CASE
A 49-year-old female presented with complaints of chest pain and associated nausea that worsened with eating. She described the chest pain as sharp, "spearlike," and radiating to the back. The pain began 10 days earlier after the patient took a bowel preparation of laxatives before a colonoscopy. She reported significant nausea and vomiting after taking the laxative. The patient rated the pain as reaching a 10/10 at times. She denied recent unintentional weight loss, odynophagia, dysphagia, heartburn, melena, fever, chills, or night sweats.
History Despite placement of an adjustable Lap-Band and a weight loss of 49 lb following bariatric surgery 18 months earlier, the patient remained morbidly obese due to poor eating habits afterward. The history was also significant for type 2 diabetes mellitus with secondary renal insufficiency, hypertension, hyperlipidemia, hypothyroidism, asthma, osteoarthritis, obstructive sleep apnea, diverticulosis, irritable bowel syndrome, colon polyps with dysplasia, depression, and anxiety. Surgical history included the aforementioned Lap-Band, appendectomy, and cholecystectomy. Esophagogastroduodenoscopy (EGD) performed 14 months before her presentation revealed multiple benign gastric polyps but was otherwise unremarkable. She was currently taking amitriptyline, venlafaxine, levothyroxine, metformin, glimepiride, insulin detemir recombinant (Levemir), insulin, aspirin, and a multivitamin. She denied alcohol or tobacco use. She said she drank 3 cups of tea daily but otherwise avoided consuming drinks containing caffeine.
Physical examination The patient appeared to be uncomfortable but was in no acute distress. She was obese at 5 ft 2 in and 196 lb with a body mass index of 35.8. She was afebrile and normotensive. The abdomen was soft and nontender; bowel sounds were normoactive. No organomegaly, guarding, or rebound tenderness were noted. Mild tenderness to palpation was present over the lower third of the sternum. Findings from heart and lung examinations were unremarkable.
Testing Barium swallow showed good orientation, pouch, and rapid transit in two planes. CT of the chest and abdomen was ordered, revealing gastric banding placement in the superior fundal region of the stomach without obstruction. An EGD performed 5 days later revealed a macroscopically normal esophagus and duodenum. The stomach appeared abnormal with evidence of a foreign body in the fundus of the stomach. Biopsies of the esophagus showed no evidence of inflammation or intestinal metaplasia, and biopsies of the duodenum demonstrated an intact villous-crypt ratio and no evidence of intraepithelial lymphocytosis. Biopsies of the stomach revealed no evidence of inflammation, dysplasia, or Helicobacter pylori infection.
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