Endocrine Abstracts

Case: 81-year-old male with history of insulin-dependent diabetes mellitus (diagnosed in 1984, HbA1c of 8.9%), hypertension presents to the emergency department with 6 days of worsening nausea, vomiting and abdominal discomfort to the point where he couldn’t tolerate any oral diet. He was admitted thrice in the last year with similar complaints. A routine evaluation was always done including X-ray, routine endoscopy which showed gastroparesis and no abnormal cytology in brushings. He responded to motility agents after a few days and was discharged home with pro-kinetic agents. He was scheduled to receive a gastroenterology evaluation for pacemaker placement in few months. Now patient also complained of a 20 lb weight loss, heart burn and early satiety, which he thinks are new for him. An abdominal X-ray showed gastric outlet obstruction. The gastroenterologist repeated an endoscopy which showed narrowed gastric outlet, mild erythema of the gastric and esophageal mucosa. A high index of suspicion lead to a endoscopic ultrasound-guided biopsies showing a diffusely thickened wall of the gastric antrum that came back positive for adenocarcinoma. The anatomic pattern confirmed the diagnosis of Linitis plastica. This was the reason for the patients gastroparesis. A PET scan confirmed FDG uptake diffusely in the stomach wall, small lesion in his liver and a few nodes.

Discussion: Diabetes-induced gastroparesis is seen in 5–12% of all diabetics. It is postulated to be secondary to the autonomic neuropathy involving the vagus nerve. It progressively gets worse with no definitive solution other than the novel treatment of using Gastric Pacemaker which has been shown to have limited success. The complacency and questionable benefits of the pacemaker placement makes many of us not do a thorough work up for such a patient, which might lead to major under diagnosis of these life-threatening conditions.