37: Intractable Nausea

A 23-year-old female with type I diabetes presents with 6 days of severe nausea.   There has been no pain, diarrhea, fever or other symptoms.  She has no other prior medical or surgical history and was taking only insulin until her doctor started her on  compazine and then phenergan, neither of which are helping.

Her exam is normal except for mild tachycardia and the fact that she is holding an empty emesis bag and occasionally having dry heaves.  Her abdominal exam is benign.

Labs including a CBC, Chem-12, UA & pregnancy test are all normal except for a potassium of 3.2, which was treated.

A plain film of the abdomen is shown below.  What finding is noted?  What is the most likely cause?

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Answer: BEZOAR from Diabetic Gastroparesis

Note the hyperdense mass in the left upper quadrant just below the bra wire.  An IUD is incidentally seen.  The bowel gas pattern is non-obstructive

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EXCERPT ON GASTROPARESIS

from

QUICK ESSENTIALS EMERGENCY MEDICINE

Path:      Delayed gastric emptying due to damage to autonomic nerves
Sx:          N/V, bloating, early satiety > abdo pain.  Vomiting often 1-2 hours after meal
Causes:   DM, Electrolytes, narcotics, gastric outlet obstruction, hypothyroid
Dx:          Gastric emptying study, (CT to rule out obstructing mass), endoscopy
Comps:    Malnutrition, bezoar
Rx:           Low fat diet, small meals.  Antiemetics, promotility (Reglan, erythromycin).  Surgery

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