Case 1

Small Group 2 November 18, 20131pm

Case 1: A 68 year old white male comes to the office with a few months of not eating right. On further questioning, he tells you that he is having an increasingly difficult time getting food down; he notes the food gets stuck in the middle of his chest 20 seconds after swallowing. He denies any coughing or regurgitation of food. Juice and water go down without a problem. His wife mentions that he is spending a longer time at meals because he is cutting his food in smaller pieces; she also notes he has lost about 15 pounds. He has a history of hypertension which is well-controlled on a thiazide diuretic and osteopenia for which he takes a calcium/vitamin D pill and alendronate. He had heartburn for many years for which he would take PRN antacids, but this has been somewhat less bothersome recently. He is a nonsmoker and is active.Physical examination is normal except for a BMI of 32. Labs reveal hemoglobin 9 mg/dL, MCV 74 fL, platelets 345K cells/mm3. Liver chemistries are normal.

Questions:1. What is the most likely diagnosis?

2. What is the next best step to confirm the diagnosis?

3. Are the laboratory abnormalities related to the primary problem?

4. What further workup would be needed?

Esophageal AdenocarcinomaYou get heartburn because the lower esophageal sphintor is open. If you have a mass is at the sphintor, it can be a barrier and protect againt heartburn.

If you have a mass, you want to:

Lab abnormalities: microcytic anemia, high platelets, iron deficiency anemia, low MCV, RDWLow MCV, high RDW: suggests iron deficiency anemiaTo confirm: check iron, TIBC Iron:TBIC ratio >15%And low ferratinWhat do to a metastatic workup. PET/CT

Case 2: A 56 year old woman presents to the GI clinic with 6 months of increasing difficulty keeping food down. She has lost 40 pounds during this time; she notes some of that weight loss may be due to 3 hospitalizations for pneumonia. Her difficulty is to both liquids and solids and ingesting anything leads to coughing several minutes after swallowing. Her symptoms have been progressive during this time. She also notes some retrosternal burning and a foul smell to her breath. She has vomited undigested food 3-4 times. Physical examination reveals mild temporal wasting. Laboratory data reveals a normal CBC and electrolytes, but the albumin is 2.8.

Questions:1. What is the diagnosis and why?Achalasia: narrowed esophagus in the bottom and food buildup. Creates heartburn symptoms and the bacteria make an acid environment. 2. What are tests you could order to confirm the diagnosis, and what would the expected findings be?Barium: see birds beakEndoscopy: need to retroflex to look for cardia tumorsSuck our food collectionManometry: see high pressure in LES that does not relax Low amplitude, 3. Are the pneumonias or heartburn-like symptoms related to the diagnosis?Yes. Achalasia can lead to stasis esophagitis4. What is the treatment?TTS balloon dilation (1-3% risk of perforation). Myotomy (surgery), botox (less effective)Nitrates/Ca-channel blockers are generally ineffective

Triad: dysphasia, halletosis, regurgitation/emesisNot achalasia!!! Zenkers diverticulum (in oral pharyngeal) can cause perforation!! Due to neurologic problems with swallowing more pressure in one area leads to outpouching. Parkinsons, stroke patients, etc.

Case 3: A 35 year old man with a long history of GERD presents with a 3 month history of a feeling of a knot in his chest. He notes this feeling after eating but not after drinking liquids. It has gotten progressively worse but he has not lost any weight. His heartburn is about the same despite once daily PPI. He denies vomiting and has no pertinent medical history otherwise.Physical examination is unremarkable, as are the CBC and chemistries.

Questions:1. What is the diagnosis?

2. What is the next step to confirm the diagnosis?Upper endoscopy, smooth tapering, narrows smoothly3. What is the long-term treatment?Dilate. TTS-ballon, savory, herst, or malony. Many ways to dilate. Rules of three. Or plastic stent.

Heartburn, uncontrolled by PPI can lead to peptic stricture. No vomiting.Case 4: A 24 year old 2nd year medical student (nervous?) presents to the ER with excessive salivation. He notes that he was celebrating his great score in the GI module at Smith and Wollensky, and while telling his friends how great the course coordinator was, he choked on a piece of filet mignon. Since then (2 hours ago), he feels it is stuck in his chest and he cannot swallow his saliva. He is breathing comfortably and has no pain. This has never happened before. His only medical history is exercise-induced asthma diagnosed in high school for which albuterol before exercise provides adequate control. He has no allergies to medications, only seasonal allergies.On physical exam, he has eczema on his scalp, which he says comes and goes. There is no subcutaneous emphysema and pulmonary exam is normal. CBC, including white blood cell differential, is normal.

Questions:1. What is the reason for the patients symptoms?

2. What is the most likely underlying disease causing this and why?

3. What is the treatment for the urgent condition?Food impaction: get it out so he does not aspirate.4. How can the underlying disease be diagnosed and treated?Biopsy: 15 eos/HPFTreat: swallow steroid fluticasone. May be responsive to PPI

Case 5: A 44 year old woman comes to the ER with severe chest pain. She has no significant medical history but she is overweight. Serial ECGs and cardiac enzymes are normal, and nitroglycerin provides symptomatic relief. A cardiac stress test the next day shows normal wall motion of the left ventricle with normal ejection fraction and no evidence of stress-induced ischemia. The pain was not exertional; it came on spontaneously. Upon further questioning, this pain happens intermittently, oftentimes associated with a feeling of food getting stuck in the mid-chest; during these episodes both solids and liquids get stuck. She has no weight loss or heartburn. Physical exam in unremarkable.

Questions:1. What is the diagnosis, and on what basis?Foods & liquids, intermittent: esophageal spasm2. What diagnostic studies could help make the diagnosis?Barium: may see corkscrew. If not, need to do mamometry3. What is the treatment?TCA (somewhat Anti-Ach), Ca-channel blockers