Persistent Vomiting

Hx: A male in his 60’s presents with persistent nausea and vomiting for 4 days. He denies any significant abdominal pain but has had some very mild diarrhea. No fever. Emesis is dark, almost black. Stool was also dark. He has been unable to tolerate any oral intake because he has vomiting within a few minutes of intake each time. He has no history of similar symptoms and no sick contacts. His only abdominal history is a prior “H. Pylori” infection that was treated years ago. He is not on any ulcer prophylaxis. He admits to occasional alcohol use. He regularly uses NSAIDS for osteoarthritis pain.

PMHx: Osteoarthritis, H. Pylori infection.
Socx: occasional alcohol, smokes cigars, no drugs
Meds: no prescriptions.

Exam: 

• Vital signs: HR 100, BP 125/85, Temp 97.8, RR 18, sat 100% RA
• General: appears ill and fatigued.
• HEENT: normal
• Resp: clear bilaterally
• Cardiovascular: mild tachycardia, regular, no murmurs
• Abdomen: mild epigastric tenderness, non-distended, soft, bowl sounds present.
• Negative murphy’s.
• Extremities: warm with equal pulses, no edema
• Neuro: Awake and oriented without defects.

Differential: 

• Gastroenteritis
• Pancreatitis
• Hepatitis
• Cholecystitis
• Ulcer Disease
• Gastritis
• Food Poisoning
• Atypical MI

ED Evaluation: 

• IV is placed and IV fluid bolus begun
• Significant lab abnormalities:
  • NA 140
  • K 3.1
  • CL 82
  • CO2 40
  • Glucose 129
  • Anion gap 18
  • UA 3+ ketones
• A CT scan of the abdomen and pelvis shows a markedly dilated stomach with normal, decompressed small bowel and colon suggesting gastric outlet obstruction.

• NG tube suction produces 1200cc of dark black fluid

Hospital Course: 

• The patient is admitted
• IV fluids are continued, and consultation is made with Gastroenterology
• He is taken to endoscopy where a peptic ulcer, significant edema and stenosis of the gastric antrum is visualized. Dilation is performed to relieve the obstruction and several biopsies are taken to ensure no malignancy is present.

Diagnosis: Acute Gastric Outlet Obstruction Due To Peptic Ulcer Disease 

Discussion: The differential for gastric outlet obstruction includes:

• Malignancy
• Peptic Ulcer Disease
• Crohn’s Disease
• Pancreatitis
• Caustic Injury due to Ingestion
• Large Gastric Polyps
• Gastric TB
• Bezoars
• PEG Tube Migration
• Gastric Volvulus

Gastric Outlet Obstruction was once a common result of peptic ulcer disease. However, with the discovery of H. Pylori and subsequent treatment protocols, universal use of proton pump inhibitors, and improved access to endoscopy, gastric outlet obstruction is now a rare complication of this disease. Instead, gastric malignancy has become the predominant cause though the overall incidence of this disease has also fallen with the above noted improvements in treatment. Today, peptic ulcer disease causes only 5% of gastric outlet obstructions. Generally, most cases (over 80%) present with vomiting. There may be a history of early satiety preceding the obstruction by up to 3 months. This presentation is also accompanied by multiple electrolyte abnormalities. Persistent vomiting causes loss of gastric acid resulting in a metabolic alkalosis. Additionally, compensatory renal absorption of hydrogen causes loss of potassium.

Therefore, in severe cases persisting for several days, a hypokalemic hypochloremic metabolic alkalosis can be seen. We are taught to expect this metabolic derangement in children with pyloric stenosis, but the mechanism of action is similar to an adult with gastric outlet obstruction. Treatment consists of replacing electrolyte and fluid losses, decompression of the stomach by placement of a nasogastric tube, and endoscopy to identify the cause of the stenosis. Strictures can be dilated, and malignancies can be biopsied during the procedure. If a malignancy is found to be the cause, surgical excision is ultimately the treatment.

However, if stricture due to peptic ulcer disease is the cause, it can be dilated and treated successfully with PPI (proton pump inhibitor) therapy. In this case, the patient also presented with dark black gastric fluid. This represents blood mixing with gastric acid. The cause of the bleeding was the patient’s peptic ulcer. Treatment included discontinuation of his NSAIDs and initiation of proton pump inhibitor therapy. He did very well and was discharged home in good condition.

Further Reading

Emergency Department Evaluation And Management Of Patients With Upper Gastrointestinal BleedingDate Release: Apr 2015This issue of Emergency Medicine Practice will focus on the management of patients with upper gastrointestinal bleeding.

Emergency Department Management Of Upper Gastrointestinal Bleeding In Pediatric PatientsDate Release: Dec 2014This issue of Pediatric Emergency Medicine Practice discusses common differential diagnoses of upper gastrointestinal bleeding and the initial clinical evaluation and management of children with a suspected upper gastrointestinal bleed.

The Young Child With Lower Gastrointestinal Bleeding Or IntussusceptionDate Release: Jan 2012This issue of Pediatric Emergency Medicine Practice will review the common differential diagnoses of LGI bleeding in children younger than 5 years of age, relying on the best available evidence from the literature.

Imaging In The Adult Patient With Nontraumatic Abdominal Pain Date Release: Feb 2007 Anyone who works in an emergency department (ED) knows that abdominal pain (or some variation of it) is one of the most frequent presenting complaints evaluated. Although it is difficult to truly quantify, it is estimated that abdominal pain accounts for 5 – 10% of all ED visits and that emergency physicians care for nearly eight million patients with abdominal pain each year.1-3 The sheer volume of potential diagnoses coupled with the lack of evidenced-based standards create a dilemma when determining a diagnostic study choice. The question of which radiological modality and when to utilize it is further complicated by the rapid advances in radiolographic technology. The goal of this Emergency Medicine Practice article is to provide a functional framework for the diagnostic evaluation of the patient with nontraumatic abdominal pain.

References

• Gastric outlet obstruction: A red flag, potentially manageableAndree H. Koop, William C. Palmer, Fernando F. StancampianoCleveland Clinic Journal of Medicine May 2019, 86 (5) 345-353; DOI: 10.3949/ccjm.86a.18035 Online
• Kumar A, Annamaraju P. Gastric Outlet Obstruction. [Updated 2021 Sep 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. PubMed

Last Updated on January 24, 2023