View
215
Download
1
Category
Preview:
Citation preview
Integrative Lecture: Esophagus, Stomach & Duodenum
RALPH LEE, MMED(DIST), MD, FRCPCGASTROENTEROLOGIST, ASSISTANT PROFESSOR AND MEDICAL EDUCATORUNIVERSITY OF OTTAWA
Case I
Case 1
A 55 year old male presents to your office with complaints of ‘heartburn’ Past Medical history
Hypertension, hypercholesterolemia, cholecystectomy
Medications: TUMS
Allergies: None
What questions would you ask?
Case 1
Characterize the symptom: Onset?
Usually after meals and with lying down
Position? Retrosternal
Quality? Burning
Radiation? To neck
Severity? 4/10
Timing? 1x every 2 weeks, for the last 6 months
Aggravating factors? Spicy foods, lying down at night
Relieving factors? Better with TUMS
Associated symptoms? Regurgitation? 1x every 2 weeks
AM sore throat, hoarse voice? None.
Case 1
Alarm symptoms? Dysphagia, odynophagia, vomiting, chest pain,
weight loss, hematemesis, melena
Patient denies any of these symptoms
Risk behaviours? Intake: Caffeine, chocolates, spicy foods, citrus
foods, carbonated beverages, alcohol, peppermints
Habits: Smoking, alcohol
Patient incidentally reports that his father died of esophageal cancer
What would you do next?
Case 1
Physical exam: Obese male, but otherwise unremarkable.
What do you believe is the diagnosis?
What would you do next?
Case 1
What would you do next?
a. Empirically treat him with a proton pump inhibitor
b. Counsel him on lifestyle measures and suggest over the counter antacids
c. Order laboratory investigations
d. Order an ECG
e. Order a barium swallow
f. Consult GI for an esophagastroduodenoscopy
g. Order a CT scan of the chest
h. Order a 24 hour pH study
Case 1
What would you do next?
a. Empirically treat him with a proton pump inhibitor
b. Counsel him on lifestyle measures and suggest over the counter antacids
c. Order laboratory investigations
d. Order an ECG
e. Order a barium swallow
f. Consult GI for an esophagastroduodenoscopy
g. Order a CT scan of the chest
h. Order a 24 hour pH study
Case 1 – Follow-up
You recommend some lifestyle measures for GERD and over-the-counter antacids
The patient’s symptoms resolve with weight loss and dietary modification
Case 2
Case 2
27 year old female with presents to your office with severe ‘stomach’ pain
Past Medical History: Left rotator cuff tear
Hypothyroidism
Appendectomy
What would you ask?
Case 2
Characterize the symptom Onset? Usually 30 minutes after meals.
Position? Epigastric.
Quality? Burning.
Radiation? To mid-back.
Severity? 8/10.
Timing? Started 1 month ago @ 1x/week, but increased in frequency to
daily. Lasts for 30-45 minutes.
Aggravating factors? Worse with eating and with alcohol.
Relieving factors? Better with TUMS and milk.
Associated symptoms? Nausea.
Case 2
Alarm Features? Vomiting, hematemesis, melena, dysphagia, odynophagia,
early satiety, unexplained weight loss, jaundice, family history of gastric CA
The patient reports that she has been having black, ‘tar-like’ stools 3x/day for the last 2 days
Medications? NSAIDs? Patient reports she has been taking 6-8 tablets of
Ibuprofen per day for the past 2 weeks
Habits? Non-smoker. EtOH: Social
Family History? No family history of gastric CA, PUD
What is the differential diagnosis?
Case 2 - DDx
Peptic ulcer disease
H. Pylori gastritis
Functional dyspepsia
Pancreatitis
Biliary cause (biliary colic, choledocholithiasis)
Cholecystitis
Gastroparesis
Gastroenteritis
Malignancy
Pregnancy
Hepatitis
Pulmonary cause
Cardiac cause
Muskuloskeletal cause
What would you do next?
Case 2
Physical exam: HR 110, BP 120/80, RR 16, T 37.5
H&N: Moist mucous membranes
Abdomen: Tender epigastric area, no rebound, no masses, no HSM
Laboratory Patient found to be anemic (Hgb 102 g/L).
What would you do next?
Case 2
What would you do next? Start her empirically on a PPI and arrange follow-
up in 2 weeks.
Counsel her on lifestyle measures and suggest over-the-counter antacids.
Arrange a barium swallow.
Send her directly to the emergency department for an urgent GI consult and EGD
Start her on a PPI and consult an outpatient gastroenterologist for a non-urgent EGD.
Arrange a CT scan.
Case 2
What would you do next? Start her empirically on a PPI and arrange follow-
up in 2 weeks.
Counsel her on lifestyle measures and suggest over-the-counter antacids.
Arrange a barium swallow.
Send her directly to the emergency department for an urgent GI consult and EGD
Start her on a PPI and consult an outpatient gastroenterologist for a non-urgent EGD.
Arrange a CT scan.
Case 2 - EGD
What would you do next?
Case 2 - Pathology
Case 2
What would you do? Treat for H. Pylori
Amoxicilin 1g po BID, Clarithromycin 500mg po BID, PPI po BID x 14 days.
Proton pump inhibitors Treat for 8 weeks, then consider trial off.
Stop the NSAIDs If unable to stop, ensure patient is on a PPI for gastroduodenal
protection
Repeat Endoscopy within 3 months To confirm healing of ulcer
Small percentage of gastric ulcers can be malignant.
Repeat H. Pylori biopsies to confirm eradication
Other methods: H. Pylori Breath test
Case 2 – Follow-up
You prescribe a course of triple therapy for 14 days and she continues with omeprazole 20 mg po bid for a total 8 weeks
A repeat EGD in 3 months confirms healing of the ulcer and gastric biopsies are negative for H. Pylori
Her pain has resolved at 3 months of follow-up
Case 3
Case 3
A 42 year old male presents to your office complaining of trouble swallowing.
Past medical history: Obesity
EtOH Abuse
What do you want to ask?
Case 3
Characterize the symptom Food sticking? Where? Difficulty initiating swallow? Choking? Nasal
regurgitation Patient reports a feeling of food sticking in his
retrosternal area. Solids and liquids or solids alone?
Patient reports it is only solid food, but he can tolerate intake of liquids. There have been occasions that solid food became stuck and he could not swallow any liquids including his own saliva.
Case 3 - DDx
Malignancy Malignancy Malignancy Peptic stricture Eosinophilic esophagitis What would you do next?
Case 3
Is it intermittent or progressive? Patient reports it started intermittently, but has
been progressively worse. He is afraid to eat any type of solid for fear it will become stuck.
Is there any associated weight loss? Patient reports a 20lb weight loss over the last 3
months.
Is there any associated heartburn? Patient denies any history of heartburn.
What is your differential diagnosis?
Case 3
What would you do next? Arrange a barium swallow
Consult GI for an upper endoscopy
Counsel the patient on lifestyle measures for GERD and prescribe over the counter medications
Empirically start the patient on a PPI and arrange a follow-up visit in 2 months
Order a CT Chest
Tell the patient to chew their food more carefully and ‘man up’.
Case 3
What would you do next? Arrange a barium swallow
Consult GI for an upper endoscopy
Counsel the patient on lifestyle measures for GERD and prescribe over the counter medications
Empirically start the patient on a PPI and arrange a follow-up visit in 2 months
Order a CT Chest
Tell the patient to chew their food more carefully and ‘man up’.
Case 3 - EGD
Case 3 – Follow-up
Biopsies confirm esophageal adenocarcinoma
CT Abdomen/Chest reveals multiple pulmonary and liver metastases (Stage IV)
The patient is referred to radiation oncology for palliative radiotherapy and back to GI for esophageal stent placement.
Questions?
Recommended