An adolescent with vomiting and weight loss.

A 17-year-old female complained of difficulty swallowing and recurrent vomiting of one year duration. She stated that she was trying to gain weight. She felt that a weight at the 5th percentile for age was appropriate for her 70th percentile height. She denied binge eating, self-induced vomiting, concern over abnormal eating, or depressed mood. She had low normal intelligence, long-standing problems with school and peer relationships, and was experiencing significant conflict with her stepfather. The mother noted that her daughter's symptoms had begun at the time her prized horse went lame. Physical examination was unremarkable except for thinness. At a two-week follow-up visit, all vomiting had ceased and the patient had gained 1.6 kg. Plans for a barium esophagogram were cancelled and psychiatric consultation was arranged. A six-week followup revealed no vomiting, although weight gain had not progressed. Six months later, the patient was seen with a two-month history of recurrent vomiting. A barium esophagogram revealed achalasia. Pneumatic dilation of the lower esophageal sphincter was successful. Seventeen months after the initial visit the patient was asymptomatic, happy, and seemingly well adjusted.