20. The Bow Tie


I was rotating in the Emergency Department. Honestly, I think this is one of the most challenging fields in medicine. Not only you are the one people call to revert a true emergency, but you are the one that decides who needs to be admitted and who can go home. 

I was going over some paperwork when a familiar face walked into the ED. It was Gavin. I specifically remembered him because of his green bow tie, which I could see he was wearing again. He was in his fifties, but he was in good shape and could easily pass as someone younger if it wasn’t for his gray hair. He had come to the ED a couple of weeks before with diarrhea and vomiting, a straightforward case of gastroenteritis. Or so I thought.

‘Gavin?’ I asked from behind the central desk and he turned to me.

‘Oh, hi Dr. Diaz!’ He smiled weakly. I was surprised at how ill he looked.

‘It’s good to see you but I’m sorry you had to come back. What happened?’

‘Same thing.’ He shrugged. ‘I took the medicines to control the symptoms like you told me to. It seemed to work in the first days, but after a week it worsened again. So I came back.’

‘I’m sorry to hear that. Give your info to the front desk and I’ll call you in soon, okay?’

‘Sure, thank you.’

I went over my last encounter with Gavin trying to figure out if I had missed something. He had come in alone on a Friday morning. He had told me he was having profuse vomiting and diarrhea for the past four days. It was a crowded day in the ED and I remember thinking of how many patients I had to check on before my shift ended when I called him in. I was relieved when he started telling me his symptoms because I could easily handle that so he could go home soon. I had put him on IV hydration and symptomatic medication and he looked great afterward. So I made the call. I told him he could go home and prescribed pills to help with symptoms while he recovered from what I thought was gastroenteritis. Was I wrong?

I decided to check my note from that first day before calling Gavin in. The HPI was pretty much what I remembered. His past medical history was significant for lower limb DVT diagnosed three months before, for which he was receiving Rivaroxaban, and gastritis, for which he took Omeprazole. No significant family or social history. I scratched my head. Nothing came to mind then.

Just before I called Gavin there was a knock on my door.

‘Hey, Liz.’ Andrew said opening a crack at the door. ‘Are you up for a small break? I’m heading for coffee now.’

Andrew was the Emergency Medicine resident. He was a tall Asian man, serious but always polite.

‘Sorry, I have a patient I need to see now. But…’

‘Want me to bring you one?’ He said before I had to. 

‘Yes.’ I smiled. ‘You’re the best.’

Gavin Bloom walked into my room with a folder in his hand. He looked terrible. Even though he was still in good shape I could see his eyes were sunken and he had lost weight.

‘So, Gavin, tell me everything again from the start.’

‘Alright.’ He cleared his throat.

Then he told me that almost three weeks before that day he started with nausea and vomiting accompanied by watery diarrhea. He said that his diarrhea had improved considerably having now only one episode a day, but the vomiting was still frequent and distressing. He couldn’t eat or drink properly and felt weaker each day. Still, he denied other symptoms such as fever or bleeding.

‘And my gastritis is attacking now. The burning is getting worse.’

‘Right, you mentioned that. I meant to ask you, how long have you had gastritis?’

‘Around five months I think. They even said I had ulcers!’

That worried me. These were all too recent. The DVT, gastritis/ulcers, vomiting and diarrhea. Could it all be connected?

‘Oh, that reminds me doc!’ Gavin continued and opened his folder. ‘I remember you told me to always bring medical papers with me when I go to the doctor.’ He gave me an envelope. ‘This is my endoscopy report.’

I opened the envelope and the first thing I saw was the final impression: multiple gastric and duodenal ulcers. I didn’t change my facial expression but something buzzed inside me. Something serious was going on with Gavin. I finished taking his history and looked through the other papers he had brought, mostly information about the DVT. After the physical exam, I sent him to receive medication while I thought about his case for a bit. Just then Andrew opened my door again.

‘Here’s your coffee.’ He handed me a cup.

‘Thank you.’ I smiled. ‘Hey, do you have a minute?’

‘Sure. What’s up?’

‘Adult male, previously healthy. Six months ago he develops significant gastritis and the endoscopy shows multiple gastric and duodenal ulcers.’

Andrew raised his eyebrows and I took it as a cue to continue.

‘He starts treatment with Omeprazole alone and life goes on. Three months later he develops left leg pain and is diagnosed with DVT.’

Now Andrew was frowning.

‘And then, three weeks ago he starts having nausea, vomiting, and diarrhea as well as worsening epigastric pain and burning.’

‘That’s a lot for someone who used to be healthy.’ He answered still frowning.

‘Right? That’s what I thought too.’

‘And these ulcers. It’s not common to have so many of them.’

‘Yeah.’ I sighed.

‘Was the DVT considered unprovoked?’

‘Yes, they found nothing to justify it.’

‘Huh…’ Andrew tapped his finger at the table. ‘Malignancy?’

‘The biopsies from the endoscopy were clear.’

‘Who says it has to be in the lumen?’

It took me a few seconds to process what Andrew said. And then I knew. 

‘Oh God, I’m so stupid. It doesn’t have to be there.’ I got up from the table. ‘Come on, we should go.’

‘Where?’ He asked already following.

‘To get him a CT. The ulcers are not cancerous. But there is a cancer causing them.’

‘Gastrinoma.’ He said realizing what I had thought of.

‘Exactly. You were right, it's not normal to have that many ulcers. Unless Gavin has Zollinger-Ellison Syndrome. A gastrinoma secreting so much gastrin that too much acid gets produced in the stomach which can cause multiple ulcers.’

‘It makes sense.’ He agreed. ‘And it can also explain the vomiting and diarrhea.’

A few hours later Andrew and I were staring at this pancreatic mass in Gavin’s CT. His gastrin levels in the blood was over ten times the upper limit. Not long after that he underwent surgical resection and was discharged for outpatient care.

Gastroenteritis. Zollinger-Ellison. Medicine can be that tricky.

Want to know more about Zollinger-Ellison Syndrome?


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Clinical Board
SS: signs and symptoms, Dx: diagnosis; Tt: treatment; PPI: proton-pump inhibitor.

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