Persistent Vomiting and Weight Loss in a 6-Year-Old
A 6-year-old boy is brought to your clinic with a 3-month history of recurrent vomiting, now occurring 4–5 times per week, mostly after meals but sometimes at night. He has lost 2 kg (from 22 kg to 20 kg, 10th percentile to 5th percentile) and has become increasingly irritable. He complains of intermittent abdominal pain, primarily epigastric, and early satiety. He has no diarrhea, fever, or dysphagia. His mother reports that he sometimes wakes at night crying with abdominal pain. Physical exam reveals mild epigastric tenderness without organomegaly or masses. Laboratory tests show a normal CBC, normal electrolytes, and normal liver enzymes. An abdominal ultrasound is normal. A trial of a proton pump inhibitor for 4 weeks provided no improvement.
1. What is the most likely diagnosis, and what key features in the history and initial workup support it?
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The most likely diagnosis is gastroparesis or a functional dyspepsia variant, but given the nocturnal symptoms, weight loss, and lack of response to PPI, eosinophilic gastroenteritis or gastroparesis should be considered. However, the combination of postprandial vomiting, early satiety, weight loss, and nocturnal symptoms in a child without mucosal disease suggests delayed gastric emptying (gastroparesis). The normal ultrasound and labs make structural causes less likely. The failure of PPI trial argues against GERD. The absence of diarrhea makes malabsorption less likely. A gastric emptying study would be the next best test to confirm gastroparesis. The key features are: chronic vomiting, weight loss, early satiety, epigastric pain, and no response to acid suppression. The nocturnal symptoms may indicate significant retention. Other considerations include rumination syndrome (but vomiting is not typically nocturnal) and superior mesenteric artery syndrome (but ultrasound was normal).
2. What diagnostic test would you order next, and what would you do if the test is normal?
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Order a gastric emptying scintigraphy (or a wireless motility capsule if available) to assess gastric emptying. If the gastric emptying study is normal, consider upper endoscopy with biopsies to evaluate for eosinophilic gastroenteritis, H. pylori, or celiac disease (though duodenal biopsies are more sensitive for celiac). Also consider antroduodenal manometry if symptoms persist and motility disorder is suspected. If all tests are normal, a diagnosis of functional dyspepsia or rumination syndrome should be considered, and behavioral therapy may be beneficial. In this case, the normal ultrasound and labs make structural causes less likely, but endoscopy is still warranted to rule out mucosal disease.