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Cannabinoid-induced hyperemesis syndrome
11%
4/35
Gastroparesis
60%
21/35
Intracranial mass
0%
0/35
Pancreatitis
26%
9/35
Small bowel obstruction
3%
1/35
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This patient with a history of poorly managed diabetes (hemoglobin A1c of 13%) is presenting with gradually worsening episodes of nausea, vomiting, constipation, and abdominal pain with a nonspecific physical exam with minor discomfort to palpation with no focal tenderness. This is most concerning for a diagnosis of gastroparesis. Diabetic gastroparesis occurs when persistent hyperglycemia leads to microvascular ischemia and injury to the enteric nervous system causing dysfunction. As a result, regular, coordinated peristalsis does not occur and patients may present with nausea, vomiting, early satiety, and bloating with a gradually worsening course if the patient's diabetes is not treated. Acute management involves intravenous fluids for rehydration, antiemetics, and analgesia. A computed tomography (CT) scan can rule out other diagnoses such as a small bowel obstruction. A gastric emptying study is considered the most appropriate confirmatory test. Management is centered on tight glycemic control, small meals, and prokinetics such as erythromycin and metoclopramide. Benard-Laribiere studied the risk of ischemic stroke after the use of an antidopaminergic antiemetic agent (ADA, e.g., metoclopramide) in 2800 patients using a case-control study design. The authors find that patients with ischemic strokes were significantly more likely to have received metoclopramide in the 2 weeks prior to the index stroke compared to a previous reference period (odds ratio, 3.53). The authors recommend counseling patients that ischemic stroke, along with drowsiness and movement disorders are side effects of metoclopramide. Incorrect Answers: Answer 1: Cannabinoid-induced hyperemesis syndrome presents with repeat episodes of severe, cyclic vomiting with symptoms that are improved by hot showers. Treatments for nausea during episodes include topical capsaicin, haloperidol, ondansetron, and warm compresses. Though this patient does have history of marijuana use, it is not cyclical and the use is not frequent enough to make this the most likely diagnosis. Answer 3: Intracranial masses can cause headaches, nausea, and vomiting that are worse in the morning secondary to increased blood flow to the brain when lying flat, leading to swelling and edema. Patients would be expected to have gradually insidious symptoms with possible neurological deficits such as ataxia. Answer 4: Pancreatitis presents secondary to gallstones or alcohol use with epigastric pain that radiates to the back, nausea, vomiting, and elevated lipase. This patient's lipase is slightly elevated but this is likely secondary to profuse vomiting. Similarly, his pain is diffuse and not focal to the epigastric region. Answer 5: Small bowel obstruction presents with nausea, vomiting, abdominal distension, a tympanitic abdomen, and a failure to pass flatus or stool. It is caused by adhesions usually secondary to abdominal surgery. The diagnosis is made with a CT scan. Observation, intravenous hydration, and placement of a nasogastric tube are the mainstay of management. This patient does not have a history of surgeries, and he is constipated but still able to have bowel movements. Bullet Summary: Diabetic gastroparesis presents in poorly managed diabetics with abdominal distension, nausea, and vomiting.
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