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هضمية 2


هضمية 2


حالة سريرية

الوصف الكامل Background

A 45-year-old male presents with a history of crushing nonradiating chest pain. Electrocardiography and exercise stress testing reveal no evidence of cardiac edema. A more detailed history is taken, and the patient states that he has had a sensation of sticking after swallowing. He notes this sensation equally whether he is eating solids or liquids. The diagnosis that is most likely to account for these symptoms is

A. achalasia
B. diffuse esophageal spasm
C. lower esophageal (Schatzki) ring
D. esophageal carcinoma
E. Zenker's diverticulum
explain your answer...

by


typical case of DES,which mimics angina pain

mbs2380's picture
mbs2380
بعد التخرج


b
-sensation of sticking after swallowing
-whether he is eating solids or liquids

Inspector's picture
Inspector
السنة السادسة


شباب طلب غليظ:
ممكن تضيفوا ترجمة للعربي لكل حالة بتنزلوها.
وبكون ممنون لإلكم. Smiling

Dr_Hero's picture
Dr_Hero
طبيب مقيم


Yeap …..it is SDES…..
We have to put in mind that achalasia also – in some rare cases – appears with heartburn, but it is mostly accompanied with weight loss, which is not found in our case.

Vince Carter

Quote:
شباب طلب غليظ:
ممكن تضيفوا ترجمة للعربي لكل حالة بتنزلوها.
وبكون ممنون لإلكم. Smiling

رجل عمره 45 سنة يعاني من قصة الم صدري عاصر غير منتشر .
بتخطيط القلب و اختبار الجهد....لم يظهر عنده أعراض وذمة قلبية.
عند تفصيل القصة....المريض قال بأنه يشعر بإحساس أن الطعام يعلق عند بلعه.
هذا الشعور يأتيه عند تناول كل من الأطعمة الصلبة و السائلة.

ما هو التشخيص الأكثر احتمالا؟؟؟
A. achalasia
B. diffuse esophageal spasm
C. lower esophageal (Schatzki) ring
D. esophageal carcinoma
E. Zenker's diverticulum

Vince Carter

Quote:
achalasia also – in some rare cases – appears with heartburn, but it is mostly accompanied with weight loss, which is not found in our case.

in heart pain ( angina , GERD ) some considrations to b taken :

a discreminting point is that if u ask the pt to bend fwd , if the pain increases , this is of cardiac origin

and if u notice a water brash -sudden appearance of excess saliva in the pt's mouth due to reflex salivation , this is a most lykly GERD

but the chest pain here is cuz this diffuse dysmotility can lead sometimes to espohageal spasm

Quote:
achalasia also – in some rare cases – appears with heartburn, but it is mostly accompanied with weight loss, which is not found in our case

so lets say :

dysphagia + heart burn + wt loss = might be achalasia
dysphagia + no wt loss + heart burn = might be benign peptic stricture
but if dysphagia + with wt loss+ a short history + and no heart burn = suspect an esophageal cancer

Quote:
-sensation of sticking after swallowing
-whether he is eating solids or liquids

some pts complain that they cant sleep too cuz of overflow of respiratory secretions during night ( aspiration pnueomonia)

okay : mention a CNS leison that produces dysphagia ?

-----------

-nice case , and important topic
thank you alot

امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة

Quote:
dysphagia + heart burn + wt loss = might be achalasia
dysphagia + no wt loss + heart burn = might be benign peptic stricture
but if dysphagia + with wt loss+ a short history + and no heart burn = suspect an esophageal cancer

mathematically speaking....that is the summary.....

Quote:

a discreminting point is that if u ask the pt to bend fwd , if the pain increases , this is of cardiac origin

and if u notice a water brash -sudden appearance of excess saliva in the pt's mouth due to reflex salivation , this is a most lykly GERD

very nice

thank you very much....go on....

Vince Carter

Quote:
okay : mention a CNS leison that produces dysphagia

?
Neuromuscular disorders include:
•Those that impair prehension and bolus formation include cranial nerve deficits (e.g., idiopathic trigeminal neuropathy and lingual paralysis-CN XII) and masticatory muscle myositis.
• Pharyngeal weakness, paresis, or paralysis causing dysphagia can be caused by myasthenia gravis and infectious polymyositis (e.g., toxoplasmosis and neosporosis), immune mediated polymyositis, muscular dystrophy, polyneuropathies, and myoneural junction disorders (e.g., tick paralysis and botulism). Rabies can cause dysphagia by affecting both the brainstem and peripheral nerves.
•Other CNS disorders, especially those involving the brainstem, can cause dysphagia.

Green Wave's picture
Green Wave


This is not to undermine the importance of clinical history and clinical clues. However you will be surprised how many times patients will not follow the above mentioned rules,i,e simple motility disorders (like DES) could lead to weight loss or cancer with no weight loss
I do want to say though that the most common esophageal cause of pain is GERD (not DES ) .Besides GERD could lead to many nonspecific motility disorders (and even DES)
The diagnosis of DES is rather elusive and pointless in many times since there is no well standerdized treatment for it that is based on clinical trials and you end up treating it with acid suppressive therapy + promolity agents trial of Ca channel blockes or nitrate with (will little help )
at the end.

ABIM's picture
ABIM


في طور القراءة .. شكراً لكم

Dr.TH's picture
Dr.TH


سقى الله تلك الايام...مهيك يا ابو الخل....

mbs2380's picture
mbs2380
بعد التخرج

Quote:
سقى الله تلك الايام...مهيك يا ابو الخل....

اي والله!!!

سبحن الله....متل الحلم....

Vince Carter


أبو الخل كم مرة منزل هالحالة Cool
http://www.hakeem-sy.com/main/node/24187
Eye-wink

Dr.TH's picture
Dr.TH
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