Interesting case

[ghost dog]

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I saw an interesting case recently, that I thought I would share.

60 yr old man with hx of DM II. Previously extremely high sugars, and now well controlled on Insulin.

He presents with 3 - 4 month hx of decreased apetite, nausea, vomiting and weight loss. He's now missing work, and the patient is a very hard working self employed businessman.

I wasn't sure what was causing the problem. However, I scripted some Maxeran for the significant nausea.

He returns the next week to tell me that the Maxeran was extremely helpful. He in fact looked a lot better during the exam.

Possible Dx ?

 

[VA Hopeful Dr]

I saw an interesting case recently, that I thought I would share.

60 yr old man with hx of DM II. Previously extremely high sugars, and now well controlled on Insulin.

He presents with 3 - 4 month hx of decreased apetite, nausea, vomiting and weight loss. He's now missing work, and the patient is a very hard working self employed businessman.

I wasn't sure what was causing the problem. However, I scripted some Maxeran for the significant nausea.

He returns the next week to tell me that the Maxeran was extremely helpful. He in fact looked a lot better during the exam.

Possible Dx ?

Damn Canadian trade names, had to google that. Did you get a gastric empyting study?

 

[ghost dog]

Damn Canadian trade names, had to google that. Did you get a gastric empyting study?

No questions - only answers !

It wasn't available to me at this point.

What is your impression at this point ?

 

[deleted87716]

Maxeran is Reglan in the U.S.

Gastroparesis is certainly possible in a diabetic with those symptoms, and would likely improve with Reglan. I wouldn't jump to that conclusion without a thorough evaluation, however, as more serious conditions (including occult malignancy) would need to be ruled out.

Of course, that's the obvious diagnosis, but since this is supposed to be an interesting case, it must be something else. 😉

 

[EdibleEgg]

Well, I'm sure VA was thinking gastroparesis, I would put it high in the differential as well. Not enough information though. With a limited history the DDX is huge.

Meds, nsaids, metformin, dig
infection
Increased intracranial pressure
Cholecystitis
Mesenteric ischemia
Pancreatitis
on and on....
all could be better with metoclopromide

 

[ghost dog]

Maxeran is Reglan in the U.S.

Gastroparesis is certainly possible in a diabetic with those symptoms, and would likely improve with Reglan. I wouldn't jump to that conclusion without a thorough evaluation, however, as more serious conditions (including occult malignancy) would need to be ruled out.

Of course, that's the obvious diagnosis, but since this is supposed to be an interesting case, it must be something else. 😉

It turned out to be Gastroparesis.

The patient did not present as straightforwardly as I described above. In fact, I believe he initially he attended the ER at first due to the severity of his symptoms.

I ordered an upper GI series, which was not helpful. His endoscopy was normal. He received a CT scan of the abdo / pelvis, which was also normal.

 

[deleted87716]

I ordered an upper GI series, which was not helpful.

A gastric emptying study may have been useful for confirmation. The other studies are worth doing to rule out other stuff.

 

[ghost dog]

A gastric emptying study may have been useful for confirmation. The other studies are worth doing to rule out other stuff.

Yup, this is the gold standard test. I referred this pt to a GI specialist, and thus the workup was performed by him. He didn't perform this test.

 

[VA Hopeful Dr]

]Well, I'm sure VA was thinking gastroparesis, [/B]I would put it high in the differential as well. Not enough information though. With a limited history the DDX is huge.

Meds, nsaids, metformin, dig
infection
Increased intracranial pressure
Cholecystitis
Mesenteric ischemia
Pancreatitis
on and on....
all could be better with metoclopromide

Yep, just didn't want to give it away with the first post too easily

 

[Shinken]

People must be healthier in Canada than the US.

A 60 y.o. previously poorly-controlled type 2 diabetic with gastroparesis is an interesting case in Canada.

In my practice in the US, it's something I see weekly. Must be in other people's practices too, since first reply on this thread already nailed the diagnosis.

 

[deleted87716]

People must be healthier in Canada than the US.

I should hope so. They have free healthcare, after all. 😉

 

[ghost dog]

People must be healthier in Canada than the US.

A 60 y.o. previously poorly-controlled type 2 diabetic with gastroparesis is an interesting case in Canada.

In my practice in the US, it's something I see weekly. Must be in other people's practices too, since first reply on this thread already nailed the diagnosis.

I described it " too clasically " I suppose; he didn't present this way.

You guys are a tough crowd !

I'm used to spoon feeding my med students and residents I guess. 🙂