3233 Massive Gastric Distention… Aaand It's Gone!

Abstract

INTRODUCTION: Gastric outlet obstruction is usually a sequelae of malignancy or PUD. When these causes are ruled out, other etiologies like gastroparesis should be considered. CASE DESCRIPTION/METHODS: A 72 year old female nursing home resident with a history of schizophrenia, depression, dementia (on Mirtazapine, Trazodone, and Donepezil), hypothyroidism, and longstanding type 2 diabetes with a Hemoglobin A1c of 6.1% was admitted with abdominal pain, emesis, and increased agitation. CT of the abdomen and pelvis revealed marked fluid filled distention of the stomach and proximal duodenum with no clear gastric outlet obstruction (Figure 1). Nasogastric tube placement was not tolerated by the patient. She was then made NPO and gradually advanced to a clear liquid diet. EGD performed six days later revealed a normal duodenum with mild stomach distention and no evidence of gastric outlet obstruction (Figures 2 and 3). Her symptoms then resolved and she was discharged. DISCUSSION: Our patient presented with non-obstructive, massive gastric distention, which improved rapidly with dietary restriction. Gastroparesis was thought to be the primary diagnosis due to her risk factors of diabetes and psychotropic medication use. The cause of gastroparesis is most commonly idiopathic, but it is also linked to diabetes, certain medications, postsurgical injuries, hypothyroidism, and post viral syndromes. In diabetes oxidative stress and long-standing disease leading to autonomic dysfunction are postulated mechanisms for gastroparesis. A recent review demonstrated the following prevalence of gastroparesis over a 10 year time period: 5.2% in Type 1 Diabetes, 1.0% in Type 2 Diabetes, and 0.2% in controls. Additionally, antidepressants and antipsychotic medications (eg, anticholinergic, dopamine agonists, tricyclic antidepressants) have been suggested as possible triggers for gastroparesis. Commonly prescribed medications including calcium channel blockers, narcotics, glucagon-like peptide-1 agonists and amylin analogues have similar effects. Our case is interesting as it demonstrates how gastric distention can develop to a massive extent in the setting of offending drugs, despite well controlled diabetes. Patients with longstanding diabetes taking multiple psychiatric medications are at a particularly high risk of developing gastroparesis.