwithout evidenceevidence ofof obstruction,obstruction, stricture,stricture, oror IBDIBD BloodBlood teststests werewere withoutwithout suggestionsuggestion ofof secondarysecondary causescauses ofof gastroparesisgastroparesis TrialTrial ofof DomperidoneDomperidone 10mg10mg TIDTID JulyJuly 30,30, 20042004 AdmittedAdmitted toto UU ofof LL HospitalHospital fromfrom DrDr WoWo’’ss clinicclinic forfor 22 daysdays ofof sharp,sharp, constant,constant, nonradiatingnonradiating,, epigastricepigastric painpain whichwhich waswas relievedrelieved withwith vomitingvomiting NoNo POPO intakeintake forfor 22 daysdays IncreaseIncrease inin typicaltypical GERDGERD painpain NoNo diarrheadiarrhea PMH:PMH: AsAs outlinedoutlined previously.previously. O/WO/W negative.negative. PSHxPSHx:: NoneNone FmHxFmHx:: NoncontributoryNoncontributory SocialSocial Hx:Hx: DoesDoes wellwell inin school,school, nono ETOH,ETOH, drugsdrugs All:All: NKDANKDA Meds:Meds: NexiumNexium 40mg40mg POPO BID,BID, DomperidoDomperidonene 1010 mgmg POPO BIDBID ROS:ROS: 1111 lblb weightweight lossloss previousprevious 33 weeksweeks PhysicalPhysical ExamExam VS: 112/79 12 96.8 68 Gen: NAD HEENT: NC/AT, EOMI, anicteric, o/p without lesion Neck: No TM, no LAN CV: RRR Lungs: CTA B Abd: S/ND/minimal TTP mid epigastrium, no HSM, no masses Ext: No c/c/e Neuro: AAOX3, nonfocal. LaboratoryLaboratory Hgb/HctHgb/Hct 16/4616/46 WBCWBC 77 PltPlt 284284 NaNa 137137 ClCl 9494 BUNBUN 1818 KK 3.63.6 CO2CO2 3030 CrCr 1.11.1 CaCa 99 TpTp 8.18.1 AlbAlb 4.74.7 AmylaseAmylase 5353 LipaseLipase 110110 ASTAST 2525 ALTALT 2424 TbiliTbili 0.080.08 ImagingImaging 7/30/20047/30/2004 CTCT AbdomenAbdomen MarkedMarked dilatationdilatation ofof thethe stomachstomach andand proximalproximal duodenumduodenum withwith aa transitiontransition pointpoint nearnear thethe thirdthird portionportion ofof thethe duodenum.duodenum. MayMay bebe secondarysecondary toto focalfocal dysmotilitydysmotility versusversus obstructionobstruction secondarysecondary toto thethe mesentarymesentary andand itsits vascularvascular structuresstructures simulatingsimulating aa SMASMA syndrome.syndrome. UpperUpper GIGI limitedlimited AugustAugust 3,3, 20042004 ThereThere isis aa fillingfilling defectdefect seenseen inin thethe secondsecond oror thirdthird portionportion ofof thethe duodenumduodenum whichwhich maymay bebe c/wc/w intrinsicintrinsic vsvs extrinsicextrinsic defect,defect, butbut intrinsicintrinsic defectdefect isis favored.favored. TheThe etiologyetiology maymay bebe ectopicectopic pancreaticpancreatic tissue,tissue, largelarge adenomatousadenomatous polyp,polyp, smallsmall bowelbowel tumortumor oror otherother multiplemultiple extrinsicextrinsic causescauses suchsuch asas SMASMA syndrome.syndrome. NonNon--obstructiveobstructive bowelbowel patternpattern EGDEGD DefinitiveDefinitive TherapyTherapy GivenGiven endoscopicendoscopic andand radiologicradiologic evidenceevidence ofof extrinsicextrinsic lesionlesion resultingresulting inin obstructionobstruction aa surgicalsurgical consultationconsultation waswas obtained.obtained. OnOn 8/4/20048/4/2004 thethe patientpatient waswas takentaken toto thethe OROR forfor exploratoryexploratory laparotomylaparotomy forfor diagnosisdiagnosis ofof sourcesource ofof duodenalduodenal obstructionobstruction OperativeOperative FindingsFindings Liver,Liver, gallbladder,gallbladder, spleen,spleen, andand stomachstomach appearedappeared normalnormal UnableUnable toto locatelocate thethe ligamentligament ofof TrietzTrietz TheThe duodenumduodenum waswas notnot fixedfixed inin usualusual retroperitonealretroperitoneal positionposition th ThickThick fibrousfibrous bandband ofof tissuetissue crossedcrossed thethe 44th portionportion ofof thethe duodenumduodenum asas anan obstructionobstruction pointpoint CecumCecum andand ascendingascending coloncolon werewere mobilemobile andand notnot attachedattached toto thethe laterallateral abdominalabdominal wallwall ThisThis waswas c/wc/w intestinalintestinal malrotationmalrotation IntestinalIntestinal MalrotationMalrotation inin thethe AdolescentAdolescent MidgutMidgut malrotationmalrotation isis estimatedestimated toto occuroccur inin approximatelyapproximately 1/5001/500 livelive birthsbirths TheThe truetrue incidenceincidence isis unknownunknown owingowing toto thosethose whowho remainremain asymptomaticasymptomatic andand gogo undiagnosedundiagnosed SurgicalSurgical seriesseries estimateestimate 5050--80%80% presentpresent inin thethe firstfirst monthmonth ofof lifelife 20%20% presentpresent withinwithin firstfirst yearyear 1010--20%20% presentpresent olderolder thanthan 11 yearyear PathophysiologyPathophysiology IntestinalIntestinal malrotationmalrotation cancan bebe simplysimply defineddefined asas anyany deviationdeviation fromfrom thethe normalnormal 270270 degreedegree counterclockwisecounterclockwise rotationrotation ofof thethe midgutmidgut duringduring embryonicembryonic developmentdevelopment NormalNormal RotationRotation InIn thethe firstfirst twotwo monthsmonths ofof developmentdevelopment thethe growthgrowth ofof thethe intestinesintestines exceedsexceeds thethe capacitycapacity ofof thethe abdomenabdomen toto containcontain
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