Persistant Vomiting

Hx: A male in his 60’s presents with persistent nausea and vomiting for 4 days. He denies any significant abdominal pain but has had some very mild diarrhea. No fever. Emesis is dark, almost black. Stool was also dark. He has been unable to tolerate any oral intake because he has vomiting within a few minutes of intake each time. He has no history of similar symptoms and no sick contacts. His only history is of a prior “H. Pylori” infection that was treated years ago. He is not on any ulcer prophylaxis. Occasionally uses alcohol. He regularly uses NSAIDS for osteoarthritis pain.

PMHx: Osteoarthritis, H. Pylori infection.

Socx: occasional alcohol, smokes cigars, no drugs

Meds: no prescriptions.

Exam: 

  • Vital signs: HR 100, BP 125/85, Temp 97.8, RR 18, sat 100% RA
  • General: appears ill and fatigued.
  • HEENT: normal
  • Resp: clear bilaterally
  • Cardiovascular: mild tachycardia, regular, no murmurs
  • Abdomen: mild epigastric tenderness, non-distended, soft, bowl sounds present.
  • Negative  murphy’s.
  • Extremities: warm with equal pulses, no edema
  • Neuro: Awake and oriented without defects.

Differential: 

  • Gastroenteritis
  • Pancreatitis
  • Hepatitis
  • Cholecystitis
  • Ulcer Disease
  • Gastritis
  • Food Poisoning
  • Atypical MI

ED Evaluation: 

  • IV is placed and IV fluid bolus begun
  • Significant lab abnormalities:
    • NA 140
    • K 3.1
    • CL 82
    • CO2 40
    • Glucose 129
    • Anion gap 18
    • UA 3+ ketones
  • A CT can of the abdomen shows a markedly dilated stomach with normal, decompressed small bowel and colon suggesting gastric outlet obstruction. (images)
GOO1.jpg

Yellow Arrow: Stomach, Red Arrow: Swollen Gastric Outlet

GOO2.jpg

Yellow Arrow: Stomach

GOO3.jpg

Yellow Arrow: Stomach, Blue Arrow: Debris In The Stomach

GOO4.jpg

Yellow Arrow: Stomach, Blue Arrow: Debris In The Stomach

GOO5.jpg

Yellow Arrow: Stomach, Red Arrow: Swollen Gastric Outlet

  • NG tube suction produces 1200cc of dark black fluid

Hospital Course: 

  • The patient is admitted
  • IV fluids are continued and consultation is made with Gastroenterology
  • He is taken to endoscopy where a peptic ulcer, significant edema and stenosis of the gastric antrum is visualized. Dilation is performed to relieve the obstruction and several biopsies are taken to insure no malignancy is present.

Diagnosis: Acute Gastric Outlet Obstruction Due To Peptic Ulcer Disease 

Discussion: 
The differential for gastric outlet obstruction includes:

  • Malignancy
  • Peptic Ulcer Disease
  • Crohn’s Disease
  • Pancreatitis
  • Caustic Injury due to Ingestion
  • Large Gastric Polyps
  • Gastric TB
  • Bezoars
  • PEG Tube Migration
  • Gastric Volvulus

Gastric Outlet Obstruction was once a common result of peptic ulcer disease. However, with the discovery of H. Pylori and subsequent treatment protocols, universal use of proton pump inhibitors, and improved access to endoscopy, gastric outlet obstruction is now a rare complication of this disease. Instead, gastric malignancy has become the predominant cause though the overall incidence of this disease has also fallen with the above noted improvements in treatment. Today, peptic ulcer disease causes only 5% of gastric outlet obstructions.Generally, the majority of cases (over 80%) present with vomiting. There may be a history of early satiety preceding the obstruction by up to 3 months.
This presentation is also accompanied by multiple electrolyte abnormalities. Persistent vomiting causes loss of gastric acid resulting in a metabolic alkalosis. Additionally, compensatory renal absorption of hydrogen causes loss of potassium. Therefore, in severe cases persisting for several days, a hypokalemic hypochloremic metabolic alkalosis can be seen. We are taught to expect this metabolic derangement in children with pyloric stenosis, but the mechanism of action is similar to an adult with gastric outlet obstruction.
Treatment consists of replacing electrolyte and fluid losses, decompression of the stomach by placement of a nasogastric tube, and endoscopy to identify the cause of the stenosis. Strictures can be dilated and malignancies can be biopsied during the procedure. If a malignancy is found to be the cause, surgical excision is ultimately the treatment. However, if stricture due to peptic ulcer disease is the cause, it can be dilated and treated successfully with PPI (proton pump inhibitor) therapy.
In this case, the patient also presented with dark black gastric fluid. This represents blood mixing with gastric acid. The cause of the bleeding was the patient’s peptic ulcer. Treatment included discontinuation of his NSAIDs and initiation of proton pump inhibitor therapy. He did very well and was discharged home in good condition.

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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