Master the board step 3

Gastroenterology
Diagnostic Testing
The best initial test is a barium study.
Treatment
Treatment depends on the kind of stricture that presents:
··
Plummer-Vinson syndrome: This is a proximal stricture found in association
with iron deficiency anemia and is more common in middle-aged
women. It is associated with squamous cell esophageal cancer.
--
Best initial therapy: Iron replacement
Eosinophilic Esophagitis
••
Dysphagia
••
History of allergies
••
Scope + biopsy
••
Treat with PPTs and
budesonide
··
Schatzki’s ring (peptic stricture): This is a distal ring of the esophagus that
presents with intermittent symptoms of dysphagia.
--
Best initial therapy: Pneumatic dilation
··
Peptic stricture: This results from acid reflux.
--
It is treated with pneumatic dilation.
Zenker’s Diverticulum
Look for a patient with dysphagia with horrible bad breath. There is rotting
food in the back of the esophagus from dilation of the posterior pharyngeal
constrictor muscles.
The best initial test is a barium study. The best initial therapy is a surgical
resection.
To avoid perforation, do
not do endoscopy or place
a nasogastric tube with
Zenker’s diverticulum.
Spastic Disorders
Diffuse esophageal spasm and “nutcracker esophagus” are essentially the
same disease. Look for a case of severe chest pain, often without risk factors
for ischemic heart disease. The case may describe the pain as occurring after
drinking a cold beverage. There is always pain, but there is not always dysphagia.
The EKG, stress test, and possibly the coronary angiography will be
presented as normal.
Diagnostic Testing
··
Most accurate diagnostic test: Manometry
··
Barium studies may show a corkscrew pattern, but only during an episode
of spasm.
Treatment
Therapy for esophageal spasm is with calcium channel blockers and nitrates
(the same treatment as for Prinzmetal’s angina).
Scleroderma (Progressive Systemic Sclerosis)
Scleroderma presents as symptoms of reflux. Treat with proton pump inhibitors.
Esophageal disorders
can mimic Prinzmetal’s
variant angina, because
the pain is sudden, severe,
and not related to exercise.
However, Prinzmetal’s
will give you ST segment
elevation and an
abnormality on stimulation
of the coronary arteries,
while esophageal spasm
will not.
189