Esophageal disorders (Darrow) Flashcards
transfer dysphagia
problem with food getting from mouth to esophagus.
Causes: stroke, Parkinson’s, corticobulbar problems (ALS, MS)
treat- thickening agents
transmit dysphagia
Problem getting food through the esophagus to the stomach
SAD CREaP
Solids and Liquids (motility):
1- Scleroderma
2- Achalasia (watch out for “pseudoachalasia”)
3- Diffuse esophageal spasm – “corkscrew esophagus”
CREaP (for solids only):
4- Carcinoma
5- Ring(Schatski’s)*/webs**
6- Eosinophilic esophagitis
and
7- Peptic stricture
NOTE:
*distal esophagus - associated with HH and reflux symptoms
**mid or upper esophagus – congenital, epidermolysis bullosa, GVHD, pemphigus, pemphigoid,
Plummer-Vinson syndrome
A 35 y/o female presents to the ER with chest “pressure” and dysphagia, having not been able to finish supper one hour ago. History is positive for asthma (allergy history) as a child. She has had intermittent food (solids only) dysphagia for three years.
An EGD is performed and a meat bolus is removed. Multiple concentric rings are seen, but the mucosa is normal. A biopsy is taken as shown.
what is the diagnosis and treatment?
Has to be one of the “creap”
Eosinophilic Esophagitis
-rings shown in the center of the esophagus
Symptoms: GERD to food impaction
History: allergies/atopy-peripheral eosinophilia
Mucosa: normal to tapered strictures (mucosa looks normal!!) but this doesn’t mean you shouldn’t biopsy
Biopsy: eosinophilia
> 20%/HPF (High power field)
Treatment: swallowed fluticasone (steroids**)
-PPI’s don’t work as well
know this will be on test
A 58 y/o Costa Rican male smoker presents with a dermatitis of the palms and soles, progressive dysphagia for solid foods and liquids ***, chest pain, cough, weight loss, and nocturnal regurgitation.
A barium swallow is ordered as follows:
-distal esohpagus - looks like a bird beak- slide 6
Skin> keratoderma or hyperkeratosis (thickening, scaling)
what are the considerations in this case:
The possibilities in this case would mainly consist of: SAD = Scleroderma, Achalasia or Diffuse Esophageal Spasm
The patient has no other evidence of scleroderma and the barium swallow appears to be achalasia (lots of dilation) (characterized by failure of the LES to relax completely with swallowing, and aperistalsis in the smooth muscle esophagus).
Diffuse esophageal spasm would look differentially (like a rope)
what is pseudoachalasia caused by:
Chagas disease – Reduviid or kissing bug–>
Triatomine bug and Trypanosoma cruzi
-must consider this in pt’s from costa rica, central america
Cancer
May also see achalasia like motor symptoms from amyloidosis, sarcoidosis, and neurofibromatosis
Chagas disease?
what symptoms does it cause
preferentially attacks the cardiac (dysrrhythmias, CHF, emboli) and smooth muscle (megaesophagus and megacolon).
“Pseudoachalasia” – invasion of the esophagus by trypanosoma cruzi.
Megaesophagus may simulate achalasia
Squamous cell carcinoma of the esophagus
Versus
Adenocarcinoma
How do you tell the difference
Squamous - mid esophagus with “rat tail” appearance
- men, blacks
- mid to lower esophagus
- risk factors alcohol, smoking, HPV, nitrates, lye, achalasia, hot liquids, tylosis >(hyperkaratosis of palms and soles), PV syndrome
Adenocarcinoma- lower esophagus
- barret’s
- obesity
- GERD
A 58 y/o Costa Rican male smoker presents with a dermatitis of the palms and soles, progressive dysphagia for solid foods and liquids ***, chest pain, cough, weight loss, and nocturnal regurgitation.
A barium swallow is ordered as follows:
-distal esohpagus - looks like a bird beak- slide 6
The patient subsequently has lab test showing a Hb of 9.5 gm with 55,000 platelets. Buffy coat exam is negative for T. cruzi. Iron and TIBC are low. Na is 128 meq/L with K of 3.5 meq/L. Bun is 12 meq/L with creatinine of 1 meq/L. Urinary Na is high with osmolality of 300 mOm/L (not appropriate for a low sodium)
This is what type of anemia?
Why might the platelets be low?
what is causing her low sodium?
What should be done next?
This is what type of anemia?
-anemia of chronic disease
Why might the platelets be low?
Low platelets due to ITP (antibodies), splenomegaly, bone marrow invasion, etc
What is causing the low sodium?
SIADH
-she is not hypovolemic, or hypervolemic, she is euvolemic
get a cxr
What should be done next?
Anemia of chronic disease
Low platelets due to ITP, splenomegaly, bone marrow invasion, etc
Low serum sodium from SIADH
CXR!
Chest Xray suggest a right mediastinal mass and CT is obtained which shows a mass encasing and constricting the right pulmonary artery. A brochoscopy and biopsy are carried out.
Chest Xray suggest a right mediastinal mass and CT is obtained which shows a mass encasing and constricting the right pulmonary artery. A brochoscopy and biopsy are carried out.
What do you expect the biopsy to show considering the
anemia, thrombocytopenia, SIADH, esophageal findings, and
chest Xray findings ?
expected to show small cell lung carcinoma
The biopsy returns showing small cell carcinoma with immunohistochemical staining showing CAM5.2 (a marker for neuroendocrine carcinomas, including small cell), thyroid transcription factor – 1 (marker for small cell lung cancer), chromogranin A (a neuroendocrine secretory protein), CD 56(NCAM/neural cell adhesion molecule) and anti Hu/ANNA-1 (anti- neuronal nuclear antibodies).
CAM5.2
marker for neuroendocrine carcinoma, including small cell
The biopsy returns showing small cell carcinoma with immunohistochemical staining showing CAM5.2 (a marker for neuroendocrine carcinomas, including small cell), thyroid transcription factor – 1 (marker for small cell lung cancer), chromogranin A (a neuroendocrine secretory protein), CD 56(NCAM/neural cell adhesion molecule) and anti Hu/ANNA-1 (anti- neuronal nuclear antibodies).
From these results how does one explain the esophageal findings? including dysphagia for solid food and liquids
The antineuronal nuclear antibodies (ANNA-1) destroy the myenteric plexus, simulating achalasia.
An HIV patient has stopped his HIV meds, but continues to take vitamin C, iron and NSAIDs for weakness and arthralgias.
He presents complaining of confusion, fever, cough, dyspnea, dyspepsia, odynophagia, anorexia, abdominal pain, diarrhea, blurred vision and weight loss.
He is asthenic and appears anxious and depressed. BP is 94/68.
His CD4 count is 48. Glucose is 70 mg/dL and Na is 130 meq/L. Dermatitis of the chest, thumb nail and mouth are shown:
- folliculitis - red inflammation around hair cells
- -Trichophyton rubrum (fungal infection) (proximal nail?)
- -Candida
What are the most likely causes of the dysphagia and odynophagia, ie the esophagitis?
- GERD with peptic stricture
- pills - tetracycline
- infections:
CMV (CD 4
An HIV patient has stopped his HIV meds, but continues to take vitamin C, iron and NSAIDs for weakness and arthralgias.
He presents complaining of confusion, fever, cough, dyspnea, dyspepsia, odynophagia, anorexia, abdominal pain, diarrhea, blurred vision and weight loss.
He is asthenic and appears anxious and depressed. BP is 94/68.
His CD4 count is 48. Glucose is 70 mg/dL and Na is 130 meq/L. Dermatitis of the chest, thumb nail and mouth are shown:
- folliculitis - red inflammation around hair cells
- -Trichophyton rubrum (fungal infection) (proximal nail?)
- -Candida
The patient is taken for a barium swallow, EGD, colonoscopy as well as fundoscopic exam. Results are shown: -large superficial ulcers -small ulcers -ulcerated friable mucosa
PCR is ordered and GI histology returns showing “owl eyes”. What is the diagnosis?
He may die if he is not placed on what treatment/meds?
CMV with retinitis, esophagitis, colitis, pneumonia and encephalitis.
The patient is started on appropriate therapy (ganciclovir), but may die if he is not placed on: (be familiar with the “As”) STEROIDS
NOTE:
You can see owl eyes similar in Hodgkin’s
what are the A’s involved in Addison Disease
and what infection might these A’s present?
Anorexia and weight loss Asthenia and weakness Arterial hypotension and fatigue Affect (flat) Abdominal pain with N, V and D Anxiety and personality change Aglycemia, anatremia Aching muscles Apigmentation (vitiligo) Axillary, areolar and anal pigmentation
CMV can cause Addison disease b/c CMV hits the adrenal glands
what are the main causes of infectious chronic gastritis ?
Helicobacter pylori***
H. Heilmanni
Mycobacterium, syphilis, histoplasmosis, mucormycosis, Blastomycosis, anisakiasis (raw fish or sushi)
Strongyloides, schistosomiasis, Diphyllobothrium
CMV, herpesvirus
what are the main causes of noninfectious chronic gastritis
Autoimmune**
Chemical **(NSAIDs, ASA, bile reflux)
Uremic Crohn’s, sarcoid, Wegener’s, CGD, eosinophilic granuloma, etc. Lymphocytic (Ceilac disease) Eosinophilic Radiation GVHD Ischemic