April 2005         

GASTRIC EMPTYING STUDY

History of Present Illness: 40-year-old white female with nausea and vomiting. She had some nausea and vomiting for three years but over the past several weeks has gotten progressively worse. She has been unable to tolerate anything p.o. for the last two days. She has had difficulty eating with nausea associated with vomiting that is clear liquid plus diarrhea yellow in color. No hematemesis, melena or bright red blood per rectum. No fevers but positive chills, positive abdominal pain which is cramping type pain located in midepigastric lower abdomen. She has not urinated in several days. She is to be evaluated for gastroparesis.

 

Past Medical History: Irritable bowel syndrome Migraine headaches Celiac sprue diagnosed 2.5 months ago Restless leg syndrome Fibromyalgia Myofascial pain Palpitations

Medications Prior to Admission: Provigil 1200 mg QHS Inderal LA 60 mg QHS Neurontin 600 mg b.i.d. Flexeril 120 mg QHS Klonopin 1mg at noon and 1.5 mg QHS Tramadol 50 mg two t.i.d. Aciphex 40 mg q. a.m. Lexapro 40 mg q. a.m. Sonata 20 mg at bedtime

FAMILY HISTORY: Mom with irritable bowel syndrome and migraine headaches.

SOCIAL HISTORY: Lives with husband and two kids. No tobacco or ethanol. Positive marijuana for nausea but not helping.

HOSPITAL COURSE: Patient admitted to floor. She was initially kept NPO and stool studies were ordered including fecal fat, WBC, leukocytes, Clostridium difficile, ova and parasites and occult blood. She was started on IV fluids.

LABS: A CT of abdomen and pelvis with contrast was obtained which showed anterior visceral collapse of the mid to distal sigmoid colon without any acute inflammatory changes. Also showed slightly prominent appendix with contrast within. There were changes of chronic inflammation along the cecum and appendix, however no signs of acute appendicitis. GI consult was also obtained who did an EGD on
03/24/05 which was normal and biopsies were taken from the duodenum. They recommended performing a gastric emptying scan and if abnormal treating that with metoclopramide.

GASTRIC EMPTYING STUDY: A standard low fat meal labeled with 0.96 mCi of Tc 99 sulfur colloid was administered. Anterior and posterior images and counts were obtained immediately and at 1, 2 and 4 hours. A geometric means was calculated at counts were corrected for decay.

FINDINGS: At 1-hour, 68% of the original contents were still present in the stomach. At 2-hours, 57% of the original counts were still present in the stomach, and at 4-hours, greater than 50% of the contents were still left in the stomach. Greater than 10% at 4-hours is considered significant for gastroparesis.

INTREPRETATION OF TEST: Gastric emptying study demonstrating greater the 50% remaining in the stomach at 4 hours. This finding is consistent with gastroparesis.

DIAGNOSIS: Gastroparesis.

DISCHARGE MEDICATIONS:
Aciphex 40 mg QHS
clonazepam 1.5 mg one QHS
gabapentin 600 mg b.i.d.
metoclopramide 5 mg QID AC.
Percocet tablet p.r.n.

DISCHARGE FOLLOWUP:
The patient is to follow up at UAMS GI Clinic in 6-8 wks. The patient was instructed to call the doctor in case she has excessive nausea, vomiting. She was instructed to eat frequent small meals and to avoid high fat food. She was also instructed to call the doctor in case she has excessive pain, fever or chills. She was given diet, exercise and medication counseling.

© 2005 Nuclear Education Online

Case study submitted by Stephanie Thomas, 2005 PharmD candidate.  Images courtesy the UAMS Dept of Nuclear Medicine.  You are welcome to submit cases to be included in future newsletters.