Integrative Lecture: Esophagus, Stomach & Duodenum

RALPH LEE, MMED(DIST), MD, FRCPCGASTROENTEROLOGIST, ASSISTANT PROFESSOR AND MEDICAL EDUCATORUNIVERSITY OF OTTAWA

Case I

Case 1

A 55 year old male presents to your office with complaints of ‘heartburn’ Past Medical history

Hypertension, hypercholesterolemia, cholecystectomy

Medications: TUMS

Allergies: None

What questions would you ask?

Case 1

Characterize the symptom: Onset?

Usually after meals and with lying down

Position? Retrosternal

Quality? Burning

Radiation? To neck

Severity? 4/10

Timing? 1x every 2 weeks, for the last 6 months

Aggravating factors? Spicy foods, lying down at night

Relieving factors? Better with TUMS

Associated symptoms? Regurgitation? 1x every 2 weeks

AM sore throat, hoarse voice? None.

Case 1

Alarm symptoms? Dysphagia, odynophagia, vomiting, chest pain,

weight loss, hematemesis, melena

Patient denies any of these symptoms

Risk behaviours? Intake: Caffeine, chocolates, spicy foods, citrus

foods, carbonated beverages, alcohol, peppermints

Habits: Smoking, alcohol

Patient incidentally reports that his father died of esophageal cancer

What would you do next?

Case 1

Physical exam: Obese male, but otherwise unremarkable.

What do you believe is the diagnosis?

What would you do next?

Case 1

What would you do next?

a. Empirically treat him with a proton pump inhibitor

b. Counsel him on lifestyle measures and suggest over the counter antacids

c. Order laboratory investigations

d. Order an ECG

e. Order a barium swallow

f. Consult GI for an esophagastroduodenoscopy

g. Order a CT scan of the chest

h. Order a 24 hour pH study

Case 1

What would you do next?

a. Empirically treat him with a proton pump inhibitor

b. Counsel him on lifestyle measures and suggest over the counter antacids

c. Order laboratory investigations

d. Order an ECG

e. Order a barium swallow

f. Consult GI for an esophagastroduodenoscopy

g. Order a CT scan of the chest

h. Order a 24 hour pH study

Case 1 – Follow-up

You recommend some lifestyle measures for GERD and over-the-counter antacids

The patient’s symptoms resolve with weight loss and dietary modification

Case 2

Case 2

27 year old female with presents to your office with severe ‘stomach’ pain

Past Medical History: Left rotator cuff tear

Hypothyroidism

Appendectomy

What would you ask?

Case 2

Characterize the symptom Onset? Usually 30 minutes after meals.

Position? Epigastric.

Quality? Burning.

Radiation? To mid-back.

Severity? 8/10.

Timing? Started 1 month ago @ 1x/week, but increased in frequency to

daily. Lasts for 30-45 minutes.

Aggravating factors? Worse with eating and with alcohol.

Relieving factors? Better with TUMS and milk.

Associated symptoms? Nausea.

Case 2

Alarm Features? Vomiting, hematemesis, melena, dysphagia, odynophagia,

early satiety, unexplained weight loss, jaundice, family history of gastric CA

The patient reports that she has been having black, ‘tar-like’ stools 3x/day for the last 2 days

Medications? NSAIDs? Patient reports she has been taking 6-8 tablets of

Ibuprofen per day for the past 2 weeks

Habits? Non-smoker. EtOH: Social

Family History? No family history of gastric CA, PUD

What is the differential diagnosis?

Case 2 - DDx

Peptic ulcer disease

H. Pylori gastritis

Functional dyspepsia

Pancreatitis

Biliary cause (biliary colic, choledocholithiasis)

Cholecystitis

Gastroparesis

Gastroenteritis

Malignancy

Pregnancy

Hepatitis

Pulmonary cause

Cardiac cause

Muskuloskeletal cause

What would you do next?

Case 2

Physical exam: HR 110, BP 120/80, RR 16, T 37.5

H&N: Moist mucous membranes

Abdomen: Tender epigastric area, no rebound, no masses, no HSM

Laboratory Patient found to be anemic (Hgb 102 g/L).

What would you do next?

Case 2

What would you do next? Start her empirically on a PPI and arrange follow-

up in 2 weeks.

Counsel her on lifestyle measures and suggest over-the-counter antacids.

Arrange a barium swallow.

Send her directly to the emergency department for an urgent GI consult and EGD

Start her on a PPI and consult an outpatient gastroenterologist for a non-urgent EGD.

Arrange a CT scan.

Case 2

What would you do next? Start her empirically on a PPI and arrange follow-

up in 2 weeks.

Counsel her on lifestyle measures and suggest over-the-counter antacids.

Arrange a barium swallow.

Send her directly to the emergency department for an urgent GI consult and EGD

Start her on a PPI and consult an outpatient gastroenterologist for a non-urgent EGD.

Arrange a CT scan.

Case 2 - EGD

What would you do next?

Case 2 - Pathology

Case 2

What would you do? Treat for H. Pylori

Amoxicilin 1g po BID, Clarithromycin 500mg po BID, PPI po BID x 14 days.

Proton pump inhibitors Treat for 8 weeks, then consider trial off.

Stop the NSAIDs If unable to stop, ensure patient is on a PPI for gastroduodenal

protection

Repeat Endoscopy within 3 months To confirm healing of ulcer

Small percentage of gastric ulcers can be malignant.

Repeat H. Pylori biopsies to confirm eradication

Other methods: H. Pylori Breath test

Case 2 – Follow-up

You prescribe a course of triple therapy for 14 days and she continues with omeprazole 20 mg po bid for a total 8 weeks

A repeat EGD in 3 months confirms healing of the ulcer and gastric biopsies are negative for H. Pylori

Her pain has resolved at 3 months of follow-up

Case 3

Case 3

A 42 year old male presents to your office complaining of trouble swallowing.

Past medical history: Obesity

EtOH Abuse

What do you want to ask?

Case 3

Characterize the symptom Food sticking? Where? Difficulty initiating swallow? Choking? Nasal

regurgitation Patient reports a feeling of food sticking in his

retrosternal area. Solids and liquids or solids alone?

Patient reports it is only solid food, but he can tolerate intake of liquids. There have been occasions that solid food became stuck and he could not swallow any liquids including his own saliva.

Case 3 - DDx

Malignancy Malignancy Malignancy Peptic stricture Eosinophilic esophagitis What would you do next?

Case 3

Is it intermittent or progressive? Patient reports it started intermittently, but has

been progressively worse. He is afraid to eat any type of solid for fear it will become stuck.

Is there any associated weight loss? Patient reports a 20lb weight loss over the last 3

months.

Is there any associated heartburn? Patient denies any history of heartburn.

What is your differential diagnosis?

Case 3

What would you do next? Arrange a barium swallow

Consult GI for an upper endoscopy

Counsel the patient on lifestyle measures for GERD and prescribe over the counter medications

Empirically start the patient on a PPI and arrange a follow-up visit in 2 months

Order a CT Chest

Tell the patient to chew their food more carefully and ‘man up’.

Case 3

What would you do next? Arrange a barium swallow

Consult GI for an upper endoscopy

Counsel the patient on lifestyle measures for GERD and prescribe over the counter medications

Empirically start the patient on a PPI and arrange a follow-up visit in 2 months

Order a CT Chest

Tell the patient to chew their food more carefully and ‘man up’.

Case 3 - EGD

Case 3 – Follow-up

Biopsies confirm esophageal adenocarcinoma

CT Abdomen/Chest reveals multiple pulmonary and liver metastases (Stage IV)

The patient is referred to radiation oncology for palliative radiotherapy and back to GI for esophageal stent placement.

Questions?