Wednesday, July 17, 2024

Why Was the Young Woman Vomiting Everything She Ate or Drank?

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The flight to Cleveland was quick. Her father picked her up at the airport and drove directly to the Cleveland Clinic Children’s hospital. Her regular doctor, Ellen Rome, the head of the Center for Adolescent Medicine there, wasn’t in the office that holiday week but arranged for the young woman to see a pediatric gastroenterologist. She immediately admitted her to the hospital.

The doctor who admitted her that night considered the possible causes of this kind of unremitting vomiting. The patient was taking medications for anxiety, so maybe the doctors in Atlanta were right — maybe this was psychogenic vomiting, caused by her longstanding psychiatric disorder. But there were other possibilities. Regular marijuana use could cause persistent vomiting. Hyperemesis gravidarum — excessive vomiting in pregnancy — was also possible. Those were easy to test for. Hyperthyroidism can cause this kind of vomiting as well. By the next morning results from the testing began to trickle in. She was not pregnant and had no evidence of marijuana in her system. Her thyroid was normal. So were the rest of the more routine studies.

That morning, Rome reached out to the team assigned to care for the young woman. When she was hospitalized at Emory, Rome explained, one of her scans showed an unusual finding. Her celiac artery, which provides blood to many digestive organs, was strangely narrowed, as if being compressed from the outside. That was suggestive of a rare disorder called median arcuate ligament syndrome (MALS), where the connective tissue that anchors the diaphragm to the spine — the median arcuate ligament — impinges on the celiac artery. Although usually characterized by severe abdominal pain, compression of that vital artery could cause the kind of nausea and vomiting she had by starving the downstream nerves and organs of adequate blood when they needed it most — right after eating.

Despite this abnormal scan, the doctors at Emory thought it was much more likely that she had some sort of anxiety-triggered vomiting than this rarity. Even so, they had suggested a specialized type of ultrasound to see if the compression was affecting blood flow through the artery. It hadn’t been done by the time the patient came to Cleveland. They needed to do it now, Rome said. The test was done the following day.

Using sound waves, Doppler ultrasound allows doctors to estimate how fast blood is flowing by measuring the rate of change in its pitch or frequency. The diaphragm moves upward when air is being breathed in, and so blood flow through the celiac artery would be normal or, if partly obstructed, faster than normal, the way water moving through a hose increases in speed when you use your thumb to partly block the opening. But when breathing out, the diaphragm moves down, and in MALS, this will reduce or even stop blood flow through the artery, depriving the targeted organs or nerves of the blood and oxygen needed to digest food.



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