A 20-year-old woman presents to the emergency department with postprandial epigastric and right-upper-quadrant pain, sometimes associated with nausea. She has been having six to eight loose bowel movements every day, with no blood or mucus, and she has lost about 20 lb despite a good appetite. The diarrhea did not improve when she tried omitting milk products and carbohydrates.
Her symptoms began several months ago, but she says that 3 days ago the pain worsened steadily, radiating to the middle of her back, with associated episodes of nonbloody, nonbilious emesis. She cannot keep down liquids or solids. She says she has never had such episodes in the past.
She reports no oral ulcers, urinary symptoms, skin rashes, musculoskeletal pain, or neurologic symptoms, and she denies being anxious or depressed.
She has no history of serious illness, surgery, or hospitalization. She smokes a half pack of cigarettes a day, drinks alcohol occasionally, and smokes marijuana occasionally. She is employed as a certified nursing assistant.
She is taking ethinyl estradiol-levonorgestrel pills for birth control and takes calcium carbonate as needed for abdominal discomfort. She is taking no other medications, including nonsteroidal anti-inflammatory drugs (NSAIDs).
Her maternal uncle died of colon cancer at age 32, and her mother had colon polyps on colonoscopy. There is no family history of inflammatory bowel disease or celiac sprue. Her father committed suicide.
Her laboratory values
- White blood cell count 10.2 × 109/L (normal range 4–11)
- Red blood cell count 4.71 × 1012/L (3.9–5.5)
- Hemoglobin 14.4 g/dL (12–16)
- Hematocrit 42.4% (37%–47%)
- Mean corpuscular volume 90 fL (83–99)
- Mean corpuscular hemoglobin 30.6 pg (27–33)
- Platelet count 230 × 109/L (150–400)
- Red cell distribution width 13.3% (11.5%–14.5%)
- Sodium 140 mmol/L (132–148)
- Potassium 3.3 mmol/L (3.5–5.0)
- Chloride 104 mmol/L (98–111)
- Bicarbonate 28 mmol/L (23–32)
- Blood urea nitrogen 9 mg/dL (8–25)
- Creatinine 0.8 mg/dL (0.7–1.4)
- Glucose 87 mg/dL (65–100)
- Alanine aminotransferase 26 U/L (0–45)
- Aspartate aminotransferase 21 U/L (7–40)
- Alkaline phosphatase 101 U/L (40–150)
- Total bilirubin 0.8 mg/dL (0–1.5)
- Albumin 3.5 g/dL (3.5–5)
- Pregnancy screen negative
- Urine toxicology screen negative.
The patient is very thin and appears quite uncomfortable. Her temperature is 99.7°F (37.6°C), pulse rate 101, respiratory rate 18, blood pressure 111/67 mm Hg, and oxygen saturation 96% on room air. Her skin is warm and dry. Her height is 66 inches, weight 116 lb, and body mass index 18.7.
Examination of the head and neck shows normal dentition, dry mucus membranes, and no oral exudates. The thyroid is normal, and no masses or lymphadenopathy are noted.
Heart sounds and rhythm are normal, and the lungs are clear with no crackles or rubs. The abdomen is scaphoid and soft, with no distention. She has epigastric tenderness but no rebound, guarding, rigidity, palpable mass, or costovertebral angle tenderness. Bowel sounds are normal. The neurologic examination is normal.
NARROWING THE DIAGNOSIS
1. Given the history and findings so far, which is the least likely cause of her symptoms?
- Lactose intolerance
- Celiac disease
- Crohn disease
- Duodenal ulcer
- Eating disorder
This young woman’s presentation has some features found in all of these conditions. However, the least likely is lactose intolerance.
Lactose intolerance results from a shortage of the enzyme lactase, which is normally produced by the cells that line the small intestine. Close to 50 million American adults have lactose intolerance. Common symptoms include nausea, cramps, bloating, gas, and diarrhea, which begin about 30 minutes to 2 hours after eating or drinking foods containing lactose.
Since the patient’s symptoms did not improve when she tried omitting milk products, and since lactose intolerance is rarely associated with pain radiating to the back and with severe vomiting, this is the least likely cause of her symptoms.
Celiac disease presents with a myriad of symptoms—sometimes without gastrointestinal (GI) symptoms. Anemia is the most common laboratory finding, due most often to iron deficiency, but also due to deficiencies of vitamin B12 and folate as a result of malabsorption.1
Our patient’s laboratory values—especially her red cell indices—do not confirm this finding. One must also remember, however, that hemoglobin tends to be falsely elevated in patients who are dehydrated.
Crohn disease often presents with occult blood loss, low-grade fever, weight loss, and anemia. Though the condition is most often ileocolic, it can affect any part of the gastrointestinal tract. Nevertheless, most patients with gastroduodenal involvement have previously been diagnosed with ileocolic disease, and gastroduodenal involvement manifests later. Nonradiating epigastric pain is very common. Obstructive symptoms due to gastroduodenal strictures (eg, postprandial vomiting, epigastric pain, weight loss, bloating) are also common. 2
Duodenal ulcer. The most important factors responsible for duodenal ulcers are NSAID use and Helicobacter pylori infection.3 Duodenal ulcers have a variety of clinical presentations, ranging from no symptoms to severe pain. Epigastric pain can be sharp, dull, burning, or penetrating. Many patients complain of a feeling of hunger and weight gain—as opposed to gastric ulcer, in which patients experience anorexia and weight loss. Abdominal pain generally occurs several hours after meals and often awakens the patient at night. Pain is often relieved by food, but this phenomenon is present in only 20% to 60% of patients and probably is not specific for duodenal ulcer.
Our patient does not use NSAIDs, but some of her symptoms, such as postprandial pain, epigastric pain radiating to the back, and nausea and vomiting are seen with duodenal ulcer.
Eating disorders. The two main types of eating disorders—anorexia nervosa and bulimia nervosa—have a significant diagnostic overlap,4 and a third type, binge-eating disorder, is currently being investigated and defined. Girls and women are 10 times as likely as boys and men to develop an eating disorder.
People with anorexia have a distorted view of their bodies. Even when they are extremely thin, they see themselves as too fat.
Bulimia is characterized by binge-eating, purging, and overexercising to compensate for the excess calories. Patients are often close to normal weight.
Binge-eating disorder involves the consumption of very large amounts of food in a short period of time. About 2% of all young adults in the United States struggle with bingeeating. They are either overweight or obese.
These disorders tend to be associated with other psychiatric disorders such as depression or obsessive-compulsive disorder. Our patient sought medical attention and was appropriately concerned about her weight loss, which make an eating disorder unlikely.