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Case Review Course In the name of God 5th session – July 31, 2013

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Presentation on theme: "Case Review Course In the name of God 5th session – July 31, 2013"— Presentation transcript:

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-cases
1 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

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