Diagnostic challenge in an adolescent patient with chronic nausea and vomiting

Abstract

Vomiting is a common reason for pediatric consultations and represents the final manifestation of various extra-intestinal and gastrointestinal disorders. We present the case of a 14-year-old male with a history of recurrent abdominal pain and nausea since age 12; he had been diagnosed with gastritis and colitis and treated on an outpatient basis with gastric protectants, antiemetics, and prokinetics, but showed no improvement. Relevant family history included a father with achalasia. He presented to the emergency department with stabbing mesogastric pain, nausea, vomiting, and hyporexia; physical examination revealed cachexia, with a weight loss of 31.7 kg over two years (from 56 kg to 24.3 kg). Laboratory tests revealed anemia (hemoglobin: 10 g/dL; hematocrit: 29.4%) and mild hypokalemia. Findings included a white blood cell count of 4,000, hemoglobin of 10 g/dL, hematocrit of 29.4%, preserved liver function, mild hypokalemia, a normal coagulogram, and negative results for acute-phase reactants and infectious disease markers. Upper gastrointestinal endoscopy showed a Forrest IIc antral ulcer; biopsy revealed eosinophilic gastritis and duodenitis. Colonoscopy showed mild mucosal erythema in the descending colon. An esophagogastroduodenal series revealed inter-loop edema and changes consistent with gastro-ileitis. Abdominal CT angiography showed an aortomesenteric angle of 8°, compatible with mesenteric compression. As these studies revealed no lesions that could account for the clinical presentation, psychological factors were suspected; the patient was evaluated by psychiatry, and although there was insufficient data to establish a definitive diagnosis, low-dose antipsychotic treatment was initiated. As symptoms persisted, an ultrasound scan of the pylorus was performed, revealing a pyloric canal length of 34 mm and a mucosal thickness of 3 mm; a diagnosis of pyloric hypertrophy was made. Manometry showed pyloric hypertonia, and a pyloroplasty was performed. A subsequent esophagogastroduodenal series showed no abnormalities. Symptoms persisted, however; the patient remains under evaluation and is currently managed with a nasojejunal tube. This case report aims to describe the diagnostic management and clinical course of an adolescent with chronic gastrointestinal symptoms of undetermined etiology.