By HANS DUVEFELT
Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.
Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.
The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.
An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.
He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.
I ordered a pulmonary consult and tonight I was thinking to myself: “Does the vagus nerve sometimes get compromised by hilar masses or adenopathy?”
My first search hit was a 2014 article about a previously unknown association between gastroparesis and pulmonary adenocarcinoma. It has been associated with upper gastrointestinal cancers since 1983 and also with small cell lung cancers and pancreatic cancer.
So my compromised vagus theory may or may not be relevant, but the general link with malignancy was news for me.
As so often in medicine, one diagnosis leads to another.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.