31

Case 31


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.


Physical examination


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.


Unintended weight loss.


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).






images


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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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 31
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