October 27, 2013

Concerning a Middle-aged Man with Diabetes Mellitus

A 52-year-old man with diabetes mellitus was admitted to hospital after presenting to the emergency department with abdominal discomfort. His symptoms began 5 weeks earlier, when epigastric discomfort developed that did not radiate elsewhere.

The pain was worse after eating and was associated with nausea and bloating that were partially relieved by belching.

Two weeks before presentation, the patient's pain began to localize to the periumbilical region and was accompanied by anorexia, early satiety, and episodes of vomiting. He had lost 4.5kg (10lb).

He reported no fevers, diarrhea, tenesmus or hematochezia.

Which four of the following best fits this patient's presentation?
  1. Biliary colic
  2. Chronic pancreatitis
  3. Diabetic gastroparesis
  4. Epigastric hernia
  5. Functional dyspepsia
  6. Gastric cancer
  7. Pyloric channel ulcer

The correct answers are chronic pancreatitis, diabetic gastroparesis, gastric cancer, and pyloric channel ulcer.

This patient’s pain and weight loss suggest several serious diagnoses.

Chronic pancreatitis typically manifests as epigastric pain that is exacerbated by eating and is often accompanied by nausea and anorexia.

Diabetic gastroparesis, gastric cancer, and pyloric ulcers may also feature nausea, vomiting, bloating, early satiety, and upper abdominal discomfort. Biliary colic produces attacks of pain in the right upper quadrant, sometimes with nausea and vomiting, but this patient’s prominent early satiety and bloating would be atypical.

Dyspepsia is a common constellation of upper gastrointestinal symptoms, including postprandial fullness, early satiety, nausea, belching, and epigastric discomfort. Most dyspepsia in primary care is functional, meaning that upper endoscopy is unrevealing.

An age greater than 55 years of age or so-called alarm symptoms — dysphagia, persistent vomiting, weight loss, or gastrointestinal bleeding — should prompt a strong suspicion of organic dyspepsia and a more aggressive evaluation.

Epigastric hernias are rare. Abdominal pain is usually mild, and incarceration and strangulation rare.

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