Please treat me with metoclopramide

Severe peptic ulcer resulting in hypertrophic pyloric stenosis is a rare clinical problem nowadays. Symptoms include vomiting, nausea, early satiety, weight loss, epigastric pain especially after eating. The physical examination may not be helpful because the pyloric mass is difficult to palpate. We report a case of a 43-year-old man who presented to the emergency department complaining of vomiting. He asked for metoclopramide, refusing initially further investigation and gastrointestinal endoscopy. Finally, he agreed to undergo a barium meal examination, which showed severe pyloric stenosis. He underwent vagotomy and enteroanastomosis. The biopsy of the removed segment of the stomach did not show any malignant changes. A 43-year-old man presented to the emergency department complain-ing of vomiting. He refused per-sistently to give any more details. He asked for an intramuscular injection of metoclopramide, refusing further investigation, since ‘‘he already knew his problem’ ’ (‘‘recurrent gastritis’’). However, he was convinced to undergo an electrocardiogram in our attempt to rule out vomiting of cardiac origin, which showed ST changes and minimal U wave, suggestive of hypokalaemia (fig 1). The physical examination on presentation was unremarkable except for epigastric tenderness. Routine laboratory testing on admission was unremarkable except for low serum potassium (2.1 mmol/l). The arterial blood gas tests showed metabolic alka-losis (pH 7.66, bicarbonate 55.2 mmol