HERE'S A real CASE STUDY FOR YOU FUTURE DOCTORS....

[Rujul]

My aunt has a serious digestion problem...and, i've made a hypothesis based on my class material(the connection between thyroid hormones and the autonomic nervous system)...No doctor can figure out what's wrong with her...so here's a real case study for all of us future doctors to look at...
Everytime my aunt eats somthing (solid, semisolid, even liqiud), she cannot keep it down...she involuntarily vomits it out...about 30 seconds after eating something light, she starts belching, and goes through a 'gag reflex' and runs to the bathroom....
She is very skinny (no more than 80 pounds)...very short....yet she has a lot of energy...she's always running around....you must be thinking "hyperthyroidism."
But, she feels very COLD all the time, and her blood pressure is waay low...her body temp is also very low...these rule out hyperthyroidism since the high BMR and calorigenic effect would not keep her body temp cold...
So, i was thinking...here's my hypothesis...please tell me what you think, and give me some of your own predictions...
She may have hypothyroidism, explaining her low body temperature. And, her low body weight is probably due to the fact that she can't eat properly.(she drinks ensure-plus and drinks crackers and tea in the afternoon). As for her high level of energy, I think it may be psychological.(she doesn't let herself get tired).
Now, if hyperthyroidism upregulates adrenergic receptors and stimulates the sympathetic pathway, could hypothyroidism increase the parasympathetic pathway(by lack of sympathetic upregulation??) THIS WOULD CERTAINLY EXPLAIN HER LOW BLOOD PRESSURE..(vasodilation)..AND, If so, then the parasympathetic post-ganglionic neurons that innervate the stomach may be making her vomit involuntarily by too much/too little peristalsis, or by up/down regulating the lower esophageal sphincter...
What do you think?
I would really appreciate your input.
She has gotten her TSH, T3, T4 levels tested a while ago..they came out normal, but a medical mistake is always plausible...
Please tell me if you have other theories as well.
Thank you...

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[IQ]

In the presence of skin discoloration, I would propose primary adrenocortical insufficiency (Addison's Disease). The symptoms are strikingly similar.

 

[reed0104]

She has an eating disorder. Bulemia/anorexia.

People who vomit all the time can do it volitionally.


Just my 1st impression


Hope she gets better!

 

[EJS]

you didn't give her height, but from her weight I would say her blood pressure is so low and she is cold because she doesn't weigh enough or have enough body fat to keep her warm. Vomiting after every meal can become very psycological as well, if you think you will, you will! You might want to get her checked for Addison's disease, but from what I have learned I don't know of any symptoms of vomiting. good luck!

 

[UHS2002]

Agree with reed0104.
First you say she vomits everything she eats "solid, semisolid, even liquid", but then she can keep the same stuff down: ensure, crackers and tea. Sounds like an eating disorder to me.
As for her low body temp, what did you expect with no body fat??? Have you ever taken the blood pressure of a little old lady? It is usually low. Small, underweight people, without essential htn, tend to have blood pressures on the low side.
If she hasn't had an EGD, she should have one, to rule out any kind of obstruction. If that is normal, I would pretty much concentrate on the psychiatric.
Addison disease is kind of a stretch from the description. It usually causes fatigue. Additionally, you have hyponatremia. A basic metabolic panel would have picked it up, which I am assuming this lady had done since her nutritional status seems a little questionable anyways.

 

[Hippocrates]

Nausea and vomiting are among the sign and symptoms of Addison's disease. Does she have joint discoloration (Bronze coloration) of the metacarpophalangeal joints, elbows and knees? This might indicate Addison's disease in the presence of the symptoms you described. The other possibility is that she is anorexic/bolemic. I think it is very unlikely that the T3/T4 blood tests were done wrong.

 

[Rujul]

SORRY GUYS...
NO SKIN DISCOLORATIONS...AND OTHER SYMPTOMS DEALING WITH ADDISON'S DON'T MATCH AT ALL...AND DEFINATELY NO EATING DISORDER...GOT ANYTHING ELSE??
COMEON FUTURE COLLEAGUES..HELP ME OUT...

<font face="Verdana, Arial, Helvetica" size="2">Originally posted by Hippocrates:
Nausea and vomiting are among the sign and symptoms of Addison's disease. Does she have joint discoloration (Bronze coloration) of the metacarpophalangeal joints, elbows and knees? This might indicate Addison's disease in the presence of the symptoms you described. The other possibility is that she is anorexic/bolemic. I think it is very unlikely that the T3/T4 blood tests were done wrong. •

 

[UHS03]

Why do you say definatly no eating disorder?

How old is she? How long has she had this problem? Is she taking any meds?

[This message has been edited by UHS03 (edited 03-12-2001).]

 

[Scooby]

Hypothyroidism may lead to constipation suggesting a possible cause of dysmotility, but I believe that?s more targeted to the small and large intestine (yet, low thyroid level?s affects on the upper GI may be possible). You describe her vomiting 30 seconds after eating which sounds like the problem may be in the upper GI (i.e. the esophagus or stomach). There?s and endless possibility of causes for the signs and symptoms you describe your aunt to be experiencing. The differential may include achalasia due to aperistalsis and increased lower esophageal sphincter tone leading to dysphagia and vomiting (any signs of chest pain or nocturnal regurgitation). Another, diffuse esophageal spasm due to large amplitude peristalsis also leads to dysphagia (often associated with eating, yet this may also be spontaneous). Others may include neuromuscular disorders (i.e. stroke, Parkinson?s, AML, myasthenia gravis, polymyositis, duchenne?s). Scleroderma causes decreased peristalsis and lower LES tone. Carcinoma and hiatal hernias should also be ruled out. In addition, herpertensive LES or hypertensive squeeze (nutcracker) are other possible etiologies. Is your aunt diabetic this may lead to gastroparesis due to vagal neuropathy. GI dyscooridination could also be present.

Has she received the endoscopic/diagnostic series? I think it would be premature to come to any concrete conclusion without all the facts. Is there any else about your aunt that appears a bit peculiar of outstanding.

 

[Billie]

Ditto Scooby,

What you mentioned were all things I first considered as I read original post.

Has any of these things been checked out?

Billie

 

[Steev2000]

I have no knowledge since I have not started medical school yet, but she may have a block. There was another lady that I saw while shadowing with similar problems and she had something stuck just above her stomach. But it took doctors forever to figure it out because they automatically think of all of these complicated conditions and often overlook the simple ones. So she went months without any improvement until she came to the doc I was shadowing as a last resort. Easy solution, problem solved.

 

[Rujul]

Thanks a lot Steeve2000..
Who was the doctor u were shadowing..a DO??
HOw can I get in touch with him?

<font face="Verdana, Arial, Helvetica" size="2">Originally posted by Steev2000:
I have no knowledge since I have not started medical school yet, but she may have a block. There was another lady that I saw while shadowing with similar problems and she had something stuck just above her stomach. But it took doctors forever to figure it out because they automatically think of all of these complicated conditions and often overlook the simple ones. So she went months without any improvement until she came to the doc I was shadowing as a last resort. Easy solution, problem solved.•

 

[Scooby]

But it took doctors forever to figure it out because they automatically think of all of these complicated conditions and often overlook the simple ones.

What a clich?!

Who was the doctor u were shadowing..a DO??

Great logic! What does this have to do with being an MD or DO?

SORRY GUYS...
NO SKIN DISCOLORATIONS...AND OTHER SYMPTOMS DEALING WITH ADDISON'S DON'T MATCH AT ALL...AND DEFINATELY NO EATING DISORDER...GOT ANYTHING ELSE??
COMEON FUTURE COLLEAGUES..HELP ME OUT...

Rujul I?m sorry you didn?t hear what you wanted.

People often want a simple problem with a simple solution because it makes their life easier, but that sometimes may not be the case. Steev2000 do you know what caused the block or constriction? Was this patient treated with meds, LES ablation, or balloon sphincterotomy? I would be hesitant and somewhat cautious to assume the Rujul?s aunt has the same problem without covering all the bases, because you?re only limiting yourself, the repercussions of which could be dire. A block, which can be detected by barium swallow or endoscopy, can have many causes. I can?t believe you would call that a simple problem! Treating the block, which may have developed from a cancerous lesion, scleroderma, achalasia, hypertensive LES tone, neuropathy, aperistalsis, neuromuscular disorders etc., while not addressing the underlying problem could be devastating.

 

[Steev2000]

I didn't mean that all of the bases should not be covered. It would be incredibly naive and stupid not to look at everything. My point is that no one even suggested to her that this may be the problem beforehand. The reason I said that it was simple, because in her case it was; it was just a large chunk of food that for whatever reason (maybe she didn't chew) was causing the problem. She was referred to someone else to fix the problem and as far as I know everything is fine now.

 

[Dr. B]

I think Scooby had alot of good ideas. The
first thing that came to my mind which I have seen films of in radiology is achalasia. Achalasia has some extra signs/symptoms that you didn't mention but the main symptom (regurgitation) is definitely there and a disease doesn't necessarily always have to manifest all of the signs/symptoms associated with it. Achalasia is easy to see on a barium swallow film. Try this link for more info:

http://my.webmd.com/content/asset/adam_disease_achalasia


Hope this helps,
Dr. B


[This message has been edited by Dr. B (edited 03-13-2001).]

[This message has been edited by Dr. B (edited 03-13-2001).]