GASTRO TOPICS common in public now .pptx

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1. Missed Common Esophageal disorders Presenter: Dr Maria Nadeem Supervisor: Dr Arsalan Shahzad

2. Learning Objectives Eosinophilic Esophagitis Diffuse Esophageal spasm Nutcracker Esophagus Esophageal Scleroderma Achalasia

3. CASE 1 A 24-year-old male presents to the emergency room with a chief complaint of “I can’t swallow .” He states that while eating dinner, chicken suddenly “got stuck, and I could not swallow.” He can swallow saliva; however, he cannot swallow liquids. He has associated mid-chest discomfort . He denies GI bleeding, heartburn, weight loss or any additional symptoms. Over the last two to three years, he has experienced intermittent solid food dysphagia , which has caused him to eat slowly and chew food repeatedly. There are no prior episodes of food impaction. He has a history of seasonal allergies for which he takes an over-the-counter antihistamine . What’s the diagnosis?

4. EOSINOPHILIC ESOPHAGITIS

5. EOSINOPHILIC ESOPHAGITIS F ood or environmental antigens stimulate an inflammatory response. Once considered a rare condition. N ow one of the most common conditions diagnosed during the assessment of feeding problems in children and during the evaluation of dysphagia and food impaction in adults.

6. Clinical findings Dysphagia, one episode of food impaction. Children: Abdominal pain, vomiting, failure to thrive. Heartburn/ Chest pain. Lab: Eosinophilia, Raised IgE. Barium Swallow: Small Caliber Esophagus, strictures, rings. Endoscopy: EREFS 5% grossly normal Endoscopy.

7. treatment PPI’s T opical corticosteroids F ood elimination diets Esophageal dilation.

8. CASE # 2 An 87-year-old woman with severe retrosternal pain and intermittent dysphagia was referred to the clinic for further evaluation. She described paroxysms of crampy pain almost exclusively during the intake of solid foods. In the past several months, she noted a weight loss of 5 kg. Endoscopy revealed no mucosal lesions. Barium swallow revealed normal study . pH manometry - no pathologic regurgitation What’s the diagnosis?

9. Diffuse Esophageal Spasm (des) On HRM, this patient had esophageal spasms, associated with symptoms, which were provoked by a multiple rapid swallowing test, and thereby was diagnosed with DES.

10. Diffuse Esophageal Spasm (des) Signs/ Symptoms: Chest pain, Dysphagia, Regurgitation. With swallowing, with emotional stress. Pain can radiate. Mimic Cardiac Angina. Imaging: Barium Swallow: Normal Cork-screw in Severe cases Manometry: More than 20% of wet swallows as simultaneous contractions. Can be entirely normal. Treatment: Reassurance. PPIs. Nitrates. Calcium channel blockers.

11. Case # 3 A 72-year-old obese woman presents to her primary care physician with intermittent chest pain and difficulty swallowing liquids and solid foods. Cardiac work up including electrocardiogram, cardiac enzymes, and coronary angiography is normal. She undergoes Barium Swallow radiography, which was normal. Further testing with esophageal manometry shows 182 mmHg of pressure created by the esophagus during peristalsis. What’s the diagnosis?

12. Nutcracker Esophagus An esophagus with hypertensive peristalsis or high amplitude peristaltic contractions in which pressures more than 180mmHg develop . E xtremely forceful peristaltic contraction leads to episodic chest pain and dysphagia . Most painful of all disorders.

13. Nutcracker Esophagus Symptoms A symptomatic C hest pain ( non- exertional ) that may radiate to arm, back, neck, or jaw dysphagia to solid and liquid foods Physical exam no specific findings.

14. Nutcracker Esophagus Imaging Upper gastrointestinal Barium Swallow can be normal  can have a spiral appearance  Esophageal Manometry diagnostic peristaltic contractions with ≥ 180 mmHg amplitude Endoscopy normal used to rule out anatomical causes of dysphagia

15. Treatment Risk factor modification weight loss First-line C alcium channel blockers  and  nitrates T razodone  antidepressant Interventional E ndoscopic injection of Botulinum Toxin Endoscopic dilatation Heller myotomy indicated for cases refractory to other treatment relaxes the lower esophageal sphincter and myenteric plexus

16. Case #4 A 48 years old male, C/C Dysphagia since adulthood. Complaint worsened in the last three months followed by odynophagia , nausea, and vomiting undigested, retained food and heartburn. W as previously diagnosed with a variant of angina pectoris but his symptoms didn't improve with medication. The patient had a history of weight loss but no anorexia, no prior history of corrosive ingestion . Physical examination revealed no abnormality. Gastroscopy revealed dilatation on the lower third of the esophagus. Computed Tomography revealed dilatation of distal esophagus.

17. Achalasia

18. Achalasia A rare swallowing disorder, but a lifelong condition L oss of peristalsis in the distal two-thirds (smooth muscle) of the esophagus I mpaired relaxation of the LES . D enervation of the esophagus resulting primarily from loss of nitric oxide–producing inhibitory neurons in the myenteric plexus Greek- ‘failure to relax’

19. Achalasia typically affects adults between 30 and 60 years of age, with a peak in the 40s. About twice as common in men than women.

20. Symptoms & Signs Occur during or after eating. The feeling that food or liquid are hard to swallow and are getting caught in the esophagus or “sticking” on the way down to the stomach Regurgitation Substernal discomfort or fullness, which can be severe and awaken the person from sleep Heartburn Coughing, especially at night Choking or aspiration. Weight loss common. Normal examination.

21. imaging

22. imaging

23. imaging

24. Special examinations Endoscopy High Resolution Esophageal manometry Endoscopic U ltrasonography Chest CT

25. treatment Botulinum Toxin Injection Pneumatic Dilation. Surgical Heller Cardiomyotomy Per Oral Endoscopic Myotomy (POEM)

26. CASE # 5 A 20-year-old female patient who had difficulty in swallowing solid foods for 2 years and liquid foods for the last four months was admitted to our clinic. History- Raynaud ’s phenomenon. Already being treated for GERD. On physical examination, cachexia, ‘ fish mouth ’ appearance , ulceration in the distal phalanges and MCP joint ulceration were identified. Esophageal endoscopy demonstrated hyperemia and extreme narrowness at 29 cm obstructing the passage of the endoscope. The endoscopic biopsy result indicated esophagitis. HRM -  decreased lower esophageal sphincter (LES) pressure and absent or ineffective peristalsis of the distal esophagus

27. Scleroderma Esophagus Occurs as part of connective tissue disorder. CREST Syndrome. Atrophy of esophageal smooth muscle with loss of LES tone and force of peristalsis. Raynaud’s phenomenon. Intramural neuronal dysfunction. Reflux esophagitis, Strictures. Pulmonary Interstitial Fibrosis. S/S: GERD, chest pain, dysphagia. Anti-Scl-70, Antiendonuclear Ab , Anti-centromere Ab.

28. Scleroderma Esophagus

29. Scleroderma Esophagus

30. Comparative Changes in manometry

31. conclusion N ot all chest pain is GERD—esophageal dysmotility disorders can masquerade as GERD, leading to misdiagnosis and ineffective treatment. Recognizing the nuances of these disorders is vital for ensuring patients receive the right care and relief.