GERD Boy revisited
We got a phone call last Thursday, saying that this teenager was still throwing up after every meal and could not attend school. The diagnosis had been GERD (gastroesophagela reflux disease) with lactose intolerance, but the symptoms should have resolved by this time. We called the parent and child in again to take another look.
He actually looked better than he looked during the initial visit. He wasn’t sweaty or disoriented. However, he did report not being able to keep food down. He had some difficulty drinking a lot of water. He said that the omeprazole had helped, but did not stop all the symptoms. He reported having red-orange and green loose stools. He did not have a fever. He did not report any bleeding. Upon physical exam, he reported epigastric pain and upon deep palpation, left upper quadrant pain. His throat appeared pink and normal.
Why is he still vomiting? I was wondering why he had suddenly started vomiting after presumably years of soda, milk, and tortilla consumption (all foods we recommended against). An infectious cause seems unlikely because of the lack of fever, rash, bites, or other family members experiencing the same effects.
The LUQ pain is a new symptom, and it could mean there are feces stuck in that area or spleen inflammation.
We were puzzled, Penny put him in for several blood labs, looking at lipids, bilirubin, amylase, etc.
Her lead working theories seem to be H. Pylori or diverticulosis. I feel like I’m missing a piece of the puzzle. I think H. Pylori would be more probable than diverticulosis.
What can make food stop at the stomach then make it come back up? An irritant? immune reaction? toxicity? ulcer?
I’m getting excited to look at labs.
I was separated from Penny all day when GERD Boy (henceforth known as GB) came back for another visit. I asked what she had found, and she said GB looked better than last time and all the labs came back normal except for an elevated alkaline phosphatase.
Alk Phos is one of the labs I’m always confused about. Things like white blood cell count and bilirubin are pretty straightforward, but alk phos seems to mean everything and nothing at the same time.
Alk Phos is found in all tissues but most of it is in the liver, bile duct, kidney, bone, and placenta. Normal range should be 20-140 IU.
High levels can mean: active bone growth, blocked bile duct, celiac disease, obstructive liver disease, renal disease,
Low levels can indicate: Malnutrition, anything lowering phosphate levels hypothyroidism, some types of anemia, rickets.
The list is pretty extensive, so not everything is up there. Unfortunately, my digital version of Robbins doesn’t have a search function so I can’t compile a good list. I think we can rule out anything involving the viscera since ALT, AST, amylase, etc came back normal. Penny was thinking a parasite might be responsible since he seemed to be experiencing cycles of feeling well then vomiting. Possible, but I wonder why no one else in the family is affected, assuming the mother prepares meals and they eat together. They haven’t mentioned anyone else at school being sick, so maybe school food is not to blame. Or he could have just played with some dirt then stuck a finger in his mouth.
So, orange and green stool. This is pretty abnormal. I was thinking bile (since he admits he hates vegetables and hardly eats them), but I was confused about orange. I thought there’d be a nice standardized stool color chart (like the Bristol chart), but there isn’t. I did find though Green and Orange both suggest a fast transit time through the colon, and bile isn’t able to interact enough with the stool. Orange could also mean there’s a lot of beta-carotene (like in carrots) in whatever the person’s eating. Examples included yams, carrots, spinach, turnip, cilantro, food colorings. I italicized things GB, based on his history, is most likely to have eaten.
On color alone, it looks like there’s some sort of obstruction to his gallbladder, or his liver. But no pain, no labs. Can this be a painless obstruction? Seems unlikely…most liver/gallbladder obstructions are very painful. And there’s no evidence to support a possible malignancy (which usually presents as painless jaundice)
Or, maybe it’s the irritated bowel that’s moving things along faster than they should be. (And cause of that still unknown)
http://www.chirocolonics.com/stoolchart.html (Not worksafe, has real photos of stool!!)