History
Ms. Smith, an 18 year old patient presented to the gastroenterology clinic with a history of vomiting for 6 months with increasing frequency. At the time of the first onset of symptoms she reported that she was unusually stressed because she was awaiting responses from colleges. At the first onset of symptoms she thought she had food poisoning but the frequency increased over time.
Ms. Smith is a tennis player and enjoys travelling with her friends and family members and trying various types of foods during her travels. She does not consume alcohol or any medications. She presents with a typical family history with no history of mental, metabolic, or eating disorders. She reports being satisfied with her body image.
She recently returned from a two month trip she took visiting several European cities with her friends and family. During her vacation she reported a worsening of her symptoms and had returned back to the States losing 15 pounds. She is anxious because college is starting in a few weeks and she reports that she needs to regain control of her life because she is unable to eat without vomiting.
Presentation
At time of presentation she reports being unable to eat food without having an “acidy” feeling followed by abdominal discomfort and nausea. She reports waking up at night feeling nauseous and feeling nauseous during and after meals. She reports feeling better after vomiting which occur either shortly after consuming food or hours later. She describes her vomit to appear like bile and have identifiable food contents present.
Actions Taken
Fasting blood panel and metabolic panel was obtained. Patient had Barium Swallow study, colonoscopy and endoscopy was performed.
Results
Blood work returned normal, however there was a decreased white blood cell count. H.pylori test was positive. Barium Swallow study was unable to be performed due to vomiting and extreme nausea. Colonoscopy and endoscopy showed inflammation of lining.
Diagnosis
Ms. Smith was diagnosed with Gastritis and Gastroesophageal Reflux Disease (GERD). Possible diagnosis of gastroparesis suspected.
Helicobacter pylori (H. pylori) is one of the most common bacterial infections in humans that has the potential to cause gastritis and even stomach cancer. H. pylori is described at a gram-negative, spiral, bacterium that is housed in human stomachs. Zandi et al describes that an infection caused by H. pylori may sometimes remain unnoticed by the patient due to the different clinical outcomes that are influenced by diet, genetics, and behavior. Sensitivity is depended on both the parasite and the host.
Gastritis is a very prevalent disease where it is estimated that more than half of the world’s population has the disease present to some degree (Sipponen et al). Gastritis and H. pylori have been found to be linked. Overall, gastritis is considered to be chronic and is defined as an inflammation of the stomach lining that could be caused by a variety of factors such as high alcohol consumption, infection, and usage of NSAIDs.
Gastroesophageal Reflux Disease (GERD) is a disorder that is considere to be multifactorial characterized by the reflux of gastric contents into the esophagus lining that are acidic and subsequently causes damage of the tissue in the associated structures (Saad et al). The role of H. pylori however, is not completely known but is considered to be remotely linked. In addition, GERD has also been associated with increased stress.
However, given the patient’s history, GERD is possible but not conclusive. The worsening of symptoms is possibly not attributed to stress since symptoms worsened over time as stress subdued. While difficult to diagnose, the patient is suspected to have gastroparesis which is symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction (Parkman et al). The possible diagnosis of gastroparesis could be explained by the fact that the patient reports abdominal discomfort followed by nausea even after consuming little food. Parkman et al cite that nausea was present in 92% of patients, vomiting in 84% and abdominal discomfort or pain was present in 46%-89% of patients. A gastric emptying study should be performed, however it must be noted that often times symptoms of gastroparesis based on patient recall are not positively correlated with gastric emptying which contributes to the fact that gastroparesis is difficult to diagnose and treat (Khayyam et al).
Treatment and Considerations
Patient was instructed take low dose of antibiotics as a gut motility stimulator and Dexilant 30mg every morning and sucralfate suspension due to inflammation of lining tissues.