History Of Recurrent Vomiting Research Articles

Wernicke encephalopathy in combination with acute polyneuropathy under the guise of a demyelinating disease in a teenager with an eating disorder

Wernicke encephalopathy is a neuropsychiatric syndrome characterized by three main symptoms: oculomotor disturbances, cerebellar ataxia, and psychiatric disturbances. The condition is associated with a high mortality and morbidity rate. Wernicke encephalopathy is most commonly seen in adolescent children presenting with a vitamin B1 deficiency. Thiamine deficiency may also cause polyneuritis syndrome, with or without the aforementioned symptoms. The condition is characterized by sensory-motor impairments in a symmetrical pattern, dysarthria, and paresis or even paralysis of the lower limbs. This report focuses on an adolescent case presenting acute oculomotor paresis, nystagmus, leg weakness, impaired gait, decreased deep tendon reflexes, cognitive impairment, and a history of recurrent vomiting, prolonged starvation, and eating behaviour disorders. The magnetic resonance imaging scan reveals symmetrical pathological foci of increased intensity in T2 in the periaqueductal region, at the Magendie’s central aperture. The patient displays a mixed motor-sensory polyneuropathic syndrome affecting both lower limbs, primarily of the axonopathy type, based on electroneuromyography data. Positive outcomes such as restored eyeball movement, enhanced gait, increased muscle strength in the lower legs and feet, and better management of sensory disorders have occurred due to thiamine treatment.

S3357 Achalasia Cardia in Child With Severe Malnutrition: A Case Report

Introduction: Achalasia cardia is an esophageal motility disorder due to the failure of the lower esophageal sphincter to relax. It is extremely rare in the pediatric population with an incidence of 0.11 per 100,000 children. In children, it is usually associated with other conditions like Adrenal glucocorticoid deficiency and Down’s syndrome. The symptoms include vomiting, regurgitation, and weight loss. Its exact etiology is still unclear. It is considered to be due to degeneration of the myenteric plexus that innervates the lower esophageal sphincter leading to difficulty with swallowing and absence of peristalsis. Case Description/Methods: We present the case of a 3-year-old girl with a history of recurrent vomiting and poor weight gain. Her symptoms have been progressive for over 2 years. The child was initially treated at multiple local hospitals for Gastroesophageal reflux disease with no improvement. At presentation, she was severely malnourished and weighed 6 kgs. On evaluation, she was also found to be anemic. After admission to our pediatric unit, she underwent a barium study which showed tapering of the distal esophagus, representing the classic bird-beak sign, and the diagnosis of achalasia cardia was confirmed. She was treated surgically by Heller’s Cardiomyotomy and Fundal Wrap. Her post-operative phase was uneventful and she was discharged with follow-up advice. She exhibited excellent recovery with good weight gain and resolution of her symptoms. Her weight at the 1-month follow-up visit was 9kgs and at 3 months it was 12kgs. (Figure) Discussion: Achalasia cardia is a rare presentation in children but can lead to major health concerns if left untreated. Due to the nonspecific symptoms, it is mostly misdiagnosed as gastroesophageal reflux disease which leads to delayed diagnosis and severe malnutrition. Diagnosis is with barium swallow study and manometry. It is followed by endoscopic biopsy in adults to rule out malignancy, however, it is not a consideration in children. Medical management has often shown recurrence of symptoms, particularly in children, and is not considered an effective choice of treatment. Surgery is the definitive treatment and includes Heller’s esophagomyotomy with or without anti-reflux procedures. Prompt diagnosis and treatment have an excellent prognosis. Peroral endoscopic myotomy is a promising new therapy in adults with achalasia but has limited studies in children. Persistent undiagnosed cases can lead to severe malnutrition and failure to thrive.Figure 1.: 1: At presentation, weight 6kgs; Fig2:At 3months, weight 12kgs; Fig.3,4,5: Barium Study; Fig6: Supraumbilical midline incision; Fig7:Cardiomyotomy; Fig8:Approximation of Crura; Fig9:Fundal Wrap.

BALLOON DILATATION TECHNIQUE VIA ENDOSCOPY PROCEDURE IN A DOG WITH ESOPHAGEAL STENOSIS: CASE REPORT

Esophageal stenosis is a morphofunctional alteration that causes inflammatory lesion in the submucosal and muscular layers of the esophagus, inducing them to fibrosis and altering the esophageal diameter. The present report addresses the use of a balloon dilator as an auxiliary way to correct esophageal stenosis in a canine, female, Pug patient, with a history of recurrent vomiting as the main complaint. Through endoscopy, it was observed that the thoracic esophagus was inflamed, with thickened and fibrotic mucosa, in addition to whitish colored fibrous rings, which hindered the passage of the probe, enabling the determination of the diagnosis of esophageal stenosis. In this report, we opted for the use of a dilator balloon, with three procedures being performed one week apart, to improve the symptomatic condition. After the dilator procedure, the favorable development of the clinical condition presented by the patient was possible.

Pancreatic cyst in a cat

ABSTRACT: Pancreatic cysts are rare in both humans and animals. They are defined as an enclosed structure externally surrounded by a capsule, internally coated with a cuboidal epithelium and filled with liquid or semi-solid content. This case described the clinical and pathological characteristics of a pancreatic cyst in a feline. A mixed breed cat with a history of recurrent vomiting was attended. Physical examination revealed pain on abdominal palpation. Abdominal ultrasonography showed a cystic, anechoic structure with well-defined edges located in the left cranial abdomen and in close contact with the duodenum and pancreas. Partial pancreatectomy was performed. Microscopically, the structure was surrounded by fibrous material, coated with cuboidal to columnar epithelium, and containing eosinophilic material. Although, pancreatic cyst is rare in animals, they should be included in the differential diagnosis of causes of vomiting in young cats.

Trichobezoar: a rare clinical rendezvous with twin sisters

Trichobezoar is very uncommon in the pediatric age group. Till now no familial predisposition has been reported. We hereby report our clinical experience with eight years old twin sisters one of whom had a huge gastric trichobezoar and other one had a history of trichotillomania with recurrent vomiting and weight loss. An eight years old female child, one of the twin, presented with history of recurrent vomiting. Abdominal examination revealed firm mass in epigastric region. X-ray abdomen showed the transverse colon pushed down. Ultrasonography revealed echogenic mass in the stomach. Preoperative diagnosis of trichobezoar was achieved by a computed tomography (CT) scan. Laparotomy was done through the midline abdominal incision after initial session of resuscitation. A huge mass of hair was retrieved from the stomach part of which was passing into the duodenum. Patient was found to have underlying trichotillomania and obsessive compulsive disorder. As the patient was one of the twins, other sibling was called and evaluated for the mental health. Interestingly, she was found to have trichotillomania and trichophagia. Examination revealed sparse scalp hair. X-ray and the sonography of the abdomen were normal. Patient was advised endoscopic examination which the guardian of the patient refused. Patient was put on outpatient department (OPD) follow up after psychiatric counselling. Trichobezoar should be suspected in a pediatric patient of gastrointestinal symptoms, epigastric mass and anemia with history of trichophagia. Open surgery gives optimum results. Sibling of an affected twin must be evaluated on the similar lines and managed accordingly.

A Five Years Old Child with Failure To Thrive and Vomiting Presenting as a Diagnostic Dilemma: A Case Report

Vomiting with failure to thrive in older children is a diagnostic challenge due to the diversity in the diagnosis. We report a case of a five-years-old girl with failure to thrive, history of recurrent vomiting and intermittent colicky pain abdomen since 45 days of life. Intestinal malrotation with Ladd's band was diagnosed based on clinical acumen, high- resolution computed tomography, barium follow through and intraoperative findings. Exploratory laparotomy with Ladd's procedure was performed under general anesthesia which showed malrotation at the duodenojejunal junction with a short route of mesentery with floating caecum with Ladd's band. Failure to thrive with malrotation of the gut in the older age group is rare in itself. As there are very few cases reported in this age group, so we undertook to report this case to increase the awareness of knowledge concerning the diagnosis and timely management to prevent the comorbidity of this condition.

Isolated cerebral mucormycosis masquerading as a tumor in an immunocompetent patient

ABSTRACTMucormycosis is an opportunistic fungal disease that commonly presents as cutaneous or rhinocerebral infections associated with immunocompromised states. It may exceptionally present as isolated involvement of the brain with a varied clinical presentation, which may be difficult to diagnose early, leading to increased mortality. Herein, we report the case of a 42-year-old immunocompetent female with left-sided limb weakness and a history of recurrent vomiting and headache for the last two years. Clinically, glioma was suspected, but histopathological examination revealed a few broad aseptate fungal hyphae. As no other organ was involved, the diagnosis of isolated cerebral mucormycosis was rendered. Reporting this case, we show an unusual presentation of a central nervous system mucormycosis masquerading a tumor in an immunocompetent patient. The case also highlights the importance of a careful histopathological examination to avoid missing the presence of occasional fungal hyphae. Ideally, recognition of fungal hyphae in the brain, during intraoperative consultation, can prompt brain tissue culture for definitive diagnosis and early empirical antifungal therapy, which may prove life-saving.

Naphthalene Mothballs Poisoning Leading to Intravascular Hemolysis: A Case Report.

Naphthalene is widely used in households as an insect repellent, but its poisoning is rare, especially in adults. Naphthalene is a strong oxidant with a pungent smell. We report a case of a 16-year-old female who ingested three naphthalene mothballs 3days prior to admission and presented with history of recurrent vomiting, severe pallor, jaundice, and hemoglobinuria. Investigation found severe hemolytic anemia, indirect hyperbilirubinemia, acute kidney injury, and evidence of intravascular hemolysis. Her urine output was normal throughout the course of illness. She was managed conservatively with i.v. fluid, oral ascorbic acid, and blood transfusion. With treatment our patient improved completely and was discharged in hemodynamically stable condition. She is doing fine after further follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physician should keep the possibility of poisoning by an oxidizing agent, such as naphthalene, when a patient presents to the emergency department with rapid onset pallor, jaundice, and hemoglobinuria.

Amitryptilline Induced Intestinal Obstruction (Ogilvie Syndrome) In A 70 Year Old: Medical And Legal Issues: A Case Report

Introduction: Anticholinergic side-effects of Tricyclic antidepressants, such as blurring of vision, dryness of the mouth, constipation and retention of urine are common are well reported. Fewer studies report that acute abdomen due to the use of antidepressants is rare. Intestinal Obstruction describes a condition in which there is failure of onward propulsion of intestinal contents. It can be non-mechanical (adynamic, paretic ileus), which involves conservative management and no surgery is required. This report support the view that intestinal obstruction can be a complication of the use of Tricyclic antidepressants. Case presentation: An 70-year old retired male civil servant, known Hypertensive, earlier seen and commenced on Amitryptilline for peripheral neuropathy by a mental health physician, presented to the Emergency Unit of a private facility in Port Harcourt, South South Nigeria, in June, 2018, with history of recurrent vomiting, abdominal pain, abdominal distention, 4 days after commencement of Tablet Amitriptilline. Was consequently admitted for clinical and radiological evaluation. Laboratory and radiological investigations did not reveal any features of intestinal obstruction. However patient was placed on nil per oral after Naso-Gastric Tube was passed. Patient emptied bowel on the 3rd day but because of missed diagnosis, a cascade of clinical events leading to dehydration, organ failure, hypovolemic shock and death on the 4th day. The medical and forensic issues are examined in this report. Conclusions: Understanding the unusual risk of intestinal obstruction among patients on Amitryptilline, adequacy of record keeping, strict adherence to practice guidelines and collaboration between the surgical and psychiatric teams, appears to be the key components in avoiding the medical and legal consequences of such missed diagnosis.

Nonalcoholic Wernicke's Encephalopathy: A Retrospective Study from a Tertiary Care Center in Northern India.

Objective:The objective of this study was to describe the demographic features, clinical presentation, and management and outcome of fifty cases of nonalcoholic Wernicke's encephalopathy from a tertiary care hospital of a region with reported incidence of thiamine deficiency disorders.Materials and Methods:In a retrospective study, fifty adult cases of Wernicke's encephalopathy were analyzed. The diagnosis of Wernicke's encephalopathy was made according to the European federation of neurological societies guidelines 2010. Response to thiamine replacement and associated brain magnetic resonance imaging (MRI) findings were also considered as supportive evidence.Results:The mean age of patients was 50.38 years with 20 males and 30 females. The most common clinical manifestations were alteration in sensorium in 30 (60%), ataxia in 18 (36%), memory impairment in 15 (30%), nystagmus in 35 (70%), ophthalmoparesis in 11 (22%), and seizures in 4 (8%). A total of 42 patients had a history of recurrent vomiting. All patients had polished rice as their staple diet. Thirty-five patients had associated polyneuropathy and 15 had a gastrointestinal disorder. Twenty patients underwent MRI which showed both typical and atypical lesions. Majority of patients showed partial or complete response to intravenous thiamine. On discharge, the most common residual symptoms were lower limb weakness, ataxia, and memory impairment.Conclusion:The study shows high incidence of nonalcoholic Wernicke's encephalopathy in the region with predominant causative factor being a thiamine deficient diet. Recurrent vomiting can be a prominent early symptom of thiamine deficiency and its recognition can help in the early diagnosis of Wernicke's encephalopathy and related thiamine deficiency disorders. Thiamine fortification of food should be done in areas with reported incidence of thiamine deficiency disorders.

Pediatric Emergency Update: Cyclic Vomiting Syndrome

Vomiting is a common chief complaint in the pediatric ED population. Emergency nurses should develop a systematic approach that is age and developmentally appropriate to evaluate the child with vomiting to identify life-threatening emergencies. Vomiting isasymptomthatcanindicateavastarrayofmedicalproblems from catastrophic to benign. Some children have chronic recurrent vomiting episodes, diagnosed as cyclic vomiting syndrome. Emergency nurses caring for pediatric patients must be objective and open to all differential diagnoses that vomiting could represent. Misdiagnosis of children with the chief complaint of vomiting is not uncommon. It is important to look at each body system of a child brought to the emergency department with recurrent vomiting. The following case report of a 4-month-old infant brought to the pediatric emergency department for frequent vomiting can serve as an example. The child was beautiful, well developed, chubby, awake, and alert, being evaluated in the outpatient setting by both his pediatrician and a gastroenterologist for recurrent vomiting. The child’s primary nurse in the pediatric emergency department noted that a complete workup was ordered, which included blood tests, urine tests, radiographs, and a computed tomography (CT) scan of the head. The child’s mother was concerned that he kept spitting up (vomiting) for no apparent reason. Part of the complete workup for this infant involved obtaining a straight catheter urine specimen. When the diaper was removed to obtain this specimen, abnormal urine flow was noted. The child’s urine stream would start and stop and then repeat this pattern. Documentation of this was placed in his medical record, and the ED pediatrician was notified. A brain tumor was identified on CT scan. Fortunately, during this pediatric emergency visit, this child with a history of recurrent vomiting was evaluated objectively, using a systematic format. The child was admitted with the newly diagnosed brain tumor for further evaluation and treatment. When all differential diagnoses—both life-threatening and benign—that may cause the child’s vomiting are eliminated, cyclic vomiting syndrome can be diagnosed. Cyclic vomiting syndrome is a chronic gastrointestinal condition identified in children as long ago as in the 1800s. The description of cyclic vomiting syndrome includes the following: the child has 3 or more distinct episodes of recurrent severe vomiting, with completely normal health between episodes, and the child’s vomiting occurs with similar timing, symptoms, and duration. The vomiting episodes of children diagnosed with cyclic vomiting syndrome have variable duration from hours to days, with no exact cause identified. The exact pathophysiology of recurrent cyclic vomiting is unknown. Emergency nurses who care for pediatric patients need to ensure that all potential life-threatening differential diagnoses are eliminated before labeling pediatric patients as having cyclic

Normal Pressure Hydrocephalus with Onset Following a Traumatic Experience

Background: Normal Pressure Hydrocephalus (NPH) is a neurological disorder caused by excessive accumulation of cerebrospinal fluid (CSF) with resultant pressure to the brain. It is a rare syndrome usually found in the sixth and seventh decades of life. The condition is often misdiagnosed because of its non specific symptoms and chronic nature, but recently NPH is receiving a great deal of media and medical attention, leading to a more efficient and timely diagnosis and treatment. Methods: This is a case report of a 40 year old widow, who presented with eight weeks history of recurrent vomiting, fearfulness and withdrawal to self following a traumatic experience. Prior to above presentation patient was normal and stable with no past history of physical or mental illness. Results: Clinical features met the criteria for diagnosis of Post Traumatic Stress Disorder following a traumatic experience. Clinical examination and investigations including (skull xray) conducted were all within normal limits. Two weeks into admission patient developed seizure, facial nerve palsy, and progressive weakness of lower limbs which warranted further investigation. The patient had Computer Tomography scan which revealed NPH, she had a ventro-peritoneal shunt at the neurosurgical unit of the hospital. Conclusion: Despite the advances in the diagnosis and treatment of hydrocephalus, there is still much to be learned about hydrocephalus and the subtle forms it can take. Even though it is more common in infants and elderly, it can occur at any time in life and as a result of a variety of causes.

Cytological, Immunohistochemical and Mutational Analysis of a Gastric Gastrointestinal Stromal Tumour in a Cat

Gastrointestinal stromal tumours (GISTs) represent a distinctive group of primary mesenchymal tumours of the gastrointestinal tract identified immunohistochemically by expression of CD117. A 10-year-old neutered female domestic shorthair cat with a history of recurrent vomiting was examined. The presence of a gastric mass was recognized and a laparotomy was performed. Cytological examination was consistent with a low-grade malignant mesenchymal tumour and histopathological investigation suggested myogenic differentiation of tumour cells. The diagnosis of GIST was confirmed by immunohistochemical expression of CD117. Sequence analysis of the KIT gene identified a deletion in exon 11. The same mutation is found often in human GISTs.

Cyclic vomiting syndrome responding to amitryptiline

A 7 year girl presented with history of recurrent vomiting and altered sensonium. Laboratory investigators were within normal limits. A diagnosis of cyclic vomiting syndrome was made and treated with amitryptiline with good results.

Multiple Cystic Intestinal Duplications in a Cat

A 7-year-old, female European shorthair cat with a history of recurrent vomiting had a 2-cm cystic mass in the midjejunum. Cross-sectioning and histology revealed 3 separate cystic structures in the muscular layer, in addition to a regularly structured intestinal lumen. One cyst had a 3-layered wall consisting of a dysplastic mucosa, a regularly structured submucosa, and partly double-layered muscularis that sporadically contained neurons resembling a myenteric plexus. The remaining 2 cysts had similar structures except for granulation tissue lining the lumen. The lesion was diagnosed as multiple cystic duplications in the midjejunum, which is unknown to the veterinary literature to date.