Gastrointestinal Clinical Case / MCQS / Uworld for Usmle step 2 and IFOM / case 3

 

Gastrointestinal Clinical Case  / MCQS / Uworld for Usmle step 2  and IFOM / case 3 with answer and explanation and references and Educational objective

A 40-year-old man comes to the office for evaluation of dysphagia. For the past 3 years, the patient has had difficulty swallowing solid foods and liquids, with symptoms worsening recently. He reports that it is easier to swallow standing upright. He has occasional regurgitation of undigested food and has lost 5 kg (11 lbs) over the past 6 months. The patient has no chest pain or muscle weakness. His only other medical problem is generalized anxiety disorder for which he takes sertraline. He does not use tobacco, alcohol. or recreational drugs. Vital signs are normal. His neck is supple without masses. Cardiopulmonary examination shows no abnormalities. Muscle strength is 5/5 in all 4 extremities, and deep tendon reflexes are 2+ symmetrically. Barium esophagogram Is shown in the exhibit. Which of the following is the patient's most likely diagnosis?

 

A.  Achalasia . B.  Esophageal cancer . C.  Esophageal web . D.  Globus sensation . E.  Polymyositis . F.   Zenker diverticulum .

 

Answer : A

Explanation:

Achalasia
Clinical presentation	•      Chrome dysphagia to solids & liquids, regurgitation •       Heartburn, weight loss
Diagnosis	•      Manometry: 1 LES resting pressure, incomplete LES •      relaxation, 1 peristalsis of distal esophagus •      Barium esophagram: Smooth "bird-beak" narrowing •      at gastroesophageal junction
Management	•     Upper endoscopy to exclude malignancy •     Laparoscopic myotomy or pneumatic balloon dilation •     Botulinum toxin injection, nitrates & CCB

CCB =calcium channel blocker ; LES = lower esophageal sphincter.

Chronic dysphagia to both solids and liquids, regurgitation, difficulty belching, and mild weight loss are all common manifestations of achalasia. Other symptoms include chest pain and heartburn; therefore, many patients are initially diagnosed with gastroesophageal reflux. On average, patients have symptoms for approximately 5 years before receiving a diagnosis of achalasia.

Achalasia is due to Impaired peristalsis of the distal esophagus and impaired relaxation of the lower esophageal sphincter (LES). This prevents food or liquid from passing through the LES until the hydrostatic pressure in the esophageal column is greater than the closing pressure of the sphincter. Being in the upright position increases the pressure in the esophagus and results in more effective swallowing.

Manometry is the most sensitive test and key to diagnosis. Barium esophagram, which may show a smooth "bird-beak" narrowing near the LES, can be helpful in patients with nondiagnostic manometry.

(Choice B) Esophageal cancer classically presents with dysphagia to solids, especially bread and meat, although tumors can eventually cause dysphagia to liquids as well.

Tobacco and alcohol use are major risk factors. In addition, the prolonged time course of this patient's symptoms and his relatively young age are less consistent with malignancy.

(Choice C) Esophageal webs are most commonly located in the upper esophagus and only cause mild focal narrowing (dysphagia to solids but not liquids). They are often associated with Iron deficiency (Plummer-Vinson syndrome).

(Choice D) Globus sensation Is a diagnosis of exclusion and is characterized by the sensation of a lump In the back of the throat. It is a functional disorder and does not cause any abnormalities on barium esophagram.

(Choice E) Polymyositis can present with dysphagia but usually affects the striated muscle in the upper third of the esophagus. and is associated with other symptoms of muscle weakness (eg, difficulty climbing stairs).

(Choice F) Zenker diverticulum, caused by an outpouching at the cricopharyngeal level of the esophagus, most commonly occurs in patients age >60 and presents with dysphagia, halitosis, and fullness of the throat.

Educational objective:

Achalasia commonly presents with chronic dysphagia to both solids and liquids, regurgitation, difficulty belching, and weight loss. Achalasia is caused by impaired peristalsis of the distal esophagus and failure of the lower esophageal sphincter to relax when food boluses reach it. Manometry is key to diagnosis. 

References: 1. Achalasia. 2. Achalasia: A review of clinical diagnosis, epidemiology, treatment and outcomes. New links : 1. Achalasia. 2. Achalasia: A review of clinical diagnosis, epidemiology, treatment and outcomes.

  

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