A 40 year old man has difficulty swallowing and reports weight loss. A barium swallow test reveals a stricture. What condition is most likely?
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Step 1: Note the key symptoms: difficulty swallowing (dysphagia) and weight loss. Show more…
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A 42-year-old woman is admitted to the hospital because of difficulty in swallowing solid foods; liquids are less difficult to swallow. Just pain follows eating, and the patient frequently regurgitates swallowed food after a meal. When the recumbent patient is observed by fluoroscopy after a barium swallow, her lower esophagus is seen to be somewhat dilated, but her upper esophagus is of normal caliber. Subsequent swallows initiated by the patient do not cause the barium to be cleared from the esophagus as rapidly as in a normal individual. Rather, it appears that the lower esophageal sphincter (LES) relaxes very transiently, allowing small amounts of barium to empty into the stomach. The administration of amyl nitrate accelerates the clearance of barium from the esophagus. The transient openings of the LES do not bear any simple temporal relationship to the swallows initiated by the patient. Esophageal manometric studies of the patient are then undertaken. The coordinated peristaltic wave that is observed in the esophagus of a normal individual after a swallow does not occur in this patient. Rather, each swallow elicits a low-pressure increase in the esophagus; the pressure increase occurs almost simultaneously at various places along the length of the esophagus. The resting pressure of the LES is about 60 mmHg and the LES pressure decreases to about 45 mmHg after a swallow. The patient is treated by dilating the LES by brief, forceful inflations of a pneumatic device. After this procedure, the patient's ability to swallow solid food is dramatically improved. 15 months after the dilation, the patient returns with the complaint that swallowing has again become difficult.
Adi S.
TS is 67 years old, with a long history of knee osteoarthritis for which he self-medicates regularly with over-the-counter (OTC) naproxen. He is in the clinic today complaining of a swallowing difficulty that has progressively worsened over the past several months. He has otherwise been healthy and has not seen a doctor in many years. He denies significant past medical history. A review of systems is negative except for arthritic symptoms and swallowing difficulty. He denies noticing blood in his stool or vomiting blood. He denies a history of gastroesophageal reflux disease (GERD) or ulcer. He does not drink alcohol, although he drank heavily many years ago. He does not smoke. The dysphagia he describes thus: "Food gets stuck in my throat and I can't get it down." The feeling occurs only after he has ingested solid food; liquids are not a problem. There is burning chest pain associated with meals. He is scheduled for an upper GI endoscopy. Answer these questions based on the chapter 36 content provided: 1. What is the likely cause of the dysphagia? 2. What advice should he be given regarding his OTC medication at this time? 3. What are the usual signs and symptoms of GERD? How will it be managed?
Madhur L.
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