History
A 52-year-old lady with a longstanding history of gastro-oesophageal reflux disease (GORD) presents with a recent increase in epigastric discomfort and heartburn. She has no tarry stools, haematemesis, dysphagia or weight loss. She has a body mass index of 28kg/m2.
•Temperature 36.5°C, fever, pulse 80 bpm, BP 120/80mmHg, SaO2 98-100% on RA.
•Obese, hydration satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Her chest is clear on auscultation.
•Abdominal examination reveals a soft, non-tender abdomen.
•No signs of oedema.
Investigations
•CBC:
–WBC 5 x 109/L;
–haemoglobin 12.5g/dL;
–platelets 278 x 109/L.
What is your differential diagnosis?
•GORD.
•Malignancy (e.g. liver, oesophageal, gastric).
•Drugs (all non-steroidal anti-inflammatory drugs [NSAIDs]).
•Pancreatic disease (chronic pancreatitis).
•Gastroparesis.
•Functional dyspepsia.
Would you arrange an oesophagogastroduodenoscopy (OGD) for this patient?
Yes. Patients with a new onset of dyspepsia after 45 to 55 years of age and those with alarming symptoms should undergo an initial endoscopy 1.
Alarming features include 1:
•Family history of upper-GI malignancy.
•GI bleeding or iron deficiency anaemia.
•Progressive dysphagia.
•Odynophagia.
•Persistent vomiting.
•Palpable mass or lymphadenopathy.
•Jaundice.
An OGD is performed showing the following (Figure 31.1).
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Please describe what you see
White light endoscopy shows no oesophagitis. The salmon-coloured mucosa noted above the oesophagogastric junction (OGJ) is suggestive of Barrett’s oesophagus. A 5mm nodule (circle) is noted in the area of Barrett’s oesophagus.
Upon endoscopic measurement, the diaphragmatic level is at 36cm and the OGJ is at 34cm. The salmon-coloured mucosa is noted at 29cm (highest point — white arrow) and 30cm (circumferential — blue arrow) to 34cm.
How would you report the Prague classification in this case?
The Prague classification is the extent of circumferential columnar-appearing mucosa above the OGJ, reported as the C value (4cm in this case), while the maximum extent of any tongue-like areas of columnar-appearing mucosa above the OGJ is reported as the M value (5cm in this case) 2
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