The weight loss assumption: A case of concerning gastric ulcer initially masked by psychiatric diagnosis
Abstract
Intro: Esophageal gastroduodenoscopy (EGD) is an important test to evaluate for upper GI abnormalities including peptic ulcer disease, malignancy as well as structural abnormalities. Important considerations should be taken for evaluation of red flag symptoms for need of EGD. In this case report, we discussed a patient presenting with failure to thrive initially thought to be from psychiatric illness but later discovered to have severe necrotic ulcer concerning for malignancy as well as structural abnormalities leading to his failure to thrive. Case: Patient is a 55-year-old male with past medical history of heart failure reduced ejection fraction with ICD placement, prior parotid resection due to warthin tumor, COPD, tobacco abuse with prior MCA with residual left-sided weakness. Patient presented to the hospital with concerns for failure to thrive. He reportedly lost 100 pounds in the preceding 3 months. He had been taking frequent Goody powder use to help relieve generalized pain. Upon initial presentation, there was initial concern for aspiration pneumonia thus he was started on a tentative course of 5-day of antibiotics with vancomycin and Zosyn to be de-escalated when appropriate. Patient there was concern for significant anxiety and depression due to recent deaths in his family leading to significant weight loss secondary to severe protein calorie malnutrition. He was initially started on antidepressants /appetite stimulation with mirtazapine and olanzapine after psychiatric consultation. Patient had been placed on NPO status given aspiration admitted concern and had abnormal barium swallow testing necessitating ENT consultation. ENT evaluated patient and believe the patient had calcified stylohyoid ligament after fiberoptic under scope assessment. It was recommended for NG tube placement as well as consideration for percutaneous G-tube placement given abnormality seen on ENT evaluation. Given clinically significant weight loss, GI was consulted for upper endoscopy evaluation which showed a large necrotic deep ulceration suggestive of malignancy. Ultimately, patient elected to go hospice and was discharged with pantoprazole 40 mg twice daily. Discussion: This case report emphasizes the need for consideration of upper endoscopy based on red flag symptoms with a clinically significant weight loss of greater than 5% in the preceding 6 to 12 months. This patient initially presenting with concerns for psychiatric etiology resulting in weight loss however EGD provides definitive resolution upper GI tract to rule out malignancy, peptic ulcer disease as well as structural abnormalities. Conclusion: Diagnostic for shadowing occurs when the patient's physical symptoms were attributed to their psychiatric illnesses. In this case the patient refusal to eat and rapidly sauce was misinterpreted as a behavior choice or as there was anatomical and potentially malignant etiology of the patient's failure to thrive. Final pathology is still pending based off EGD results.
Start Time
15-4-2026 1:30 PM
End Time
15-4-2026 4:30 PM
Room Number
Culp Ballroom 316
Poster Number
20
Presentation Type
Poster
Presentation Category
Health
Student Type
Graduate and Professional Degree Students, Residents, Fellows
Faculty Mentor
Janet Lubas
The weight loss assumption: A case of concerning gastric ulcer initially masked by psychiatric diagnosis
Culp Ballroom 316
Intro: Esophageal gastroduodenoscopy (EGD) is an important test to evaluate for upper GI abnormalities including peptic ulcer disease, malignancy as well as structural abnormalities. Important considerations should be taken for evaluation of red flag symptoms for need of EGD. In this case report, we discussed a patient presenting with failure to thrive initially thought to be from psychiatric illness but later discovered to have severe necrotic ulcer concerning for malignancy as well as structural abnormalities leading to his failure to thrive. Case: Patient is a 55-year-old male with past medical history of heart failure reduced ejection fraction with ICD placement, prior parotid resection due to warthin tumor, COPD, tobacco abuse with prior MCA with residual left-sided weakness. Patient presented to the hospital with concerns for failure to thrive. He reportedly lost 100 pounds in the preceding 3 months. He had been taking frequent Goody powder use to help relieve generalized pain. Upon initial presentation, there was initial concern for aspiration pneumonia thus he was started on a tentative course of 5-day of antibiotics with vancomycin and Zosyn to be de-escalated when appropriate. Patient there was concern for significant anxiety and depression due to recent deaths in his family leading to significant weight loss secondary to severe protein calorie malnutrition. He was initially started on antidepressants /appetite stimulation with mirtazapine and olanzapine after psychiatric consultation. Patient had been placed on NPO status given aspiration admitted concern and had abnormal barium swallow testing necessitating ENT consultation. ENT evaluated patient and believe the patient had calcified stylohyoid ligament after fiberoptic under scope assessment. It was recommended for NG tube placement as well as consideration for percutaneous G-tube placement given abnormality seen on ENT evaluation. Given clinically significant weight loss, GI was consulted for upper endoscopy evaluation which showed a large necrotic deep ulceration suggestive of malignancy. Ultimately, patient elected to go hospice and was discharged with pantoprazole 40 mg twice daily. Discussion: This case report emphasizes the need for consideration of upper endoscopy based on red flag symptoms with a clinically significant weight loss of greater than 5% in the preceding 6 to 12 months. This patient initially presenting with concerns for psychiatric etiology resulting in weight loss however EGD provides definitive resolution upper GI tract to rule out malignancy, peptic ulcer disease as well as structural abnormalities. Conclusion: Diagnostic for shadowing occurs when the patient's physical symptoms were attributed to their psychiatric illnesses. In this case the patient refusal to eat and rapidly sauce was misinterpreted as a behavior choice or as there was anatomical and potentially malignant etiology of the patient's failure to thrive. Final pathology is still pending based off EGD results.
