Presentation on theme: "Case Review Course In the name of God 5th session – July 31, 2013"— Presentation transcript:
1Case Review Course In the name of God 5th session – July 31, 2013 By Mohammad Reza Emami
2Agenda 1 2 3 4 5 6 Approach to the patient with dysphagia Discussing differential diagnosesReview the List of GI disorders123456Symptoms of Gastrointestinal DiseasesEvaluation of a caseReview some mini-cases
31- Review the list of GI disorders Esophageal disorders :Gastroesophageal Reflux Disease (GERD)Barrett’s EsophagusHiatal herniaRings and WebsEsophageal diverticulumAchalasiaDiffuse Esophageal Spasm (DES)EsophagitisInfectious esophagitisNon-infectious esophagitis
41- Review the list of GI disorders (continue) Stomach disorders :Peptic Ulcer Disease (PUD)Zollinger-Ellison Syndrome (ZES)GastritisMénétrier's disease
51- Review the list of GI disorders (continue) Nutritional and malabsorption disorders :Celiac diseaseTropical sprueShort Bowel SyndromeBacterial Overgrowth Syndrome (BOS)Food allergiesLactose intoleranceIrritable Bowel Syndrome (IBS)Whipple’s diseaseProtein-Losing Enteropathy
61- Review the list of GI disorders (continue) Gastroenteritis :Bacterial gastroenteritisViral gastroenteritisParasitic gastroenteritis
71- Review the list of GI disorders (continue) Inflammatory intestinal disorders :Inflammatory Bowel Disease (IBD)Ulcerative ColitisCrohn’s DiseaseMicroscopic colitis
81- Review the list of GI disorders (continue) Anorectal disorders :Diverticular diseaseDiverticulosisDiverticulitisProcidentiaFecal incontinenceHemorrhoidal diseaseAnorectal abcessAnal fistuleAnal fissure
91- Review the list of GI disorders (continue) GI Neoplasms :Esophageal cancerGastric cancerSmall intestine tumorsColorectal cancerAnal cancer
102- 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
11Table 1 - Common Causes of Common GI Symptoms Abdominal PainNausea and VomitingDiarrheaGI BleedingObstructive JaundiceAppendicitisGallstone diseasePancreatitisDiverticulitisUlcer disease EsophagitisGI obstructionIBDFunctional bowel disorderVascular diseaseGynecologic causesRenal stoneMedicationsMotor disordersEnteric infectionPregnancyEndocrine diseaseMotion sicknessCentral nervous system diseaseInfection Poorly absorbed sugarsMicroscopic colitisCeliac diseasePancreatic insufficiencyHyperthyroidismIschemiaEndocrine tumorUlcer diseaseEsophagitisVaricesVascular lesionsNeoplasmDiverticulaHemorrhoidsFissuresInfectious colitisBile duct stonesCholangiocarcinomaCholangitisSclerosing cholangitisAmpullary stenosisAmpullary carcinomaPancreatic tumor
123- 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 ?
133- Approach to the patient with dysphagia (continue)
144- Evaluation of a caseA 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?
155- Discussing differential diagnoses A. Breast cancer relapseB. Diffuse esophageal spasmC. Esophageal cancerD. Myocardial infarctionE. Nutcracker esophagus
16A. Breast cancer relapse 5- Discussing differential diagnoses (continue)×A. Breast cancer relapseAnswer 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.
17B. Diffuse esophageal spasm 5- Discussing differential diagnoses (continue)B. Diffuse esophageal spasmThe 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.
19D. Myocardial infarction 5- Discussing differential diagnoses (continue)×D. Myocardial infarctionAnswer 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 esophagusAnswer 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”
21Nutcracker 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 contractionsDoes not progress.Does not have any complications.Treatment → Controlling symptoms
241 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.PericarditisAortic dissectionMICostochondritisGERDEsophageal ruptureECGCPK-MB, troponinCXREchocardiographyCBCUpper endoscopy
252 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.IBSIBDCeliac diseaseChronic pancreatitisGI parasitic infectionLactose intoleranceRectal exam, stool for occult bloodCBCElectrolytesStool for ova and parasitologyAXRCT – abdomen/pelvis
263 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.PneumoniaBronchitisLung abcessLung cancerTBPericarditisCBCSputum Gram stain and cultureCXRCT – chestECGPPD
274 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 pyelonephritisNephrolithiasisRenal Cell Carcinoma (RCC)Lower UTIUAUrine culture and sensitivityCBC, BUN/CrU/S – renalCT – abdomen
28Esophageal chest pain Cardiac chest pain vs. non-exertionalprolongedinterrupts 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.
29Thank you “That which does not kill us makes us stronger.” Friedrich NietzscheThank you