A 43-year-old woman comes to the office due to nausea, vomiting, and intermittent epigastric pain for the last 6 months. Her symptoms have gradually worsened and now she cannot finish a regular meal without feeling full quickly. Although the patient has a decent appetite, she is afraid to eat due to postprandial bloating and heartburn. Fatty foods and salads are particularly bothersome. Consequently, the patient has lost 6.8 kg (15 lb).
Other medical problems include hypertension, type 1 diabetes mellitus complicated by diabetic nephropathy and neuropathy, hypercholesterolemia, and nonalcoholic fatty liver disease. Medications include insulin glargine, insulin lispro, lisinopril, gabapentin, simvastatin, low-dose aspirin, and ranitidine. The patient has no known drug allergies.
Examination reveals a distended and nontender abdomen with an obvious succussion splash. Rectal examination shows brown stool negative for occult blood.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 43-year-old woman comes to the office due to nausea, vomiting, and intermittent epigastric pain for the last 6 months.  Her symptoms have gradually worsened and now she cannot finish a regular meal without feeling full quickly.  Although the patient has a decent appetite, she is afraid to eat due to postprandial bloating and heartburn.  Fatty foods and salads are particularly bothersome.  Consequently, the patient has lost 6.8 kg (15 lb).
Other medical problems include hypertension, type 1 diabetes mellitus complicated by diabetic nephropathy and neuropathy, hypercholesterolemia, and nonalcoholic fatty liver disease.  Medications include insulin glargine, insulin lispro, lisinopril, gabapentin, simvastatin, low-dose aspirin, and ranitidine.  The patient has no known drug allergies.
Examination reveals a distended and nontender abdomen with an obvious succussion splash.  Rectal examination shows brown stool negative for occult blood.
Laboratory results are as follows:
 Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97f3_88ec_853d_8f95c0d8405e_MD0002_00 This patient's presentation (postprandial reflux, vomiting, succussion splash) is most consistent with impaired gastric emptying, which can be due to the following: Gastric dysmotility (eg, gastroparesis)Gastric outlet obstruction (GOO) due to mechanical (eg, pancreatic cancer, gastric polyp) or mucosal (eg, scarring from peptic ulcer disease) causes Gastric dysmotility (eg, gastroparesis) Gastric outlet obstruction (GOO) due to mechanical (eg, pancreatic cancer, gastric polyp) or mucosal (eg, scarring from peptic ulcer disease) causes Although this patient likely has gastric dysmotility due to diabetic gastroparesis, the definition of gastroparesis requires proving delayed gastric emptying in the absence of obstruction. Therefore, the first step in the workup of any patient with impaired gastric motility is to exclude mechanical or mucosal etiologies using upper endoscopy to evaluate for causes of GOO. Patients should also undergo imaging studies, such as CT/MR enterography (eg, to exclude small bowel mass). Once mechanical and mucosal causes have been excluded, the next step is to establish the diagnosis of gastroparesis by proving the presence of delayed gastric emptying (eg, gastric-emptying scintigraphy showing >10% gastric retention 4 hours following a solid meal) (Choice D). Once gastroparesis has been established, evaluation for the underlying etiology, such as diabetes mellitus, thyroid disease, and autoimmune disease, should occur. Gastroduodenal manometry and autonomic testing can also be helpful for distinguishing between myopathic and neuropathic causes. (Choice A) This patient has multiple signs of poorly controlled diabetes (eg, glycosuria), and modifying the insulin regimen is an important step in managing diabetic gastroparesis; however, prior to treating diabetic gastroparesis the patient should undergo an evaluation to exclude mechanical or mucosal etiologies. (Choice B) Ultrasound is useful for diagnosing gallstones, but it is not as sensitive or specific for gastric obstruction. This patient's symptoms of postprandial epigastric pain, early satiety, and weight loss are more concerning for impaired gastric emptying, which requires endoscopic evaluation, than for gallstone disease. (Choice E) Metoclopramide helps treat confirmed gastroparesis, but it should not be started empirically because of its significant adverse effects (eg, extrapyramidal symptoms). Gastroparesis should first be confirmed with a nuclear scintigraphic study. Educational objective: Impaired gastric emptying usually presents with early satiety, postprandial reflux, nausea, vomiting, and a succussion splash on examination. All patients should first be evaluated for mechanical or mucosal causes with an upper endoscopy. __________ References: Epidemiology, mechanisms, and management of diabetic gastroparesis. (http://www.ncbi.nlm.nih.gov/pubmed/20951838)

A 43-Year-Old Woman Comes to the Office Due to Nausea