1. Case with chronic vomiting. Dr A-ALSHAIKH

2. HISTORY. 76 years old saudi gentelman complain of vomiting. 3 months duration. Upper abdominal pain, decreased appetite and loss of weight. Lower limbs swelling.

3. History 2. Been seen in different hospital and admitted but no clear diagnosis. Investigation in the other hospital revealed, CBC normal, endoscopy normal. Increased liver enzymes and total Billirubin, urea and creatinine also normal. Ultrasound only hepatomegaly and CT scan showed same. Echocardiography. Medication but no improvement.

4. History 3 Diabetic on sulphonylurea not well controlled. Skin lymphoma and started methotrexate and steroid sometimes. Bronchial asthma treated with bronchodilator and steroid. He stopped methotrexate and steroid 4 months back.

5. Examination in our hospital. Blood pressure 140/90, pulse 80/minute. Tem 38 cº. Jaundice, not pale. No lymphoadenopathy. Lower limbs odema. Chest examination; good air entry, few coarse crepitation. Heart ; regular pulse with normal heart sounds and no added sound and JVP was normal. Abdomen; distended, hepatomegaly, no splenomegaly, and no ascitis.

6. Investigation; CBC normal. Urea, creatinine, and electrolytes were normal. Chest xray ; normal. Liver enzymes; elevated transiminase doubled of normal, alkaline phosphates was elevated less than doubled, G- GT also elevated more than 300. PT, PTT, were normal. Total Billirubin was high both direct and non direct. Stool and urine analysis were normal.

7. Investigation 2. Ultrasound of the abdomen was normal. CT Scan of the abdomen was normal with evidence of fatty liver. ANA ; weakly positive, smooth muscle antibodies antibody was normal, and kidney and liver soluble antibody was positive. Hepatitis markers were negative. Cortisol level was low and low ACTH. Low testosterone and normal prolactine. Endoscopy mild dudenitis only.

8. Management. Antibiotics, proton pump inhibitor. Antiemetic, intravenous fluid. Insulin slidding scale.

9. Indication of steroid. Possibility of adrenal insufficiency due to chronic exposure to exogenous steroid.

11. Gastrointestinal Nausea, vomiting, abdominal pain and constipation or diarrhea. The cause not known. Endoscopy and radiology usually normal. Gastric emptying delayed. Peptic ulcer is rare.