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

Case Review Course

5th session – July 31, 2013

In the name of God

By Mohammad Reza Emami

Review the List of GI disorders

Evaluation of a case

Approach to the patient

with dysphagia

Discussing differential diagnoses

Review some mini-

cases

1 2 3 4 6Symptoms

of Gastrointestinal Diseases

Agenda

5

Esophageal disorders :

I. Gastroesophageal Reflux Disease (GERD)

II. Barrett’s Esophagus

III. Hiatal hernia

IV. Rings and Webs

V. Esophageal diverticulum

VI. Achalasia

VII. Diffuse Esophageal Spasm (DES)

VIII. Esophagitis

• Infectious esophagitis

• Non-infectious esophagitis

1- Review the list of GI disorders

Stomach disorders :

I. Peptic Ulcer Disease (PUD)

II. Zollinger-Ellison Syndrome (ZES)

III. Gastritis

IV. Ménétrier's disease

1- Review the list of GI disorders (continue)

Nutritional and malabsorption disorders :

I. Celiac disease

II. Tropical sprue

III. Short Bowel Syndrome

IV. Bacterial Overgrowth Syndrome (BOS)

V. Food allergies

VI. Lactose intolerance

VII. Irritable Bowel Syndrome (IBS)

VIII. Whipple’s disease

IX. Protein-Losing Enteropathy

1- Review the list of GI disorders (continue)

Gastroenteritis :

I. Bacterial gastroenteritis

II. Viral gastroenteritis

III. Parasitic gastroenteritis

1- Review the list of GI disorders (continue)

Inflammatory intestinal disorders :

I. Inflammatory Bowel Disease (IBD)

• Ulcerative Colitis

• Crohn’s Disease

II. Microscopic colitis

1- Review the list of GI disorders (continue)

Anorectal disorders :

I. Diverticular disease

• Diverticulosis

• Diverticulitis

II. Procidentia

III. Fecal incontinence

IV. Hemorrhoidal disease

V. Anorectal abcess

VI. Anal fistule

VII. Anal fissure

1- Review the list of GI disorders (continue)

GI Neoplasms :

I. Esophageal cancer

II. Gastric cancer

III. Small intestine tumors

IV. Colorectal cancer

V. Anal cancer

1- Review the list of GI disorders (continue)

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

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 ?

3- Approach to the patient with dysphagia (continue)

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?

4- Evaluation of a case

5- Discussing differential diagnoses

A. Breast cancer relapse

B. Diffuse esophageal spasm

C. Esophageal cancer

D. Myocardial infarction

E. Nutcracker esophagus

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.

5- Discussing differential diagnoses (continue)

A. Breast cancer relapse×

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.

B. Diffuse esophageal spasm

5- Discussing differential diagnoses (continue)

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.

5- Discussing differential diagnoses (continue)

C. Esophageal cancer×

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.

5- Discussing differential diagnoses (continue)

D. Myocardial infarction×

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.

5- Discussing differential diagnoses (continue)

E. Nutcracker esophagus×

See more information about “Nutcracker esophagus”

1- Diffuse Esophageal Spasm (DES)

4- Achalasia

2- Esophageal stricture

3- Esophageal cancer

Figure 1,2,3,4 – Esophageal disorders

6- Review some mini-cases

1 2

3 4

6- Review some mini-cases (continue)

1Presentation 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

6- Review some mini-cases (continue)

2Presentation 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

6- Review some mini-cases (continue)

3Presentation 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

6- Review some mini-cases (continue)

4Presentation 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

Esophageal chest pain

Cardiac chest painvs.

• 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.

Thank you

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