IT is an ultimate Catch-22 where either choice could prove fatal. Caitlin White, a 19-year-old with a rare gut condition which causes her to throw up more than 30 times a day, has been told that artificial feeding may kill her. But without it she also faces potentially deadly organ failure.
The teenager, from Perth, is now desperate for help from gastroenterology experts anywhere in the world as she faces up to a seemingly hopeless dilemma over her future treatment.
Ms White, who is 5ft 5 but weighs just six stone, survives on high-calorie soup, gels and powders as a result of gastroparesis, a painful condition which means her stomach is partially paralysed.
It has led her to develop cyclical vomiting syndrome, meaning she is often sick more than 30 times a day, and was forced to have six teeth extracted earlier this month as a result of acid damage.
Extreme constipation - six to seven weeks can elapse between bowel movements - has also led to a build up of bacteria in her small intestine that has ravaged her immune system, and she has suffered a string of sepsis infections.
In April, Scotland's chief medical officer Dr Catherine Calderwood intervened in Ms White's case to instruct that NHS Tayside refer the teenager to another specialist in Glasgow amid concerns over her care.
However, she said she feels in limbo after the Glasgow consultant, Dr Ruth McKie, warned that she was at "extremely high risk" of complications, including death, if doctors attempt to feed her using Total Parenteral Nutrition (TPN), where nutrients including glucose, salts, amino acids, fat molecules, vitamins and minerals are directly pumped into a person's bloodstream via a drip.
A previous line inserted at Ninewells hospital in Dundee in March 2015 led Ms White to develop the potentially deadly blood infection septicaemia.
Dr McKie warned that attempting TPN again could result in "life-threatening complications" including chronic liver failure and blood clots on the brain, and stressed that it should only be trialled for a set period and suspended if the number of infections exceeded a predetermined amount.
However, Ms White - who weighed 11 stone before falling ill aged 14 - was also warned that lack of nutrition is jeopardising her immune system.
She said: "You have to weigh up the risks, but effectively my organs could go into failure without giving me TPN.
"The risks of doing nothing are that my immune system is weakened from lack of nutrition and my liver, kidneys and heart could be affected further than they already are in the long term.
"I will require longer hospital visits than I already do every day, and if the vomiting continues I will have lost all of my teeth by this time next year."
Ms White was previously an inpatient at Ninewells hospital in Dundee for 10 months, but numerous attempts to insert feeding tubes directly into her stomach and bowel failed due to her constant vomiting and a condition called Ehlors Danloss syndrome, which means Ms White's muscles are abnormally slack.
However, relations between Ms White and her family and her gastroenterology team at Ninewells broke down when staff claimed Ms White was sabotaging her treatment by dislodging the tubes on purpose - something she strongly refutes.
Her grandmother, who she lives with, was left furious when nurses implied Ms White had an eating disorder and that her agonising stomach cramps were "phantom pains", despite a private gastroenterologist telling the family it was one of the worst cases of gastroparesis he had ever seen.
Ms White was eventually discharged from Ninewells in June 2015 and since then has spent eight to nine hours a day as an outpatient at Perth Royal Infirmary receiving infusions of potassium, magnesium, iron and phosphate to keep her alive.
Despite the risks, Ms White says she would be willing to try TPN again - but not at Ninewells. She says she has lost faith in consultants there and has had no medical input from the gastroenterology team for three years.
However, a spokeswoman for NHS Tayside said PRI lacks the expertise needed to deliver the treatment. She said: "The multidisciplinary expertise required for long term parenteral nutrition exists on the specialist gastroenterology ward at Ninewells Hospital and does not exist elsewhere in NHS Tayside."
The spokeswoman added that while the health board could not comment on individual cases, it was "committed to delivering effective, safe healthcare to patients in an appropriate environment with the necessary expertise from staff".
Ms White said she has written to experts in gut health all over the world and hopes someone might be able to help.
"My condition is so complex unfortunately, but there must be someone willing to take it on or there must be a way round them giving me TPN," she said.
"I've been reading a lot about gut motility disorders and there are people in Europe and the US with the expertise to take on conditions like this but whether or not that would be an avenue to go down, I don't know.
"I don't know what else to do and I don't think anyone else does to be honest. My hope from speaking out is that someone knows something about it or could offer help."
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