A 22 year old man with persistent regurgitation and vomiting: case progression

Last week ( BMJ 2006;332:) we presented the case of Mr Neville, a 22 year old student with persistent severe epigastric pain and regurgitation and vomiting after meals. Investigation suggested gastro-oesophageal reflux disease, but treatment with acid suppression and prokinetics was only partially effective and he was readmitted to hospital with persistent symptoms and weight loss. His persistent reflux symptoms were treated aggressively with oral esomeprazole 40 mg twice daily and later with intravenous pantoprazole. This reduced his epigastric pain and heartburn but not the regurgitation and vomiting. He did not tolerate conventional antiemetics, developing a dystonic reaction with prochlorperazine and mental agitation with metoclopramide and cyclizine. Regular ondansetron reduced the sensation of nausea but did not prevent …