What is the cause of intermittent vomiting in a patient with normal blood pressure, currently controlled with lisinopril (angiotensin-converting enzyme inhibitor), and what is the necessity of continuing this medication?

Evaluation of Intermittent Vomiting and Lisinopril Necessity in a Young Adult

Primary Concern: Eosinophilic Esophagitis (EoE) is the Most Likely Missed Diagnosis

The clinical presentation of intermittent vomiting with a sensation of throat fullness or tightness during/after eating, relieved by vomiting, and recurring weekly in a 21-year-old male strongly suggests eosinophilic esophagitis (EoE), which requires upper endoscopy with esophageal biopsies for diagnosis.

Key Diagnostic Features Supporting EoE:

• Intermittent dysphagia/throat tightness during eating is the hallmark symptom in young adults with EoE
• Relief after vomiting suggests food impaction or esophageal dysmotility
• No relationship to specific foods is typical, as EoE can be triggered by multiple allergens
• Absence of heartburn helps distinguish this from GERD
• Young male demographic (EoE predominantly affects males aged 20-40)

Immediate Next Steps:

• Refer to gastroenterology for upper endoscopy with esophageal biopsies (minimum 6 biopsies from proximal and distal esophagus)
• Consider empiric trial of proton pump inhibitor (PPI) twice daily for 8 weeks before endoscopy, as PPI-responsive esophageal eosinophilia is part of the EoE spectrum
• Obtain complete blood count with differential to assess for peripheral eosinophilia (present in only 50% of EoE cases)

Alternative Diagnoses to Consider:

• Achalasia: Would typically present with progressive dysphagia to both solids and liquids, regurgitation of undigested food
• Esophageal stricture or ring: Usually causes dysphagia with solid foods specifically
• Gastroparesis: Would present with early satiety, bloating, and postprandial fullness (symptoms explicitly absent here)
• Rumination syndrome: Characterized by effortless regurgitation within minutes of eating, typically without nausea

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Lisinopril Assessment: Discontinuation is Strongly Recommended

This 21-year-old patient with a current blood pressure of 122/76 mmHg does NOT require antihypertensive medication and lisinopril should be discontinued. 1

Rationale for Discontinuation:

1. Blood Pressure is Normal Without Treatment Indication

• Current BP of 122/76 mmHg falls into the elevated BP category (systolic 120-129 mmHg), not hypertension 1
• The 2024 ESC Guidelines define hypertension as BP ≥140/90 mmHg 1
• Elevated BP in a young adult without high cardiovascular risk does not warrant pharmacological treatment 1

2. Age-Inappropriate Prescribing

• At age 21, this patient has extremely low baseline cardiovascular risk (<1% 10-year risk)
• The 2024 ESC Guidelines recommend pharmacological treatment for elevated BP (130-139/80-89 mmHg) only in patients with sufficiently high CVD risk after 3 months of lifestyle intervention 1
• Pharmacological treatment is recommended when confirmed BP ≥140/90 mmHg, irrespective of CVD risk 1, which does not apply here

3. Lack of Compelling Indications

• No evidence of:
  • Diabetes mellitus
  • Chronic kidney disease
  • Heart failure
  • Left ventricular dysfunction
  • Proteinuria
  • Previous myocardial infarction 1

4. Potential Harm from Unnecessary Treatment

• Risk of symptomatic hypotension, particularly in a young, otherwise healthy individual 2
• Possible medication-related adverse effects including angioedema (higher risk in young males) 2
• Rare but documented risk of ACE inhibitor-induced pancreatitis 3
• Unnecessary medication burden and cost

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Recommended Management Algorithm

Step 1: Discontinue Lisinopril

• Taper is not required for ACE inhibitors (unlike beta-blockers or clonidine)
• Inform patient that BP was likely never high enough to require medication
• Monitor BP weekly for 4 weeks after discontinuation to confirm stability

Step 2: Implement Lifestyle Modifications

The 2024 ESC Guidelines recommend the following for elevated BP 1:

• Dietary changes: Mediterranean or DASH diet
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm
• Physical activity: 150 minutes/week moderate-intensity aerobic exercise plus resistance training 2-3 times/week
• Sodium restriction: <5g/day (2g sodium)
• Alcohol limitation: <100g/week of pure alcohol
• Tobacco avoidance: If applicable

Step 3: Blood Pressure Monitoring Schedule

• Home BP monitoring twice daily (morning and evening) for 1 week after stopping lisinopril 1
• If BP remains <130/80 mmHg: recheck every 6-12 months
• If BP rises to 130-139/80-89 mmHg: continue lifestyle modifications and recheck every 3-6 months
• If BP rises to ≥140/90 mmHg on repeated measurements: consider restarting treatment

Step 4: Address the Vomiting

• Urgent gastroenterology referral for upper endoscopy with esophageal biopsies
• Consider empiric PPI trial: omeprazole 40 mg twice daily or esomeprazole 40 mg twice daily for 8 weeks
• Dietary diary to identify potential trigger foods
• If EoE confirmed: treatment options include topical corticosteroids (swallowed fluticasone or budesonide), dietary elimination therapy, or biologic agents

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Common Pitfalls to Avoid

Pitfall 1: Treating "White Coat Hypertension"

• The initial "slightly raised BP" that prompted lisinopril was likely an isolated elevated reading
• Always confirm hypertension with multiple readings over several weeks or with ambulatory/home BP monitoring before initiating treatment 1

Pitfall 2: Assuming Young Patients Need Treatment for Borderline BP

• Pharmacological treatment in young adults with elevated BP (120-139/70-89 mmHg) should only occur after documented failure of 3 months of lifestyle intervention AND presence of high cardiovascular risk 1

Pitfall 3: Missing EoE Due to Atypical Presentation

• EoE can present with vague symptoms that don't fit classic GERD
• The combination of intermittent dysphagia, food-related symptoms, and young male patient should trigger consideration of EoE
• Standard imaging (ultrasound, X-ray) and blood work will be normal in EoE

Pitfall 4: Continuing Unnecessary Medications

• Once started, antihypertensives are often continued indefinitely without reassessment
• Regular review of medication necessity is essential, especially when prescribed for borderline indications 1

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Summary of Recommendations

Immediate Actions:

1. Discontinue lisinopril - no indication for treatment at current BP of 122/76 mmHg 1
2. Refer to gastroenterology for upper endoscopy to evaluate for eosinophilic esophagitis
3. Implement lifestyle modifications for BP management 1
4. Home BP monitoring to confirm stability after medication discontinuation 1

Follow-up:

• Recheck BP in 1 month, then every 6-12 months if stable
• Gastroenterology appointment within 4-6 weeks
• Consider empiric PPI trial while awaiting endoscopy