Abdominal Pain in a Patient with an Eating Disorder

Hiroki Fukushima M.D., Yu Akaishi M.D., Ph.D., Yoshimi Harada M.D., Ph.D. and Yoji Hirayama M.D., Ph.D.

May 22, 2017

A 21-year-old woman was admitted to our hospital for a 3-day history of abdominal pain. The pain started in the epigastric region, but quickly spread to encompass the entire abdomen. Her pain intensity was 4 on a scale of 1 to 10. She was admitted for associated nausea and compulsive self-induced vomiting. She carried a diagnosis of an eating disorder and a dissociative disorder. She had been well controlled on antipsychotics and anxiolytics.  
Physical examination revealed a blood pressure of 119/68 mmHg, a pulse rate of 55 beats/min, a respiratory rate of 16 breaths/min, an oxygen saturation of 96% on room air, and a temperature of 38.2ºC. Overall, she appeared well. Abdominal examination revealed positive bowel sounds, mild diffuse distention without rigidity, and rebound tenderness in the epigastric region. Laboratory evaluation revealed a white blood cell count of 8200/μL (84% neutrophils) and a C-reactive protein level of 6.8 mg/dL. Her urinalysis was normal. Abdominal CT demonstrated a low-density lesion involving the hepatic marginal region and the serosa of the stomach (See Image 1), with ascites in the pouch of Douglas. She was suspected to have peritonitis and was kept nil per os, supported with intravenous fluids and empiric antibiotics. Urgent upper gastrointestinal endoscopy was performed (See Image 2). 

What is the most likely cause of her peritonitis?

A. Gastric ulcer
B. Gastric anisakiasis
C. Foreign body ingestion
D. Stomach cancer

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References:

1. Jakubaschk J1, Böker W. Disorders of pain perception in schizophrenia. Schweiz Arch Neurol Psychiatr. 1991; 142: 55-76. 

Author Information:

1. Hiroki Fukushima M.D. is a Physician in the Department of General Medicine and Primary Care at Tokyo Medical University Hospital. 
2. Yu Akaishi M.D., Ph.D. is a Physician in the Department of General Medicine and Primary Care at Tokyo Medical University Hospital. 
3. Yoshimi Harada M.D., Ph.D. is an Assistant Professor in the Department of General Medicine and Primary Care at Tokyo Medical University Hospital. 
4. Yoji Hirayama M.D., Ph.D. is a Professor in the Department of General Medicine and Primary Care at Tokyo Medical University Hospital.