10/19- Case Studies Flashcards
Might just want to do the Dickey deck…
This one’s okay, though
- 74-year-old man presented to his PCP
- Dyspepsia (heartburn)
- Physical exam unremarkable
Which of the following diagnoses is most likely?
A. Esophageal perforation
B. Infectious esophagitis
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Barrett’s esophagus
A. Esophageal perforation
B. Infectious esophagitis
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Barrett’s esophagus
According to the Guidelines of American College of Gastroenterology (ACG) in 2005 for diagnosis and treatment of reflux, the symptoms most specific for GERD are what?
- Regurgitation
- Heartburn
- Or both
What is seen in this endoscopy?
A. Esophageal perforation
B. Infectious esophagitis
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Barrett’s esophagitis
A. Esophageal perforation
B. Infectious esophagitis
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Barrett’s esophagitis
- Hyperemia (redness, indicative of reflux)
- Esophageal mucosa may be unremarkable
- Helpful here to do a biopsy
What is the diagnosis based on the microscopic findings?
A. Esophageal perforation
B. Infectious esophagitis
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Barrett’s esophagitis
A. Esophageal perforation
B. Infectious esophagitis
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Barrett’s esophagitis
- Impressive basal cell hyperplasia (~1/3 thickness of mucosa)
- Lymphocyte infiltration
Summarize endoscopy and microscopoic findings of reflux esophagitis
Endoscopy
- Simple hyperemia (redness)
MICROSCOPY
Mild GERD:
- Unremarkable mucosal histology
Mores significant GERD:
- Intraepithelial eosinophils and lymphocytes
- Basal zone hyperplasia
- Congestion of small vessels with associated microhemorrhage
What is the first choice of therapy for reflux esophagitis? Other treatment guidelines (how long to treat?)
A. Proton pump inhibitor
B. Histamine 2 antagonist
C. Sucralfate, a coating agent
D. Life style modification
E. Corticosteroid
A. Proton pump inhibitor
B. Histamine 2 antagonist
C. Sucralfate, a coating agent
D. Life style modification
E. Corticosteroid
Treatment based on ACC GERD guideline:
- PPIs is more effective than H2RAs for GERD based on highest-level evidence
- Greater percentage of patients with reflux esophagitis healed when treated with PPIs than with H2RA
- Treatment for 2-4 weeks and re-assessment
If the patient presents 10 years after the reflux esophagitis with similar symptoms and had the following endoscopy and histology, what is the diagnosis?
A. Reflux esophagitis
B. Infectious esophagitis
C. Eosinophili esophagitis
D. Barrett’s esophagus
E. Adenocarcinoma
A. Reflux esophagitis
B. Infectious esophagitis
C. Eosinophili esophagitis
D. Barrett’s esophagus
E. Adenocarcinoma
What are the endoscopic findings expected with Barrett’s esophagus?
- Salmon color tongue (characteristic)
- Extensive color change (widespread involvement)
How should a patient with Barrett’s esophagus found on endoscopy/biopsy be managed/followed up?
- Repeat endoscopy in 6 mo
- Multiple biopsies
What is the diagnosis with this histology?
A. Reflux esophagitis
B. Dyspasia
C. Barrett’s esophagus
D. Barrett’s esophagus and dysplasia
E. Adenocarcinoma
A. Reflux esophagitis
B. Dyspasia
C. Barrett’s esophagus
D. Barrett’s esophagus and dysplasia
E. Adenocarcinoma
- Dysplasia here, because don’t really see any metaplasia (no goblet cells)
What is the next step for the patient with dysplasia/Barrett’s esophagus found on biopsy?
A. Extensive biopsy (mapping)
B. Endoscopic mucosal resection
C. Esophagectomy
D. Follow up
E. Discuss the options with the patient
A. Extensive biopsy (mapping)
B. Endoscopic mucosal resection
C. Esophagectomy
D. Follow up
E. Discuss the options with the patient
- Can do extensive biopsy…
- Will NOT do espohagectomy; significant morbidity and mortality
- Follow up alone is insufficient; must do biopsies and endoscopies as well
Patient with dysplasia/Barrett’s is followed up with in 6 mo and this is found.
What is the diagnosis?
A. Infectious esophagitis
B. Reflux esophagitis
C. Barrett’s esophagus
D. Dysplasia
E. Worrisome for adenocarcinoma
A. Infectious esophagitis
B. Reflux esophagitis
C. Barrett’s esophagus
D. Dysplasia
E. Worrisome for adenocarcinoma
- Can see a lot of dysplasia here and fibroblastic activity… worried about adenocarcinoma
- The difference between this and dysplasia is the degree; limited to superficial would indicate dysplasia while adenocarcinoma concerns go deeper
Treatment for the past case?
Endoscopic mucosal resection
What is your diagnosis for this histology found on biopsy of esophageal nodule?
Intramucosal adenocarcinoma
- Evaluation of margin hindered by marked cautery effect
- Follow up continues…