Donald came in for his routine physical prior to his senior year in high school. Already he had been undergoing strenuous activities relating to the sports programs for the coming year. This included running the bleachers at the stadium, working out at the boathouse on the rowing machines and long-distance running.
Although he had engaged in these same sports activities last year, now there was a new problem. It seems these activities cause him to vomit. He has even vomited during competition. He was very concerned that this might lead to a dangerous physical problem.
After finding nothing unusual from his physical examination I tried to set Donald's mind at ease. Vomiting before an athletic event is a common reaction to the nervous stress that afflicts competitors before they perform. He reminded me that the vomiting happened during and not before the activity.
Something had changed from last year when he was not bothered with this problem. We listed his pre-exertion eating and drinking habits. Overfilling the stomach prior to an activity could lead to his symptoms. Had he altered his diet in any way, such as dietary supplements, special protein drinks or medications to lose body water?
Next, we evaluated how he looks upon his athletic pursuits this year. Does he feel more stress because he is coming to the end of his high school career and is looking for these sporting activities to provide college placement or current awards? Either of these things would greatly enhance the emotional stress and the associated symptoms. Could he be trying harder this year than last, thus pushing himself beyond his physical tolerance?
Primarily I wanted to be sure that the valve at the top of the stomach was functioning properly. During exertion, the pressure in the stomach may increase. If the valve opens inappropriately, regurgitation and vomiting may occur. A condition known as hiatal hernia may have developed which impeded the valve's function and leads to vomiting. In this condition, the stomach slides through the diaphragm into the chest cavity causing heartburn and regurgitation.
Assessment of these considerations should be handled by having a barium-swallowed X-ray study done to evaluate competency of the valve and the possibility of a hiatal hernia. If the procedure did not shed any light on the problem I would recommend a consult with a gastroenterologist for further studies to determine if reflux of the stomach contents into the esophagus was occurring.
I commended Donald for bringing this concern to my attention. It was important for the cause to be found so that corrective measures could be taken. Whether dietary, emotional or surgical we needed to know the cause of his symptoms.