Cases That Test Your Skills

The patient who couldn’t stop vomiting

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Persistent vomiting severely compromised Ms. M’s quality of life. Through her four hospitalizations and the loss of 50 lbs across 5 months, clinicians from various disciplines could not pinpoint the cause of her emesis. How would you help this woman?



Case history: A sudden GI problem

Ms. M, 32, was transferred to our university medical center’s psychiatric ward for assessment and treatment of persistent vomiting. She had been in good health until 5 months previously, when she was hospitalized with dehydration after a weeklong bout with acute nausea and vomiting. An ultrasonogram of the abdomen and pelvis and oral cholecystography were normal.

Ms. M’s diagnosis at that time was gastroenteritis. She received IV rehydration and was released after 5 days, with results of thyroid stimulating hormone (TSH) tests pending. TSH results received 1 week post-hospitalization were 50 mU/ml. (A normal reading is

Symptoms re-emerged 3 weeks later, and the patient was hospitalized again for persistent fatigue, nausea, vomiting, and dehydration. Additional lab test results were normal. The patient was discharged tolerating a regular diet following 2 days of IV rehydration and an increase in antiemetic chemotherapy.

The patient’s emesis continued despite treatment, and she was losing weight. A general surgeon examined Ms. M 3 months after she became ill. He recommended no further work-up, citing the absence of abdominal pain or stool changes and an unclear etiology.

Three weeks later, Ms. M was referred to a dermatologist for evaluation of pigmentation changes of her lips and gums. Hyperpigmentation of the oral mucosa had developed over several weeks. A dermatologic evaluation indicated hypervitaminosis, although vitamin supplementation was denied.

Severe continuous vomiting resulting in dehydration precipitated the third hospitalization in 4 months. Ms. M continued to lose weight, dropping 25 lbs since illness onset. Diagnostic studies, including a head CT, urine drug screen, electrolyte assessment, and thyroid function tests were normal. Again no specific etiology was identified, and a psychologist was consulted. Results of the Minnesota Multiphasic Personality Inventory test demonstrated a strong tendency toward somatization. Significant depression also was noted, and Ms. M was diagnosed with dysthymia.

Ms. M’s clinical status improved slightly after 3 more days of IV rehydration. She was discharged tolerating a regular diet, and the treatment plan included psychological counseling. Three days later, the patient was admitted to a hospital psychiatric ward with continuous vomiting. She was noted to be confused, lethargic, and hysterical.

At this point, would you suspect anorexia nervosa or bulimia? If not, how else would you explain Ms. M’s persistent vomiting?

Dr. Wiseman’s and Dr. Dunlop’s observations

Psychogenic vomiting is a form of chronic emesis where the etiology is unrelated to a primary anatomic or physiologic defect. It differs from anorexia nervosa or bulimorexia because it lacks the characteristic features of body image distortion, abnormal fear of weight gain, or self-induced vomiting.1 Symptoms include absence of nausea, insignificant weight loss, occurrence usually after meals, and limited control over emesis.2

Out of 24 patients with psychogenic vomiting examined by Rosenthal, 18 received psychological evaluation and testing.3 The illness was found to be chronic but not debilitating in these patients. Most were without major psychiatric diagnoses or personality disorders, although stressful life events were temporally related with acute exacerbations of vomiting.

Muraoka, in a study of 59 patients admitted with psychogenic vomiting, concluded that most subjects had previous structural or functional GI problems and a history of emesis.4

Ms. M did not exhibit body image distortion, nor was she causing herself to vomit or attempting to lose weight. Instead, there appeared to be no medical reason for her symptoms. It was therefore assumed she had psychogenic vomiting.

Patient history: A ‘death-bed’ promise

According to the social history obtained by the hospital’s psychiatric team. Ms. M is a married mother of three who works part-time. She denied using alcohol or other substances and had recently stopped smoking with the aid of hypnosis. She did not follow a special diet, took no medications, and was quite active when healthy. Her father had been treated for hyperthyroidism; otherwise her medical, psychiatric, and family history were noncontributory.

The patient described her relationship with her husband and her children as good, without significant interpersonal conflicts. The psychiatric team, however, viewed her husband as domineering and her as dependent upon him to make decisions.

The patient reported the death of a friend from complications of anorexia nervosa 6 months before the onset of her current symptoms. Ms. M had made a “death-bed promise” to care for her friend’s elderly mother. A contract was written, and Ms. M was remunerated for providing companionship and housekeeping. Before her symptoms developed, the patient’s time commitment to this task increased to the point that she felt “she was neglecting her own family.” Upon becoming ill, however, she willingly terminated this agreement.

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