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Flashcards in 10/19- Case Studies Deck (23)
1

Might just want to do the Dickey deck...

This one's okay, though

2

- 74-year-old man presented to his PCP

- Dyspepsia (heartburn)

- Physical exam unremarkable

Which of the following diagnoses is most likely?

A. Esophageal perforation

B. Infectious esophagitis

C. Reflux esophagitis

D. Eosinophilic esophagitis

E. Barrett’s esophagus

A. Esophageal perforation

B. Infectious esophagitis

C. Reflux esophagitis

D. Eosinophilic esophagitis

E. Barrett’s esophagus

3

According to the Guidelines of American College of Gastroenterology (ACG) in 2005 for diagnosis and treatment of reflux, the symptoms most specific for GERD are what?

- Regurgitation

- Heartburn

- Or both

4

What is seen in this endoscopy?

A. Esophageal perforation

B. Infectious esophagitis

C. Reflux esophagitis

D. Eosinophilic esophagitis

E. Barrett's esophagitis

A. Esophageal perforation

B. Infectious esophagitis

C. Reflux esophagitis

D. Eosinophilic esophagitis

E. Barrett's esophagitis

- Hyperemia (redness, indicative of reflux)

- Esophageal mucosa may be unremarkable

- Helpful here to do a biopsy

5

What is the diagnosis based on the microscopic findings?

A. Esophageal perforation

B. Infectious esophagitis

C. Reflux esophagitis

D. Eosinophilic esophagitis

E. Barrett's esophagitis 

A. Esophageal perforation

B. Infectious esophagitis

C. Reflux esophagitis

D. Eosinophilic esophagitis

E. Barrett's esophagitis 

- Impressive basal cell hyperplasia (~1/3 thickness of mucosa)

- Lymphocyte infiltration

6

Summarize endoscopy and microscopoic findings of reflux esophagitis

Endoscopy

- Simple hyperemia (redness)

MICROSCOPY

Mild GERD:

- Unremarkable mucosal histology

Mores significant GERD:

- Intraepithelial eosinophils and lymphocytes

- Basal zone hyperplasia

- Congestion of small vessels with associated microhemorrhage

7

What is the first choice of therapy for reflux esophagitis? Other treatment guidelines (how long to treat?)

A. Proton pump inhibitor

B. Histamine 2 antagonist

C. Sucralfate, a coating agent

D. Life style modification

E. Corticosteroid

A. Proton pump inhibitor

B. Histamine 2 antagonist

C. Sucralfate, a coating agent

D. Life style modification

E. Corticosteroid

Treatment based on ACC GERD guideline:

- PPIs is more effective than H2RAs for GERD based on highest-level evidence

- Greater percentage of patients with reflux esophagitis healed when treated with PPIs than with H2RA

- Treatment for 2-4 weeks and re-assessment

8

If the patient presents 10 years after the reflux esophagitis with similar symptoms and had the following endoscopy and histology, what is the diagnosis?

A. Reflux esophagitis

B. Infectious esophagitis

C. Eosinophili esophagitis

D. Barrett's esophagus

E. Adenocarcinoma 

A. Reflux esophagitis

B. Infectious esophagitis

C. Eosinophili esophagitis

D. Barrett's esophagus

E. Adenocarcinoma 

9

What are the endoscopic findings expected with Barrett's esophagus?

- Salmon color tongue (characteristic)

- Extensive color change (widespread involvement)

10

How should a patient with Barrett's esophagus found on endoscopy/biopsy be managed/followed up?

- Repeat endoscopy in 6 mo

- Multiple biopsies

11

What is the diagnosis with this histology?

A. Reflux esophagitis

B. Dyspasia

C. Barrett's esophagus

D. Barrett's esophagus and dysplasia

E. Adenocarcinoma

A. Reflux esophagitis

B. Dyspasia

C. Barrett's esophagus

D. Barrett's esophagus and dysplasia

E. Adenocarcinoma

- Dysplasia here, because don't really see any metaplasia (no goblet cells)

12

What is the next step for the patient with dysplasia/Barrett's esophagus found on biopsy?

A. Extensive biopsy (mapping)

B. Endoscopic mucosal resection

C. Esophagectomy

D. Follow up

E. Discuss the options with the patient

A. Extensive biopsy (mapping)

B. Endoscopic mucosal resection

C. Esophagectomy

D. Follow up

E. Discuss the options with the patient

- Can do extensive biopsy...

- Will NOT do espohagectomy; significant morbidity and mortality

- Follow up alone is insufficient; must do biopsies and endoscopies as well

13

Patient with dysplasia/Barrett's is followed up with in 6 mo and this is found.

What is the diagnosis?

A. Infectious esophagitis

B. Reflux esophagitis

C. Barrett's esophagus

D. Dysplasia

E. Worrisome for adenocarcinoma

A. Infectious esophagitis

B. Reflux esophagitis

C. Barrett's esophagus

D. Dysplasia

E. Worrisome for adenocarcinoma

- Can see a lot of dysplasia here and fibroblastic activity... worried about adenocarcinoma

- The difference between this and dysplasia is the degree; limited to superficial would indicate dysplasia while adenocarcinoma concerns go deeper

14

Treatment for the past case?

Endoscopic mucosal resection

15

What is your diagnosis for this histology found on biopsy of esophageal nodule? 

Intramucosal adenocarcinoma

- Evaluation of margin hindered by marked cautery effect

- Follow up continues...

16

New case:

- 40 yo man

- Dyspepsia and heartburn

- Proton pump inhibitor for a while

- Partially relieve heartburn and dyspepsia

- Refer to gastroenterologist

- Upper GI endoscopy

What is the probably diagnosis?

A. Pill gastritis

B. Peptic gastritis

C. Obstruction

D. Tumor

E. Metastatic disease

A. Pill gastritis

B. Peptic gastritis

C. Obstruction

D. Tumor

E. Metastatic disease

17

What is the diagnosis based on these histological findings?

A. Pill gastritis

B. Peptic gastritis

C. Obstruction

D. Tumor

E. Metastatic disease 

A. Pill gastritis

B. Peptic gastritis

C. Obstruction

D. Tumor

E. Metastatic disease 

- Associated with Helicobacter pylori (can see little spiral bacilli in higher power picture)

18

What is the appropriate treatment for this man with peptic gastritis?

A. Proton pump inhibitor

B. Surgery

C. Antibiotic therapy

D. A and B

E. A and C

A. Proton pump inhibitor

B. Surgery

C. Antibiotic therapy

D. A and B

E. A and C

19

- This patient with H pylori peptic gastritis came back with similar signs and symptoms every 2-3 yrs

- PCP repeated the treatment, considering recurrence

- On his recent presentation, the patient requested to be seen by a gastroenterologist as he had read about his disease on internet

- Patient is referred and undergoes another upper endoscopy and biopsy

What is the diagnosis?

A. Pill gastritis

B. Peptic gastritis

C. Intestinal metaplasia

D. Adenocarcinoma

E. Metastatic disease 

A. Pill gastritis

B. Peptic gastritis

C. Intestinal metaplasia

D. Adenocarcinoma

E. Metastatic disease 

20

How should this patient with recurrent H pylori infections and intestinal metaplasia be followed?

A. Repeat endoscopy every 5 years

B. Repeat endoscopy every year

C. If the patient has extensive disease, especially multi focal atrophy of gastric mucosa, he should be followed regularly

D. No endoscopic follow up is needed, unless the patient has some GI symptoms

E. There is no need for follow up

A. Repeat endoscopy every 5 years

B. Repeat endoscopy every year

C. If the patient has extensive disease, especially multi focal atrophy of gastric mucosa, he should be followed regularly

D. No endoscopic follow up is needed, unless the patient has some GI symptoms

E. There is no need for follow up

21

What is the possible diagnosis based on this endoscopy and histology?

A. Pill gastritis

B. Peptic gastritis

C. Intestinal metaplasia

D. Adenocarcinoma

E. Metastatic disease

A. Pill gastritis

B. Peptic gastritis

C. Intestinal metaplasia

D. Adenocarcinoma

E. Metastatic disease

22

How should the previous patient with adenocarcinoma be managed?

- Pt is referred to oncology

- Underwent 6 cycles of chemotherapy

- Underwent total gastrectomy

23

What is the prognosis with the following gatrectomy and biopsy findings?

Depends on the stage

- 5-year survival rate of early gastric cancer after surgery > 90%, even if lymph node metastases are present

- 5-year survival rate for advanced gastric cancer under 20%