Vague symptoms brought this patient to the ED three times before physicians made a rare diagnosis.
Mrs. C, 91 years old, lives with her 96-year-old husband in a nursing home. She enjoys reading and spending time with friends and family, especially her husband. I monitor her regularly for a number of medical problems, including hypertension, depression, osteoporosis, and hypothyroidism. Fortunately, all are well-controlled on medication.
RECURRENT GI SYMPTOMS
During the past six months, Mrs. C had visited the emergency department (ED) twice and was admitted both times for overnight evaluation of abrupt-onset severe epigastric pain and retching. The differential diagnosis for these symptoms is extensive. Common causes include cholelithiasis, peptic ulcer disease, MI, and pancreatitis. The diagnostic workup involved Helicobacter pylori testing, serum amylase and lipase determinations, complete blood count, liver enzymes, ECG, and cardiac enzymes, all of which were unremarkable.
Upper endoscopy demonstrated a large diaphragmatic hernia and mild gastritis. A CT of the abdomen and pelvis (obtained after Mrs. C's symptoms had improved) was normal, and ultrasound of the abdomen did not reveal any gallstones. The gastroenterologist attributed her recurrent epigastric pain and retching to the hiatal hernia and gastritis noted on endoscopy.
Mrs. C was started on a proton-pump inhibitor and given IV fluids. Each time, following a brief hospital stay, she was discharged with a presumptive diagnosis of epigastric pain and gastritis.
The true diagnosis of Mrs. C's condition was confirmed when she returned to the ED for a third episode of epigastric pain.
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