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Old 06-25-2011
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Question Choking and abnormal Barrium swallow

A 42-year-old woman presents to the emergency room after suffering from a choking spell at a nearby restaurant. She was eating a large steak when a piece became lodged at the level of the sternal notch. She became cyanotic and was unable to speak until the food was dislodged by the Heimlich maneuver. In the last 6 months, she has had four similar episodes of episodic choking. Additionally, she notes that she has become increasingly tired, lethargic, and short of breath over this period. She denies chest pain, palpitations, or unintentional weight loss. Her previous medical history is notable for leiomyomas of the uterus. On examination, there is appreciable angular cheilitis and generalized pallor. A barium swallow is performed and reveals a thin projection at the level of the hypopharynx. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Diet modification
B. Endoscopic dilation
C. Iron replacement therapy
D. Surgical excision
E. Vitamin B12 replacement therapy

Last edited by USMLE-Syndrome; 06-25-2011 at 01:48 PM.
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  #2  
Old 06-25-2011
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is this plummer vinson ? i think it is...i m with c iron repplacement therapy...

angular cheilitis is found in iron defficiency anemia...

and the cause is
leiomyomas of the uterus...


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Old 06-26-2011
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D. Surgical excision
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Old 06-26-2011
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still no right answer
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Old 06-26-2011
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The answer would be B. Endoscopy dilation. I agree with Plummer Vinson rings diagnosis however in this case it is a symptomatic web and all symptomatic esophageal webs must be treated with mechanical dilation.

Correct me if I wrong please, because I am not 100% sure.
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Old 06-26-2011
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Option B (Endoscopic dilation) is correct. This patient has signs and symptoms consistent with Plummer-Vinson syndrome, which describes the triad of postcricoid dysphagia, esophageal webs, and iron-deficiency anemia. The postcricoid dysphagia is suggested by the repeated choking episodes; the iron-deficiency anemia is suggested by the physical examination findings, the presence of leiomyomas, and shortness of breath; the esophageal webs are seen on barium swallow. Treatment for these webs is dilation on endoscopy when they significantly impede swallowing.

Option A (Diet modification) is incorrect. Diet modification is used in mild cases of Plummer-Vinson syndrome and would not be appropriate in this case.

Option C (Iron replacement therapy) is incorrect. Although iron replacement therapy can be warranted in this patient, correction of the iron deficiency will not result in resolution of the esophageal web.

Option D (Surgical excision) is incorrect. Excision of the esophageal web is only performed when dilation has failed.

Option E (Vitamin B12 replacement therapy) is incorrect. There is no suggestion of Vitamin B12 deficiency in this patient.

High-yield Hit 1
Clinical features
Usually the patient is asymptomatic, but high-level dysphagia may occur when tough fibrous food is swallowed without care. There may be a history of a persistent cough due to the aspiration of pharyngeal secretions.
Anemia may present as part of the Plummer-Vinson syndrome (see below).
Diagnosis and investigation
Barium swallow-demonstrates narrowing of the esophagus by fibrous tissue. The proximal part of the esophagus may be distended with barium.
Endoscopy-webs may be difficult to see, especially those in the postcricoid area.

From Crash Course: Gastroenterology by Thuluvath
High-yield Hit 2
Etiology and pathogenesis
The cause of esophageal webs is unknown. There is a different clinical outcome depending on site of the web. Two types are commonly recognized:
Postcricoid web.
Lower esophageal web.
Postcricoid web
Also known as Plummer-Vinson or Paterson-Brown Kelly syndrome.
Associated with iron-deficiency anemia and atrophic glossitis.
Lower esophageal web
Lower esophageal web is also known as Schatzki ring, where there is a small, fibromuscular band that originates from the diaphragm. It is often associated with a hiatal hernia.
Complications
There is an increased risk of developing postcricoid carcinoma of the pharynx associated with Plummer-Vinson syndrome.
Treatment
Dilatation of the obstruction is rarely needed.
Oral iron supplementation may be required if iron-deficiency anemia, associated with Plummer-Vinson syndrome, is present.
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