Chief Complaint (CC): H.M., a 28-year-old Caucasian female, presents with complaints of intermittent abdominal pain and bloating that have persisted for the past six months. Subjective Data: History of Present Illness (HPI): H.M. reports that the abdominal pain and bloating began approximately six months ago and have been intermittent since then. The pain typically occurs after eating large meals, and she often experiences relief after vomiting. H.M. relates the onset of her symptoms to a particularly stressful day at work six months ago, during which she felt ill and vomited after consuming a large lunch. Since that incident, H.M. has been engaging in self-induced vomiting as a strategy to avoid weight gain. She admits to feeling out of control during eating episodes and has noticed a pattern of consuming large quantities of food, particularly late at night. H.M. reports vomiting at least three times a week and adheres to a low-calorie diet. Additionally, she engages in rigorous physical activity, attending yoga and exercise classes six times a week. Past Medical History (PMHx): H.M. has no significant past medical history that she reports. Demographics: 28-year-old Caucasian female. Past Surgical History (PSHx): No reported surgical history. Allergies: No known drug allergies. Lifestyle: H.M. works as a catering manager at a resort hotel, which places her in constant contact with food throughout the day. She lives with her parents and a younger brother following a recent breakup with her boyfriend. Psychosocial History: H.M. is noted to have a history of being highly conscious about her weight, particularly over the past year as she has gained weight. Her mother describes H.M.’s previous weight as slender (105 pounds at 5'1"), but she has recently gained a significant amount of weight, now likely over 140 pounds. H.M.’s mother has observed unusual eating patterns, including consuming large amounts of food late at night and isolating herself in the bathroom after meals. H.M. admits to feeling bad about her eating habits and struggles with a perceived loss of control over her eating. Assessment: Differential Diagnoses: The following three differential diagnoses are considered based on H.M.’s presenting symptoms and history:
- Bulimia Nervosa
- Irritable Bowel Syndrome (IBS)
- Gastroesophageal Reflux Disease (GERD)
- Bulimia Nervosa:
- Occurrence: Bulimia nervosa is more common in young women and often develops during adolescence or early adulthood. It is characterized by recurrent episodes of binge eating followed by compensatory behaviors, such as vomiting, to prevent weight gain.
- Pathophysiology: The exact cause of bulimia nervosa is not fully understood, but it is believed to involve a combination of genetic, psychological, and environmental factors. Neurobiological abnormalities, particularly in the brain’s regulation of hunger and satiety, may contribute to the development of bulimia. The recurrent vomiting associated with bulimia can lead to electrolyte imbalances, esophagitis, and dental erosion (American Psychiatric Association, 2013).
- Presentation: Patients with bulimia nervosa often present with normal or slightly overweight body types. They may report symptoms such as abdominal pain, bloating, sore throat, and chronic gastrointestinal disturbances due to frequent vomiting. Psychological symptoms include feelings of guilt, shame, and a distorted body image.
- Irritable Bowel Syndrome (IBS):
- Occurrence: IBS is a common functional gastrointestinal disorder that affects up to 20% of the population, with a higher prevalence in women. It is characterized by chronic abdominal pain, bloating, and changes in bowel habits (diarrhea, constipation, or both).
- Pathophysiology: The pathophysiology of IBS is multifactorial, involving altered gastrointestinal motility, visceral hypersensitivity, and dysregulation of the gut-brain axis. Psychological factors, such as stress and anxiety, can exacerbate IBS symptoms (Chey et al., 2015).
- Presentation: Patients with IBS often present with recurrent abdominal pain and bloating that are relieved by defecation. The pain is typically associated with changes in stool frequency or form. Unlike bulimia, IBS does not involve compensatory behaviors like vomiting, and patients do not exhibit a distorted body image.
- Gastroesophageal Reflux Disease (GERD):
- Occurrence: GERD is a chronic condition that affects approximately 20% of the adult population. It is characterized by the reflux of stomach contents into the esophagus, leading to symptoms such as heartburn and regurgitation.
- Pathophysiology: GERD results from the dysfunction of the lower esophageal sphincter, which allows gastric acid to flow back into the esophagus. This can cause mucosal damage and inflammation, leading to symptoms such as heartburn, chest pain, and regurgitation (Vakil et al., 2006).
- Presentation: Patients with GERD typically present with persistent heartburn, acid regurgitation, and bloating. Unlike bulimia, GERD is not associated with compensatory behaviors or psychological distress related to body image. However, the chronic regurgitation seen in GERD may be confused with the vomiting associated with bulimia.
- Bulimia Nervosa: The diagnosis of bulimia nervosa is primarily clinical, based on the patient’s history and reported behaviors. However, laboratory tests may be conducted to assess for electrolyte imbalances, dehydration, and other complications associated with frequent vomiting. The SCOFF questionnaire is a validated screening tool for eating disorders that can be utilized in clinical practice (Morgan et al., 2000).
- Irritable Bowel Syndrome (IBS): The diagnosis of IBS is also clinical, based on the Rome IV criteria, which include recurrent abdominal pain associated with defecation and changes in stool frequency or form. Additional testing may include stool studies, colonoscopy, and blood tests to rule out other conditions such as celiac disease or inflammatory bowel disease (IBD) (Chey et al., 2015).
- Gastroesophageal Reflux Disease (GERD): The diagnosis of GERD is often based on the patient’s symptoms and response to proton pump inhibitors (PPIs). Additional diagnostic tests, such as upper endoscopy, pH monitoring, and esophageal manometry, may be indicated for patients with atypical symptoms or those who do not respond to empirical treatment (Vakil et al., 2006).
- Bulimia Nervosa: The American Psychiatric Association’s guidelines recommend a comprehensive evaluation for patients suspected of having bulimia nervosa, including a thorough history, physical examination, and psychological assessment. Treatment typically involves a combination of cognitive-behavioral therapy (CBT) and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) (American Psychiatric Association, 2013).
- Irritable Bowel Syndrome (IBS): The American College of Gastroenterology’s guidelines recommend a positive diagnostic strategy for IBS based on symptom-based criteria, such as the Rome IV criteria, rather than exhaustive exclusion of other conditions. First-line treatments include dietary modifications (e.g., low FODMAP diet) and pharmacotherapy tailored to the predominant symptom (Chey et al., 2015).
- Gastroesophageal Reflux Disease (GERD): The American College of Gastroenterology’s guidelines recommend an initial trial of lifestyle modifications and PPIs for the management of GERD. Diagnostic testing, such as endoscopy, is reserved for patients with alarm symptoms (e.g., dysphagia, weight loss) or those who do not respond to initial treatment (Vakil et al., 2006).
