GI1 Case C Answers

A patient comes to your primary care clinic, Ms. Spyz Curry, complaining of chest pain. The pain feels like heartburn she's felt before. She's noticed that she's had this nagging nocturnal cough that hasn't gone away even though she doesn't feel sick. Her dentist has recently commented on the gradual disappearance of enamel to her teeth most proximal to her throat. She often feels bloated after belching.

You get an EKG:

NORMAL EKG

Based on the history and EKG, you believe Ms. Spyz Curry has what?

GERD

On Physical exam, you also note bowel sounds heard over the left lung base. This changes your initial diagnosis in what way?

GERD 2/2 to a Possible Hiatal Hernia

How do you treat Sliding Hiatal Hernias through pharmacologic and nonpharmacologic means? (Goljan)

Pharma

1. H2 Antagonist

2. PPI

3. Prokinetic Agents

NonPharma
1. Reduce foods/drugs that lower esophageal tone sphincter tone like coffee, chocolate, and calcium channel blockers

2. Avoid large quantities of food (no more buffets)

3. Sleep with head of bed elevated
4. Possible Surgery

Besides your clinical gestalt, name 3 other ways you can diagnose GERD?
1.  24hr esophageal pH monitoring
2. Esophageal Endoscopy
3. Manometry (LES pressure <10mmHg)

Using the following image, name this complication of uncontrolled GERD:

"These two endoscopic views demonstrate Barrett esophagus areas of mucosal erythema of the lower esophagus, with islands of normal pale esophageal squamous mucosa. If the area of Barrett mucosa extends less than 2 cm above the normal squamocolumnar junction, then the condition is called "short segment" Barrett esophagus, as shown below." -UTAH Path


Describe the following image, retrieved from the distal esophagus, in pathological terms:

"Another cause for inflammation is a so-called "Barrett's esophagus" in which there is gastric-type mucosa above the gastroesophageal junction. Note the columnar epithelium to the left and the squamous epithelium at the right. This is "typical" Barrett's mucosa, because there is intestinal metaplasia as well (note the goblet cells in the columnar mucosa)." -UTAH Path

Name 2 Complications of Barrett's Esophagus:

1. Ulceration with stricture formation
2. Glandular dysplasia leading to distal adenocarcinoma