Gastrointestinal Clinical Case / MCQS / Uworld for Usmle step 2 and IFOM / case 2 with answer and explanation and references and Educational objective
A
62-year-old man comes to the office due to difficulty swallowing both solids
and liquids. The patient's symptoms have progressively worsened over the last 3
months. He also has occasional regurgitation of undigested food and a nighttime
cough that disturbs his sleep. He has never had similar symptoms before. The
patient has lost 4.5 kg (10 lb) during this period but has no other medical
problems and takes no medications. He has a 20-pack-year smoking history but
quit 10 years ago. He drinks wine on the weekends. Vital signs are normal, and
his physical examination is
unremarkable. Chest x-ray reveals a widened mediastinum, and barium studies show a dilated esophagus with smooth tapering of the distal esophagus. Which of the following is the best next step in management of this patient?
|
A. CT scan
of the chest . B. Endoscopic
evaluation . C. Esophageal
pH monitoring . D. Laparoscoplc
myotomy . E. Reassurance
and calcium channel blocker . F. Trial
of proton pump Inhibitor . |
Answer : B
Explanation:
This patient's presentation, with dysphagia to solids and liquids and a dilated esophagus with smooth tapering of the distal esophagus, suggests either primary achalasia (le, loss of peristalsis In the distal esophagus with lack of lower esophageal sphincter relaxation) or pseudoachalasia due to esophageal cancer. Several clues point to pseudoachalasia (eg, narrowing of distal esophagus not due to denervation) caused by malignancy.
Tobacco use Is a major risk factor for esophageal adenocarcinoma and squamous cell carcinoma; alcohol use Is also an important risk factor for esophageal squamous cell carcinoma. Significant weight loss, rapid symptom onset (<6 months), and presentation at age >60 all increase the likelihood of malignancy (by comparison, patients with achalasia have symptoms for approximately 5 years before receiving a diagnosis, and they typically only have mild weight loss). Tumor metastasis (eg, mediastinal lymph nodes) or local Involvement may gave a radiologic appearance similar to that seen with a widened mediastinum. Endoscopic evaluation can differentiate between achalasia and pseudoachalasla. In achalasia, this evaluation usually shows normal-appearing esophageal mucosa and a dilated esophagus with possible residual material; in addition, It Is generally possible to easily pass the endoscope through the lower esophageal sphincter (unlike In malignancy).
(Choice A) If endoscopy shows a malignancy, a CT scan can be performed for staging. CT scan can also be obtained If endoscopy is nonrevealing and there is still concern for malignancy.
(Choices C and F) Esophageal pH monitoring is typically used to confirm gastroesophageal reflux disease (GERD) In patients who have symptoms consistent with GERD but who fall a trial of proton pump inhibitor (PPI) therapy. Although GERD can present with food regurgitation and nighttime cough, it would not explain the patient's weight loss and dysphagia or the barium esophagram findings. In addition, PPIs do not significantly Improve the symptoms of achalasia.
(Choices D and E) Laparoscoplc myotomy and pneumatic balloon dilation are the treatments of choice for patients with achalasia who are at low surgical risk. Options for patients at high surgical risk Include botulinum toxin injection, nitrates, and calcium channel blockers. However, all these treatments should be considered only after malignancy is excluded and the diagnosis of achalasia is confirmed.
Educational objective:
Pseudoachalasia,
which Is due to narrowing of the distal esophagus secondary to causes other
than denervation (eg, esophageal cancer), can closely mimic achalasia. Clues
pointing to pseudoachalasia include significant weight loss, rapid symptom
onset, and presentation at age >60. Consequently, endoscopy is recommended
to exclude malignancy in all patients with suspected achalasia.
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