Let's begin a new case.
So we have a 65-year-old man seen in clinic for
a 2-week history of frequent nausea and vomiting.
He vomits about 30
minutes after eating meals
and notes frequent stomach
gurgling and bloating between meals
He has a history of uncontrolled type 2
diabetes and had a cholecystectomy 10 years ago.
He lost 2 kg in the last month but denies
dysphagia, odynophagia or abdominal pain.
His vitals are normal, and on
exam when auscultating the stomach,
he has an audible splashing sound
when he is rocked side to side.
What is the most likely diagnosis?
So some key features of this case include:
his dyspepsia with vomiting
immediately after meals,
and he has a history of uncontrolled
diabetes plus a history of abdominal surgery.
In addition on exam, he has
what's called a "succussion splash"
which is when you hear audible food splashing
around when the patient is rocked side to side.
This indicates the presence
of gas and food in the stomach.
So how do we know that this patient
does not have a small bowel obstruction?
In any patient, coming in
with nausea and vomiting,
you should always make sure that you
have ruled out a small bowel obstruction.
So you must ask about abdominal pain, constipation,
obstipation, and any history of abdominal surgeries.
So let's talk a bit about
this condition, gastroparesis.
Gastroparesis is when you have slow
or delayed clearance of gastric contents.
In general, patients come in with a
feeling of being full very soon after eating,
so early satiety and postprandial fullness.
They may have nausea and vomiting,
abdominal pain and bloating, and weight loss.
Gastroparesis is a condition that's easily confused
for many other diagnoses such as the ones listed here.
Because of this, endoscopy must be
done to rule out any malignant obstructions
such as the mechanical obstruction and you may
also do a test called a 'gastric emptying test'
to confirm this diagnosis.
In general, the treatment consist
of treating the patient's dehydration
or any electrolyte disturbances
that result from their gastroparesis.
You may also do dietary modification, such as
encouraging the patient to eat small, frequent meals,
avoiding meals high in fiber which
can make their symptoms worse,
and providing anti-emetics
for symptom control.
So we spoke earlier about
a gastric emptying study.
A gastric emptying study is done by
giving the patient barium contrast to swallow
and then taking abdominal x-rays at
various time points after ingesting contrast
In this example, on the left side, you can
see the stomach highlighted with contrast
immediately after the
patient drank barium contrast.
20 hours later, on the right side, you
now see that there is contrast in the stomach
and some of it has passed on to the bowel.
In normal study, what have shown, all of the contrast
leave the stomach by this point since it's been 20 hours
however in this case ,there
is still contrast in the stomach
which indicates a positive
test for gastroparesis.
So why does gastroparesis occur?
You should always make sure
to look for an underlying etiology
Frequent causes include diabetes,
thyroid disease, neurologic disease,
prior history of gastric surgery, any
autoimmune disorders and post-viral syndromes.
So now let's go back to our case.
We had a 65-year-old man with
dyspepsia, vomiting immediately after meals,
a history of uncontrolled diabetes and
abdominal surgery with a succussion splash on exam,
which is abnormal.
So his uncontrolled diabetes places
him at high risk for gastroparesis,
and his history of abdominal
surgery places him at risk for an SBO.
In this case, the most likely diagnosis is
gastroparesis due to his underlying diabetes.
Thank you very much for your attention.