1. Case Review Course In the name of God 5th session – July 31, 2013
By Mohammad Reza Emami

2. Agenda 1 2 3 4 5 6 Approach to the patient with dysphagia
Discussing differential diagnoses
Review the List of GI disorders 1 2 3 4 5 6
Symptoms of Gastrointestinal Diseases
Evaluation of a case
Review some mini-cases

3. 1- Review the list of GI disorders
Esophageal disorders :
Gastroesophageal Reflux Disease (GERD)
Barrett’s Esophagus
Hiatal hernia
Rings and Webs
Esophageal diverticulum
Achalasia
Diffuse Esophageal Spasm (DES)
Esophagitis
Infectious esophagitis
Non-infectious esophagitis

4. 1- Review the list of GI disorders (continue)
Stomach disorders :
Peptic Ulcer Disease (PUD)
Zollinger-Ellison Syndrome (ZES)
Gastritis
Ménétrier's disease

5. 1- Review the list of GI disorders (continue)
Nutritional and malabsorption disorders :
Celiac disease
Tropical sprue
Short Bowel Syndrome
Bacterial Overgrowth Syndrome (BOS)
Food allergies
Lactose intolerance
Irritable Bowel Syndrome (IBS)
Whipple’s disease
Protein-Losing Enteropathy

6. 1- Review the list of GI disorders (continue)
Gastroenteritis :
Bacterial gastroenteritis
Viral gastroenteritis
Parasitic gastroenteritis

7. 1- Review the list of GI disorders (continue)
Inflammatory intestinal disorders :
Inflammatory Bowel Disease (IBD)
Ulcerative Colitis
Crohn’s Disease
Microscopic colitis

8. 1- Review the list of GI disorders (continue)
Anorectal disorders :
Diverticular disease
Diverticulosis
Diverticulitis
Procidentia
Fecal incontinence
Hemorrhoidal disease
Anorectal abcess
Anal fistule
Anal fissure

9. 1- Review the list of GI disorders (continue)
GI Neoplasms :
Esophageal cancer
Gastric cancer
Small intestine tumors
Colorectal cancer
Anal cancer

10. 2- Symptoms of Gastrointestinal Diseases
The most common GI symptoms are: abdominal pain, heartburn, nausea and vomiting, altered bowel habits, GI bleeding, and jaundice. Others are: dysphagia, anorexia, weight loss, fatigue, and extraintestinal symptoms.
See Table 1

11. Table 1 - Common Causes of Common GI Symptoms
Abdominal Pain
Nausea and Vomiting
Diarrhea
GI Bleeding
Obstructive Jaundice
Appendicitis
Gallstone disease
Pancreatitis
Diverticulitis
Ulcer disease Esophagitis
GI obstruction
IBD
Functional bowel disorder
Vascular disease
Gynecologic causes
Renal stone
Medications
Motor disorders
Enteric infection
Pregnancy
Endocrine disease
Motion sickness
Central nervous system disease
Infection Poorly absorbed sugars
Microscopic colitis
Celiac disease
Pancreatic insufficiency
Hyperthyroidism
Ischemia
Endocrine tumor
Ulcer disease
Esophagitis
Varices
Vascular lesions
Neoplasm
Diverticula
Hemorrhoids
Fissures
Infectious colitis
Bile duct stones
Cholangiocarcinoma
Cholangitis
Sclerosing cholangitis
Ampullary stenosis
Ampullary carcinoma
Pancreatic tumor

12. 3- Approach to the patient with dysphagia
A 43-year old man has persistent dysphagia following cancer of the right buccal space. To treat the cancer, he had radiation therapy and neck dissection. He currently exhibits pharyngeal dysphagia, aspiration, hoarse vocal quality, and right lower facial weakness. He currently receives nutrition through a NG-tube.
What would be your next measure ?

13. 3- Approach to the patient with dysphagia (continue)

14. 4- Evaluation of a case
A 64-year-old white woman with a history of breast cancer treated with lumpectomy and radiation, hypertension, high cholesterol, and ovarian polyps presents to her primary care physician complaining of difficulty and pain with swallowing, as well as occasional chest pain. She indicates that her problem started with liquids, but has progressed to solids, and that the food “just gets stuck in my throat.” The chest pain was once so bad that she took one of her husband’s nitroglycerin pills and the pain subsided, but it has since occurred many times. The physician orders an x-ray of the chest, but it is not diagnostic. Manometry is conducted, and it shows uncoordinated contractions.  What is the most likely diagnosis?

15. 5- Discussing differential diagnoses
A. Breast cancer relapse
B. Diffuse esophageal spasm
C. Esophageal cancer
D. Myocardial infarction
E. Nutcracker esophagus

16. A. Breast cancer relapse
5- Discussing differential diagnoses (continue) ×
A. Breast cancer relapse
Answer A is incorrect. Although this patient has had cancer in the past, she does not seem to be suffering from it again. Her symptoms do not indicate any such etiology.

17. B. Diffuse esophageal spasm
5- Discussing differential diagnoses (continue)
B. Diffuse esophageal spasm
The correct answer is B. Spasms of the esophagus are characterized by problems with both solids and liquids, causing odynophagia and dysphagia, as well as noncardiac angina. Globus pharyngeus, or the feeling of food stuck in one’s throat, is also very common. Nitroglycerin may actually confuse the diagnosis because it acts to relax the smooth muscle, thereby relieving the pain. X-rays may be helpful in diagnosis by showing what is known as a corkscrew formation of the esophagus. The anatomy of the esophagus may be divided into three parts, and when these three do not contract in a uniform manner as with spasms, then a food bolus may become trapped and cause pain. Manometry establishes the diagnosis by showing these uncoordinated contractions.

18. × 5- Discussing differential diagnoses (continue) C. Esophageal cancer
Answer C is incorrect. Usually, cancer will cause dysphagia only for solids and may not cause the pain this patient is experiencing unless it has spread beyond the walls of the esophagus.

19. D. Myocardial infarction
5- Discussing differential diagnoses (continue) ×
D. Myocardial infarction
Answer D is incorrect. A myocardial infarction will not present with the given history of progressive dysphagia. Remember that chest pain does not always translate into a cardiac etiology.

20. × 5- Discussing differential diagnoses (continue)
E. Nutcracker esophagus
Answer E is incorrect. Very similar to spasms, nutcracker esophagus differs in the fact that it is characterized by continuous, coordinated contractions on manometry. This difference is important with treatment because spasms may ultimately be treated with a myotomy, while nutcracker cannot.
See more information about “Nutcracker esophagus”

21. Nutcracker Esophagus Is a disorder of the movement of the esophagus.
Causes dysphagia to both solids and liquids, and chest pain.
Can also be asymptomatic.
Is more common in the 6th and 7th decades of life.
Diagnosis → Esophageal manometry : increased pressures during peristalsis, and continuous, coordinated contractions
Does not progress.
Does not have any complications.
Treatment → Controlling symptoms

22. Figure 1,2,3,4 – Esophageal disorders
2- Esophageal stricture
1- Diffuse Esophageal Spasm (DES)
4- Achalasia
3- Esophageal cancer

23. 6- Review some mini-cases1 2 3 4

24. 1 6- Review some mini-cases (continue) Presentation DDx Workup
34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI one week ago.
Pericarditis
Aortic dissection MI
Costochondritis
GERD
Esophageal rupture
ECG
CPK-MB, troponin
CXR
Echocardiography
CBC
Upper endoscopy

25. 2 6- Review some mini-cases (continue) Presentation DDx Workup
30 yo F presents with alternating constipation and diarrhea and abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
IBS
IBD
Celiac disease
Chronic pancreatitis
GI parasitic infection
Lactose intolerance
Rectal exam, stool for occult blood
CBC
Electrolytes
Stool for ova and parasitology
AXR
CT – abdomen/pelvis

26. 3 6- Review some mini-cases (continue) Presentation DDx Workup
58 yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
Pneumonia
Bronchitis
Lung abcess
Lung cancer TB
Pericarditis
CBC
Sputum Gram stain and culture
CXR
CT – chest
ECG
PPD

27. 4 6- Review some mini-cases (continue) Presentation DDx Workup
45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea over the past three days. There is left CVA tenderness on exam.
Acute pyelonephritis
Nephrolithiasis
Renal Cell Carcinoma (RCC)
Lower UTI UA
Urine culture and sensitivity
CBC, BUN/Cr
U/S – renal
CT – abdomen

28. Esophageal chest pain Cardiac chest pain vs.
non-exertional
prolonged
interrupts sleep.
is meal-related.
is relieved with antacids.
is accompanied by heartburn, dysphagia, or regurgitation.
is not influenced by changes in body position.
lasts for only an hour or less.
may sometimes radiate down the left arm, across the left shoulder and upper back, or up to the neck and to the lower jaw.
is accompanied by anxiety, profuse sweating, nausea and vomiting, shortness of breath, and fainting.
is not exacerbated by respiration.

29. Thank you “That which does not kill us makes us stronger.”
Friedrich Nietzsche
Thank you