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Old 11-07-2012
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Arrow Gyrus Daily Questions; Internal Medicine #73

A 48-year-old woman with diet-controlled diabetes reports difficulty swallowing for the last year She has difficulty swallowing both solids and liquids, and has an associated weight loss of about 20 lb She has no history of heartburn and takes no medications Abdominal examination is normal Chest x-ray shows an air-fluid level in the mediastinum Barium swallow fluoroscopy reveals a dilated esophagus with pointlike tapering Manometry reveals incomplete relaxation of the lower esophageal sphincter and no peristalsis in the proximal part of the esophagus Which of the following is the most appropriate next step in management?

A. Botulinum toxin
B. Calcium channel blockers
C. Endoscopy
D. Nitrates
E. Pneumatic dilation
F.-Surgical myomectomy
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achalasia.....according to me E is the answer
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ans--E. Pneumatic dilation is best initial therapy for Achalasia, and if not effective and patient candidate for surgery do surgical sectioning if not candidate Botulinum toxin can be use
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endoscopy i think to rule any other cause before a diagnosis of achlasia is made
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C. Endoscopy
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The correct answer is C. Endoscopy

This patient has achalasia.
which is characterized by progressive dysphagia of solids and liquids Upper gastrointestinal radiography shows a smooth. beaklike tapering and failure of peristalsis in the esophagus. with increased tone of the lower esophageal sphincter

Endoscopy is necessary to confirm the diagnosis because it is necessary to rule out a secondary achalasia due to cancer or lymphoma. Some tumors may invade into the esophageal neural plexus. causing failure in relaxation of the LES (lower esophageal sphincter). Rapid weight loss over a short period of time with the barium swallow findings described above suggests secondary achalasia due to malignancy

Achalasia that is not due to malignancy may have a history of weight loss due to dysphagia. but that would be expected to occur over a long period of time So secondary achalasia due to malignancy should be ruled out (especially when the patient is older).

if symptoms are of less than 6 months' duration, and when there is a history of marked weight loss Botulinum toxin (choice A) is an alternative therapy for achalasia It is effective in about two-thirds of patients Repeat injections are required because relief is always temporary.

Calcium channel blockers (choice B) and nitrates (choice D) can be used for the relief of diffuse esophageal spasms

Once secondary achalasia is ruled out. treatment is focused on opening the lower esophagus Pneumatic dilation (choice E) of the lower esophagus is the most appropriate treatment of achalasia In pneumatic dilation, a large. 4-cm balloon is inflated within the lower esophagus to tear the sphincter open The technique is associated with a small risk of perforation

Surgical myotomy (choice F) is also very effective in treatment of achalasia Surgical myotomy is reserved for refractory cases
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