Story 9 The curious case of Cyclical Vomiting

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28 year old women known to suffer from “Cyclical Vomiting” presented to ED as she felt poorly. Vomiting a dozen times daily was a routine but today was something different. She had thrown up >20 times in a day.

Her initial observations were

Pulse 127/min BP 95/59 SpO2 93% on air

Abdomen was tender in epigastrium with no guarding. She appeared severely dehydrated.

Initial blood gas showed

pH 7.2

HCO3 16

Base excess -11

Glucose 7.8 mmol

Lactate 9

Urea 8.1 mmol/L

No obvious cause of shock was recognised. Pt was resuscitated with IV fluids and was given broad spectrum anti-biotics.

Significant lab results were

Urea 8.9 mmol/L Creatinine 136 umol/L GFR 39 INR 1.2

After 3.5 litres of fluids, repeat ABG showed

pH 7.14 HCO3 13  Base excess -10 Glucose 14 mmol Lactate 11.5


So glucose was rising, acidosis was worsening & lactate was creeping up. ketones were tested which were high (6.6).At this point, patient was started on DKA protocol as she met the criteria(hyperglycemia, ketonemia and acidosis).

But this wasn’t a simple DKA. Patient was in multi organ failure with high lactate and refractory acidosis. CT abdomen was arranged and ITU were involved.


Fig 1 Large amount of free air can be seen in the pancreas

This was a case of necrotizing pancreatitis associated with DKA and multi organ failure as a complication.She was taken to ITU where she made a gradual but full recovery.

moral 1 of the story 9



Case report

Case series

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