Case 2: Epigastric Pain in a 14-year-old Boy

Presentation

A 14-year-old boy with a medical history significant for mild intermittent asthma presents to the emergency department with 5 days of epigastric pain, chest pain, poor oral intake, and subjective fevers. On initial presentation he is diagnosed as having viral gastritis and is sent home from the emergency department with an antiemetic drug and instructions for supportive care. However, his symptoms worsen and he is referred back to the emergency department by his primary care physician, ultimately resulting in his admission. The patient is afebrile on presentation, with age-appropriate vital signs. Physical examination findings are normal except for discomfort with deep palpation of his epigastric region. Results of initial evaluation (including abdominal radiography, blood cell count, electrolyte levels, liver function testing, lipase levels, and urinalysis) are within normal limits. Therefore, the initial concern is for a combination of gastritis and constipation: he is treated symptomatically without improvement.

As symptoms persist, he is unable to tolerate any oral intake due to pain and eventually requires placement of a nasogastric tube to maintain proper nutrition. He notes that his most prominent pain localizes to the substernal region. In addition, he begins complaining of odynophagia. A thorough review of the patient’s history …