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Old 05-19-2013
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Default Gastroenterology q7

A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment.
She takes hydrochlorothiazide for hypertension.
Review of symptoms reveals chronic cough.
Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation.
Gastric biopsies are unremarkable. Helicobacter pylori testing is negative.

1. What is the most likely etiology of the patientís stricture?
(A) alcohol ingestion (B) tobacco use (C) gastroesophageal reflux (D) hydrochlorothiazide (E) spicy food ingestion

2.. What is the next best step in therapy for this patient?
(A) esophageal dilation (B) histamine receptor antagonist therapy (C) PPI therapy (D) esophageal dilation with histamine receptor antagonist therapy (E) esophageal dilation with PPI inhibitor therapy
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Old 05-19-2013
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Quote:
Originally Posted by cingulate.gyrus View Post
A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment.
She takes hydrochlorothiazide for hypertension.
Review of symptoms reveals chronic cough.
Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation.
Gastric biopsies are unremarkable. Helicobacter pylori testing is negative.

1. What is the most likely etiology of the patientís stricture?
(A) alcohol ingestion (B) tobacco use (C) gastroesophageal reflux (D) hydrochlorothiazide (E) spicy food ingestion

2.. What is the next best step in therapy for this patient?
(A) esophageal dilation (B) histamine receptor antagonist therapy (C) PPI therapy (D) esophageal dilation with histamine receptor antagonist therapy (E) esophageal dilation with PPI inhibitor therapy
Esophageal adenocarcinoma is common in the distal esophagus, I liked the wording of this vignette, Esophageal squamous cancer is associated with both smoking and alcoholism, however it is more common in the first 2/3rds of the esophagus....
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Old 05-20-2013
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Originally Posted by XpaezX View Post
Esophageal adenocarcinoma is common in the distal esophagus, I liked the wording of this vignette, Esophageal squamous cancer is associated with both smoking and alcoholism, however it is more common in the first 2/3rds of the esophagus....

1. (C)
2. (E)

Explanations

The patient has a peptic stricture, seen in the setting of long-standing untreated gastroe-sophageal reflux with esophagitis. The history of progressive solid food dysphagia without weight loss is typical. Tobacco, alcohol, thiazide diuretics, and spicy foods do not predispose to benign esophageal strictures.
The patient has developed a peptic stric-ture, a serious complication of GERD. The patient needs esophageal dilation (either with mechanical or pneumatic dilators) and maxi-mal acid suppression. PPI therapy is superior to histamine receptor antagonist therapy in terms of healing erosive esophagitis.
Patients with long-standing GERD are at increased risk of developing Barrett esophagus, a risk factor for esophageal adeno-carcinoma. GERD is not a risk factor for esophageal squamous cell cancer, gastric cancer, or duodenal cancer. Patients with chronic H. pylori infection (which this patient did not have) are at increased risk for a form of gastric lymphoma known as a MALT-oma. (


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