Category Archives: Morning Report

Gastroparesis

Today we discussed the case of an elderly woman with history of diabetes and afib who presented with subacute onset nausea/emesis and epigastric abdominal pain, with gastric emptying study showing marked delayed gastric emptying with >90% of food retained at 4 hours.

We discussed a framework for nausea/emesis as well as how to approach and treat gastroparesis.

Nausea/Emesis can be broken into Acute and Chronic etiologies.

Common etiologies for ACUTE nausea/emesis:

Infections- acute gastroenteritis

Postop Nausea/Emesis- 1/3 of surgical pts have nausea/emesis or both after general anesthesia

Vestibular Neuritis- Rapid onset severe vertigo w/ nausea/emesis, gait instability

Chemo- Common; Anticipatory antiemetic indicated when highly emetogenic chemo regimen given

Common etiologies for CHRONIC nausea/emesis:

Gastroparesis – delayed gastric emptying w/o mechanical obstruction – idiopathic, diabetic

GERD

Gastric Outlet obstruction- pyloric stenosis from malignancy or PUD

Chronic idiopathic

Functional nausea/vomiting disorder

Peritoneal Tuberculosis

Earlier this week, we discussed the case of a young woman who immigrated from Mexico as a child, who presented with subacute fever, increased abdominal girth and acute onset abdominal pain, nausea, and PO intolerance found to have ascites with SAAG <1.1 consistent with exudative ascites, and diffuse peritonitis on CT.

We reviewed the differential for exudative ascites as the following:
Peritoneal Carcinomatosis
Peritoneal Tuberculosis
Pancreatitis
(additionally serositis, nephrotic syndrome, bowel perforation/infarction)

We reviewed the diagnostic studies for peritoneal TB and notably learned that elevated ascites fluid adenosine deaminase level is particularly helpful in supporting in a diagnosis of peritoneal TB and against diagnosis of peritoneal carcinomatosis.

We reviewed the utility of different imaging modalities when suspecting gynecologic malignancy, notably Ultrasound being first line imaging modality, MRI having the role of detecting pelvic extent of disease and local staging, and finally CT and PET/CT to evaluate extra-pelvic disease and distant metastases.

post-tPA complications; hemorrhagic conversion and angioedema

Today we discussed the case of an elderly woman with prior history of ischemic stroke, HTN, HLD who presented with dysarthria and hemiplegia found to have an acute ischemic stroke for which she was given tPA with subsequent hemorrhagic conversion and angioedema.

We reviewed inclusion and exclusion criteria for tPA administration and discussed managed of angioedema post tPA.

Images from Up to Date.

Nitrous oxide–induced vitamin B12 deficiency

Today we discussed the case of a young man with recent use of Whippets who presented with acute onset bilateral lower extremity and upper extremity numbness and paresthesias, found to have Vitamin B12 deficiency despite lack of anemia or macrocytosis.

We learned that Nitrous Oxide acts by direct depletion of Vitamin B12 as it irreversibly binds to cobalt ions of vitamin B12 and inactivates it. In turn the pathways that rely on Vitamin B12 in order to synthesize DNA, RNA and myelin are disrupted, leading to demyelination and damage in the dorsal columns.