Nausea and vomitting, It’s not always what you think.

vomiting

Posted by Sara Ghotb, MD PGYIII Internal Medicine, Monmouth Medical Center

Case history:

This 74 y/o African American male presented to the emergency department with a 1-week history nausea ad intractable vomiting.

His past medical history included surgery for esophageal cancer in 2012 and hypertension.

He was admitted to the hospital for a gastrointestinal evaluation.  His symptoms did not improve with antiemetics and he also began to complain of headache and dizziness.  He was scheduled for an upper GI endoscopy.

What would you do next?

A.  Go ahead and do the upper GI endoscopy

B.  Order a brain imaging study

C.  Do a more detailed examination

D.  Prescribe more antiemetic medication

Advertisements

Lactic Acid gone to your head?

ataxia
D-Lactate Encephalopathy and Periodic Ataxia
Posted by Michael Twomey, Drexel MSIV, Class of 2014

Remember that pain in your side during a long hard workout? That’s the buildup of lactic acid or L-lactate which is a way for your body to burn energy when it there isn’t much oxygen around (like when you think it’s a good idea to run 5 miles). This feeling, although uncomfortable, won’t make you loopy–it’s twin brother, however, has no such qualms.

D-lactate is just like normal old lactic acid, only completely different. In fact, it is the mirror image of the molecule that causes us such grief. For those of us who have forgotten organic chemistry, or would rather walk on broken glass than take such a torturous class, think
of it like a pair of gloves. L-lactate would be your left hand glove and D-lactate the right. They look like the same darn thing from a distance (made out of the same leather and thread, and stuffing), but no matter how you rotate them, you could never get them to match up.

FIGURE 1

Our bodies happen to be finicky. Like the 7 year old fussy eater we all know and (hopefully still) love, the human body can only make and break down L-lactate. Thus, under factory settings, we all have an undetectable level of D-lactate in our blood. Bacteria, however, are wired a bit differently (shocking, I know). Some can take the same sugars that we eat, turn them into D-lactate, and when those buggers are in your intestinal system–this form of lactic acid can enter our blood stream.

Lactobacilli (the bad guys)

It just so happens that high levels of D-lactate effects the brain just as much as it does the rest of our bodies. We aren’t exactly sure the why or how this compound acts on our central nervous system, but it can cause anything from making you unbalanced to putting a patient in a delirious state. Case reports show symptoms of sleepiness, hallucinations, clumsiness, blurred vision, disorientation, dizziness, lethargy, excessive irritability, and abusive behavior. All of which can last up to a few days! The gait can be very unsteady (ataxic) during each episode, and this syndrome is one of the causes of “periodic ataxia”.

To make the diagnosis these patients also had an elevated amount of acid in their blood (something normal Lactic Acid can do as well) and high levels of D-lactate.
So can you blame the next time you trip over the doormat on bacteria? Probably not.
Fortunately the only reports of this syndrome have been found in people with extensive small intestine surgery. It turns out that the bacteria who can make D-lactate tend to live in our large intestine where they almost never see large amounts of sugar. Normally our small intestine is long enough to absorb all of those nutrients and leaving them to digest your Mexican meal instead. People with short bowel syndrome, however, should be aware of this possibility and eat appropriately. Otherwise having meals high in simple sugars could cause you to end up in the hospital with some strange behaviors and a nice long course of antibiotics!

Another reason to take snoring seriously! Sleep apnea linked to strokes.

sleepdisorder

Sleep apnea, the disorder that causes a person to stop breathing suddenly while sleeping, is already known to increase the risk of high blood pressure, heart failure, and daytime sleepiness.

seep apnea consequences

A new study suggests that the sleep disorder is also linked with small brain lesions and a symptomless form of stroke, known as silent stroke.

In the study, 56 men and women ( aged 44 to 75 years) who’d had a recent stroke or TIA underwent overnight polysomnograms.  91% had sleep apnea.

Furthermore, having more than five episodes of sleep apnea in a night was linked with having multiple extra “silent strokes” on their brain imaging studies.

silent stroke

Silent strokes don’t cause any symptoms as they occur, so a person typically doesn’t know he or she has suffered one, but they can eventually lead to memory loss and difficulties with walking, as their effects accumulate over the years.”

Yet another reason to take the on-line sleepiness test, and if your score is >10 see a sleep specialist and/or get an overnight polysomnogram in a certified sleep laboratory.

Monmouth Neuroscience NPH Success Story

ventriculostomy-hydrocephalus

Hydrocephalus before (A) and after (B) CSF diversion

Normal pressure hydrocephalus (NPH) is caused by excessive accumulation of cerebrospinal fluid (CSF) and enlargement of the brain’s ventricular system, putting increased pressure on surrounding brain tissue, and leading to a distinctive gait disturbance, urinary incontinence and dementia.

NPH can be effectively treated by a surgical procedure to divert the CSF from the ventricles into the peritoneal cavity via a ventriculoperitoneal shunt.

Early diagnosis and treatment are important for this surgical treatment to be effective.

However NPH is frequently unrecognized or misdiagnosed as arthritis, Parkinson’s disease, Alzheimer’s disease, or “senility”, leading to other ineffective treatments and nursing home confinement.

However, many patients with dementia or gait problems and large ventricles on a brain imaging study will not improve after shunting.  Performing surgery on all such patients, without further selection, can result in ineffective surgery, and more importantly other potential complications like bleeding around the brain (a subdural hematoma).

Therefore selecting the patients with suspected NPH who are most likely to benefit from surgery is of the utmost importance.  Studies have shown that careful evaluation of patients using objective measures during prolonged CSF drainage via a lumbar drain is the most sensitive and specific way to predict which patients will improve with surgery.

The neurologists and neurosurgeons at the Monmouth Neuroscience Center have developed a multidisciplinary hydrocephalus assessment program to evaluate patients with suspected NPH and determine who is most likely to benefit from a shunting procedure.

Here’s one of out recent success stories!

Find out more about:

Normal Pressure Hydrocephalus

Other funny walks and extreme gait apraxia

The Hydrocephalus Program at Monmouth Neuroscience Institute

Extreme Gait Apraxia – Parkinson’s Patient Can’t Walk But Can Ride a Bike!

Apraxia is a disorder of motor planning leading to the loss of ability to carry out a learned purposeful movement, despite having the desire and the physical ability to perform that movements.

For example, patients with dressing apraxia, which can be caused by stroke or dementia, can move their limbs normally, but cannot figure out how to put their clothes on properly:

Patients with gait apraxia, caused by Parkinsonism, NPH or frontal lobe dysfunction, have particular difficulty initiating gait and making turns, often with a tendency to freeze, but a relative preservation of straight-line gait once initiated:

A newspaper article from the UK reported the case of a 58-year-old man with Parkinson’s and severe “gait freezing”. He required visual guides to help him move one foot in front of the other and was unable to turn while walking. After a few steps he would lose his balance and then require his wheelchair.  However, he could still ride his bicycle, flawlessly:

This is extreme gait apraxia – he is able to move his legs and control he balance enough to ride a bike, and yet is unable to do so for the (much easier) task of walking.

Click here to read the full article.

Click here to see more funny walks.

Baclofen Pump Success Story

This 47 year old woman had spastic paraparesis from spinal cord injury related to both transverse myelitis and cervical spondyl0tic myelopathy.

Her gait was slow and spastic, and she could barely walk with a walker.

She had either not improved, or suffered side effects, from oral medications including baclofen, clonazepam and cyclobenzaprine.

Her walking improved after a trial of intrathecal baclofen, and she has now has a permanent intrathecal baclofen pump.

She is able to walk with a cane, but I had her walk using the wheelchair as a walker to make the before and after videos more comparable.

Find out more about spasticity management, the Spasticity Center at Monmouth Neuroscience Institute  and Intrathecal Baclofen Therapy.

New Monmouth Neuroscience Clinic Space

125th-annv-logo-blue-and-gray

The Neuroscience Institute at Monmouth Medical Center is proud to announce the opening of its brand new out-patient clinic space on the 4th floor of the Wimpfheimer building, which will will be the home of many new  innovative programs.

View of Monmouth from Third Ave, showing Winpfheimer building (center).

View of Monmouth from Third Ave, showing Wimpfheimer building (center).

This historical building was erected in 1919 with money donated by board of trustee member Charles A. Wimpfheimer, in memory of his 19-year old son Jacques, who when stricken with pneumonia while in military service requested that he be given the same treatment as the other privates, and as a result was sent to a ward in a Hoboken hospital, where he died.

wimp-plaque

MMC clinic

DIRECTIONS:
Click here for directions to Monmouth Medical Center.

Once you arrive, enter the hospital from 3rd Avenue (1), park (2) and enter the hospital via the Radiation-Oncology Entrance (3).  Register at the desk:

MMC map

You will be directed to elevators that will bring you up to the 4th floor (BBR4), where you will pass through a nursing evaluation, then proceed to out brand new out-patient space on Wimpfheimer 4.