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- W2911883669 abstract "A 20-year-old man with no significant history presented with 2 months of sudden onset but progressively worsening epigastric pain followed by nausea and vomiting. Initially, symptoms occurred only at night, with vomitus containing slightly digested food; they then occurred after small meals as well. There was accelerating weight loss. Physical exam noted fullness of the right abdominal wall. Laboratory testing was unremarkable including hemoglobin A1c. Computed tomography and ultrasound were normal. As esophagogastroduodenoscopy (EGD) revealed retained food, a gastric emptying scan (GES) was performed showing delayed gastric emptying. After an initial diagnosis of gastroparesis, he was managed unsuccessfully by multiple other clinicians. Consequently, alternative diagnoses, including median arcuate ligament syndrome (MALS), were entertained; initial angiography and duplex ultrasound, though, identified no celiac impingement. Given continued suspicion for MALS, celiac ganglion injection was performed with immediate (but temporary) symptom relief. Therefore, definitive surgical decompression was considered. Repeat pre-operative duplex sonography showed celiac artery velocity increasing by 200% with expiration, consistent with MALS. His symptoms completely resolved after his operation. MALS has unclear prevalence given variable presenting symptoms usually associated with other disorders. Confusingly, patients with significant celiac artery stenosis may be asymptomatic. A neuropathic component has also been posited, explaining the patient's improvement with celiac ganglion injection. Operative decompression is generally recommended, at times paired with vascular intervention. Elements of this patient's clinical course reflect common pitfalls of diagnostic testing. Namely, EGD and GES findings caused anchoring bias after the constellation of symptoms was incorrectly interpreted as gastroparesis. Prior clinicians should have found the diagnosis inadequate given the atypical symptom progression and relatively rapid clinical deterioration. Only by recognizing the limitations of routine evaluation for chronic nausea and vomiting was further testing and intervention considered that ultimately yielded the correct diagnosis. This case demonstrates the importance of interpreting diagnostic testing within the patient-specific context. It also reminds us to consider MALS despite its non-specific symptoms given how quality of life can be improved once it is identified." @default.
- W2911883669 created "2019-02-21" @default.
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- W2911883669 date "2017-10-01" @default.
- W2911883669 modified "2023-09-26" @default.
- W2911883669 title "Anchored Down: Diagnostic Pitfalls in the Evaluation of Chronic Nausea and Vomiting" @default.
- W2911883669 doi "https://doi.org/10.14309/00000434-201710001-02439" @default.
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