Gastrointestinal Dysmotility

Abstract

Case Presentation and EvolutionA 42 year-old previously healthy man was admitted to Stanford University hospital because of severe nausea and vomiting. He had been well until 3 weeks before admission, when he first experienced nausea, vomiting, and profound sweating without chills or fever, lasting up to 24 h. The symptoms became progressively worse and occurred with any oral intake of solids or liquids. He also noted the sensation of food being stuck in his throat despite swallowing small bites.An upper endoscopy that had been performed at another hospital showed a small hiatal hernia, antral and gastric body erythema, and gastric food retention. At that time, an abdomen CT scan revealed mild bowel wall thickening in the distal ileum. His symptoms had gradually improved and he was discharged. However, soon thereafter, his symptoms worsened to the point that he could no longer tolerate either solids or liquids and he was admitted to Stanford hospital. In the course of the three weeks before admission, he had lost 25 pounds but did not experience any abdominal pain or diarrhea. The use of anti-emetics was only marginally helping his nausea. He did however, note significant constipation, with his last bowel movement being one week before his admission to Stanford hospital. He had no known sick contacts, and had not recently traveled.His past medical and surgical histories were negative. His father had died of colon cancer at age 70. His sister had cholelithiasis. He worked as a mechanic, did not smoke, and only consumed alcohol socially.On examination, he was afebrile with a pulse of 53, blood pressure of 118/69, and oxygen saturation of 99% on room air. He appeared frail with some temporal wasting but otherwise he did not have any lymphadenopathy and he was anicteric. His abdomen was soft and non-tender but hypoactive bowel sounds could be heard. No abdominal masses were palpable. There was no edema, rashes, or erythema.His laboratory values were: hemoglobin 12.9 with MCV of 92.4. His INR was 1.1 with sodium of 132. His liver enzymes were normal as was his thyroid stimulating hormone. Although a random serum cortisol was 2 lg/dl (normal range: 4-26 lg/dl), an ACTH stimulation test revealed appropriate response from 12 to 33 lg/dl.An esophagogram revealed reduced primary esophageal peristalsis and tertiary contractions in the distal esophagus (Fig. 1). There was delay of passage of contrast, with the barium column reaching the level of the thoracic inlet; delayed gastric emptying (Fig. 2) and a small sliding hiatal hernia were also noted. Gastric emptying scan showed severe gastroparesis, with 74% of the radioactive tracer still remaining in the stomach at the end of 4 h (normal range: 0-10%) (Fig. 3). Esophageal motility study was suspicious for vigorous achalasia versus severe nutcracker variant of diffuse esophageal spasm (Fig. 4).To further evaluate the etiology of his gastrointestinal dysmotility, a paraneoplastic workup was performed and it was negative. Head and body CT showed no masses. Systemic markers of ...

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