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Question 2#

A 60-year-old woman with depression and poorly controlled type 2 diabetes mellitus complains of episodic vomiting over the last 3 months. She has constant nausea and early satiety. She vomits once or twice almost every day. In addition, she reports several months of mild abdominal discomfort localized to the upper abdomen. The pain sometimes awakens her at night. She has lost 5 lb of weight. Her diabetes has been poorly controlled (glycosylated hemoglobin recently was 9.5). Current medications are glyburide, metformin, and amitriptyline.

Her physical examination is normal except for mild abdominal distention and evidence of a peripheral sensory neuropathy. Complete blood count, serum electrolytes, BUN, creatinine, and liver function tests are all normal. Gallbladder sonogram is negative for gallstones. Upper GI series and CT scan of the abdomen are normal.

What is the best next step in the evaluation of this patient’s symptoms?

A) Barium esophagram
B) Scintigraphic gastric emptying study
C) Colonoscopy
D) Liver biopsy
E) Small bowel biopsy

Correct Answer is B

Comment:

Delayed gastric emptying (gastroparesis) is a common cause of recurrent vomiting, nausea, early satiety, and weight loss in poorly controlled diabetics. Abdominal discomfort is often nonspecific, but may be localized to the upper abdomen and often awakens the patient at night. Drugs with anticholinergic properties may aggravate the problem. The best diagnostic test is a scintigraphic gastric emptying study, which will show delay in gastric emptying. Treatment includes withdrawal of aggravating drugs such as opiates and anticholinergics, good diabetes control, and drug therapy with metoclopramide or erythromycin. The patient’s symptoms are not those of esophageal disease (dysphagia, odynophagia), so a barium esophagram would not be useful. Her symptoms also do not suggest colonic pathology; in the absence of iron deficiency, colonoscopy would not be indicated. You would not order a liver biopsy in a patient with normal liver enzymes and CT scan of the abdomen. Small bowel biopsy would be indicated if her symptoms suggested intestinal malabsorption.