Intern Case Discussion 2.4

intern-report

 

 

Presented by Debia Kim, MD

Case

CC: Abdominal pain, nausea, and diarrhea
HPI: 9 y/o boy who was recently diagnosed with DM1 (2 months ago) presents to the ED with 7 days of waxing and waning vomiting and diarrhea associated with persistent nausea.  Today his abdominal pain is more severe.  Mom says he vomited 5 times yesterday and 4 times this morning before coming to the ED.  The vomitus was clear and not associated with coughing or eating.  He also has brown diarrhea.  He had 3 episodes yesterday and 4 this morning.     A crampy and stabbing generalized abdominal pain varies from a 5 to a 10 out of 10 in severity and is persistently present.  His appetite and activity are decreased.  He denies fever/chills, headache, dysuria, frequency, hematuria, cough and rash.  One week prior to his current presentation the patient was evaluated in Endocrine clinic, where he was told his blood work was “normal.”  Four days prior to his current presentation, he was evaluated at another ED and was dischared home with a prescription for ondansetron and recommended to follow at Children’s Hospital if his pain persisted and concern for possible appendicitis.

PMH: DM diagnosed 2 months ago when he presented in DKA.
PSH: None
Medications: Lantus 8 units subq qhs, zofran prn
Allergies: NKDA
Immunizations UTD
FH: htn
SH: lives with mom, dad, siblings, no smokers in the home.  He is in 3rd grade, doing well at school.

Exam:
VS – BP 125/70, HR 80, RR 30, T 36.6 (temporal), 98% on RA
Constitutional – alert, cooperative male in NAD, well-hydrated
HEENT – NCAT, PERRL bilaterally, EOMI, sclera noninjected, oral mucosa moist without lesions,     no posterior pharyngeal erythema, TMs are clear bilaterally.
Neck – supple, no meningismus, no lymphadenopathy
CV – RRR, +S1, +S2 without murmurs/rubs/gallops.  Cap refill < 2 sec.
Resp – CTAB, no rales, wheezes, rhonchi
Abd – soft, flat, ND, +BS everywhere.  +mild tenderness to palpation in RUQ.  No rebound, no     guarding.  Negative Murphy’s, negative Rovsing, no tenderness at McBurney’s point.  No     palpable masses, no flank/CVA tenderness.
Rectal – No stool present in the rectal vault, hemeoccult negative.
Genitalia – normal external male genitalia with descended testicles bilaterally
Extremities – warm, dry, 2+ pulses x all 4 ext.  FROM, no tenderness, swelling, no rashes.

Lab Results:
cbg 7.33/35/74.3/18/97%, lactate 1.8
10.1>13.7/38.5<340
139/4/108/21/9/0.6<125
serum acetone neg
serum Osm 295
Ca 10.2
Mag 1.8
Phos 4.5
ALT/AST 33/27
stool cx neg
rotavirus neg
U/A: LE neg, nitrite neg, glucose neg, ketones neg, bili neg, protein neg, RBC

Diagnostic Studies
Abd Xray: Nonspecific bowel gas pattern, with a few air-fluid levels seen in nondilated loops of small bowel on the right.
Abd US: Multiple prominent mesenteric lymph nodes with no sonographic evidence of appendicitis.

Questions

A. What is the most likely diagnosis?

  1. Early appendicitis
  2. Gastroenteritis
  3. Diabetic Ketoacidosis
  4. Cyclical Vomiting Syndrome
  5. Inflammatory Bowel Disease

B.  True or false: this patient may benefit from an anti-motility agent and early attempts at solid food intake
True
False

C.  Which of the following anti-emetic drugs works both centrally in the vomiting center and peripherally in the afferent visceral nervous fibers?

  1. Prochlorperazine
  2. Diphenhydramine
  3. Ondansetron
  4. Meclizine
  5. Marinol

Answers

Gastroenteritis
True
Ondansetron

Discussion

Patients who present to the ED with vomiting, diarrhea, and nausea generate a huge differential diagnosis.  Gastrointestinal dysfunction is often the final common pathway for many disease processes.  A complete and thorough history is usually the best tool for narrowing the diagnosis.  Evaluating female patients with these symptoms warrants the clinician to also think about obstetrical and gynecologic etiologies.  After the initial ABCs are addressed in an acutely ill patient, treatment must be focused on the underlying disease causing the symptoms.  In patients who have unclear diagnoses, a safe discharge must involve confidence in a non life-threatening cause of diarrhea/nausea/vomiting and a PO challenge with reliable follow-up in case symptoms return.

Our patient, given his age group and past medical history, necessitates the inclusion of DKA and appendicitis in his differential diagnoses.  However, his history and physical exam suggest abdominal pain secondary to the vomiting and diarrhea (rather than vomiting and diarrhea secondary to pain and appendicitis) and his laboratory studies do not demonstrate ketosis (normal anion gap and urinalysis).  The lack of blood in the stool as well as certain other extra-intestinal manifestations of IBD are absent as well.  Although past medical literature suggests that giving an anti-motility agent in a patient with serious infectious diarrhea (Shigella) increased mortality, current studies on traveler’s diarrhea demonstrate that loperamide and antibiotics often shorten duration of symptoms.  Similarly, early solid food intake also has been shown to expedite the recovery from diarrheal illness as long as the patient is not continually nauseated and is properly counseled on the avoidance of lactose, sorbitol, and caffeine-containing foods/liquids.  The viscera is richly ennervated with vagal afferent nerves, which respond to 5-HT3 (serotonin) agonists.  Ondansetron is the only 5-HT3 receptor agonist listed in the answer choices that works both centrally in the vomiting center and peripherally in the afferent visceral nervous fibers

Clinical Pearls

  • Be sure to ask the patient what they specifically mean by the terms “diarrhea” and “vomiting” — for many patients, “diarrhea” is when they have soft stools or maybe more than one stool per day and “vomiting” may simply mean “coughing up sputum.”
  • Most true diarrheal emergencies in the US ( eg GI bleeds, thyroid storm, mesenteric ischemia, toxicologic exposures, etc, are noninfectious.
  • Don’t let your diarrhea patients rehydrate with juice or milk.

This case discussion presented by Dr Debia Kim

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: