Case report--the 46 year old man with a 5 month history of vomiting.

Malawi On the 23rd of January 2011, we admitted a 46-year-old man to Queen Elizabeth Central Hospital (QECH) with a 5-month history of recurrent vomiting. This was associated with nausea. He would vomit at least 5 times per day. The vomitus was non-projectile, would usually take the colour of the food eaten and was never bilious. There was no history of abdominal pain, dysphagia, fever or headache. The colour of stools was normal but he had complained of constipation for 6 days prior to admission. He also admitted to weight loss, which could not be quantified. Prior to attending QECH he had been seen in several health facilities and had been treated with promethazine, but had had no relief of his symptoms. An endoscopy done at another hospital was documented as follows: ‘endoscopy shows reflux oesophagitis and lax lower oesophageal sphincter’ There was no comment on whether there were structural abnormalities at the level of the pylorus or duodenum. He had been diagnosed with type 2 diabetes mellitus in December 2010 on the basis of high random blood glucose readings. He had been prescribed glibenclamide but stopped as he felt it was making him vomit more, and was now only taking metformin. Blood glucose measurements since the start of treatment were not available so we do not know how well the diabetes had been controlled. He had a history of moderate alcohol consumption (< 20 units per week) but had not taken alcohol since the symptoms started. He had no history of smoking. He was HIV negative. He used to work as a foreman for a construction company but had stopped work owing to the severity of his symptoms. He was married with 3 children. There was no family history of diabetes. On examination, he was moderately cachexic and dehydrated. His blood pressure (BP) was 130/80 mmHg, temperature 37oC, pulse 92/minute, respiratory rate 28/minute. His conjunctivae were pink, there were no oral lesions and he had no lymphadenopathy, including Virchow’s node. Chest examination was normal. Abdominal examination was normal except there were hard stools in the rectum. His fundoscopy showed dot and blot haemorrhages, consistent with background diabetic retinopathy. His random blood glucose concentration was 252mg/dl and there were no ketones in his urine. Blood potassium and sodium were 3.1 mmol/L (3.6 – 5.0) and 127 mmol/L (135 – 145) respectively. He had a normal blood creatinine and no proteinuria. Questions 1) What is the differential diagnosis of his vomiting? 2) What further investigations are indicated for the vomiting? 3) What further assessments are indicated for his diabetes?