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

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

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

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

3 Esophageal disorders : I. I.Gastroesophageal Reflux Disease (GERD) II. II.Barretts Esophagus III. III.Hiatal hernia IV. IV.Rings and Webs V. V.Esophageal diverticulum VI. VI.Achalasia VII. VII.Diffuse Esophageal Spasm (DES) VIII. VIII.Esophagitis Infectious esophagitis Non-infectious esophagitis 1- Review the list of GI disorders

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

5 Nutritional and malabsorption disorders : I. I.Celiac disease II. II.Tropical sprue III. III.Short Bowel Syndrome IV. IV.Bacterial Overgrowth Syndrome (BOS) V. V.Food allergies VI. VI.Lactose intolerance VII. VII.Irritable Bowel Syndrome (IBS) VIII. VIII.Whipples disease IX. IX.Protein-Losing Enteropathy 1- Review the list of GI disorders (continue)

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

7 Inflammatory intestinal disorders : I. I.Inflammatory Bowel Disease (IBD) Ulcerative Colitis Crohns Disease II. II.Microscopic colitis 1- Review the list of GI disorders (continue)

8 Anorectal disorders : I. I.Diverticular disease Diverticulosis Diverticulitis II. II.Procidentia III. III.Fecal incontinence IV. IV.Hemorrhoidal disease V. V.Anorectal abcess VI. VI.Anal fistule VII. VII.Anal fissure 1- Review the list of GI disorders (continue)

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

10 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. 2- Symptoms of Gastrointestinal Diseases See Table 1

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

12 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. 3- Approach to the patient with dysphagia What would be your next measure ?

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

14 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 husbands 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? 4- Evaluation of a case

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

16 5- Discussing differential diagnoses (continue) A. Breast cancer relapse ×

17 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 ones 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. B. Diffuse esophageal spasm 5- Discussing differential diagnoses (continue)

18 C. Esophageal cancer ×

19 5- Discussing differential diagnoses (continue) D. Myocardial infarction ×

20 5- Discussing differential diagnoses (continue) E. Nutcracker esophagus × 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 1- Diffuse Esophageal Spasm (DES) 4- Achalasia 2- Esophageal stricture 3- Esophageal cancer Figure 1,2,3,4 – Esophageal disorders

23 6- Review some mini-cases

24 6- Review some mini-cases (continue) 1 1 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 6- Review some mini-cases (continue) 2 2 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 6- Review some mini-cases (continue) 3 3 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 6- Review some mini-cases (continue) 4 4 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 painCardiac 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


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