Nausea, vomiting, and epigastric pain in an elderly diabetic.

A 61-year-old man presented with the complaints of nausea, vomiting, and severe epigastric pain. An anteroposterior roentgenogram of the abdomen demonstrated a conclusive diagnostic finding. History The patient was a noncompliant, poorly regulated diabetic receiving 54 units of isophane insulin (NPH [neutral protamine hagedorn] insulin) and 20 units of insulin by subcutaneous injection daily. His medical history was significant for multiple sequelae of diabetes. On physical examination, he was febrile (temperature, 38.5 °C), alert, and in no apparent distress. His abdomen was moderately distended, tender, and had normal bowel sounds. Laboratory findings included an elevated serum glucose level of 345 mg/ dL, urine glucose concentration of 3%, and white blood cell count of 19,000/cu mm. Roentgenograms of the chest and abdomen demonstrated radiological findings that will be described subsequently (Fig 1). (To the reader: Observe the area of the stomach with extra care.) Diagnosis Gastric emphysema associated with gastroparesis in