A 50-year-old male presents with difficulty swallowing. Esophageal manometry demonstrates absence of peristaltic waves and a nonrelaxing lower esophageal sphincter (LES). Which of the following is the most likely diagnosis?
Answer(s): C
Esophageal achalasia is characterized by the findings of aperistalsis/atony and a failure of the LES to relax normally, resulting in esophageal dilatation proximally with a functional obstruction at the LES. Long- standing achalasia results in the characteristic barium swallow finding of a "bird's beak." Iatrogenic or tumor-related elevation of LES pressure can result in a "pseudoachalasia," but should have normal peristaltic patterns on manometry. Patients with Barrett's esophagus may have a "cobblestone" appearance on barium swallow, with normal peristalsis, and do not characteristically demonstrate esophageal dilatation; LES pressures may be normal or low. Finally, patients with Plummer-Vinson syndrome develop cervical dysphagia due to irondeficiency anemia; patients often present with cervical esophageal webs and can be at higher risk for developing esophageal squamous cell carcinoma.
Which of the following statements is true regarding Barrett's esophagus?
Answer(s): D
Barrett's esophagus is a condition in which the normal stratified squamous esophageal mucosa is replaced by a columnar-lined epithelium. It is often the result of chronic GERD. If
A 49-year-old male presents with crushing substernal pain and rules out for a myocardial infarction. He is noted to have subcutaneous emphysema of the chest and neck and precordial crackles that correlate to his heartbeat but not his respirations.Which of the following is the most likely diagnosis?
Answer(s): B
"Hamman's crunch" is precordial crackles heard on auscultation that correlate with heart sounds in the setting of mediastinal emphysema and is suggestive of esophageal perforation. When present along with subcutaneous emphysema of the chest and neck, pneumomediastinum from an esophageal perforation is the most likely diagnosis. The most common cause of esophageal perforation is iatrogenic, but it may be spontaneous (Boerhaave's syndrome) or secondary to a malignancy or stricture. Diagnosis is often made after clinical suspicion by endoscopy or a swallow study with water- soluble contrast. If diagnosed early (within 24 hours), a primary repair is the first approach to treatment. Closure is dependent on the amount of infected or necrotic tissue, tension on the anastomosis, etiology of the perforation, and the ability to adequately drain the contaminated areas. Late perforations may be complicated in their management, requiring several procedures or diversion to provide for adequate healing.
A 49-year-old male presents with crushing substernal pain and rules out for a myocardial infarction. He is noted to have subcutaneous emphysema of the chest and neck and precordial crackles that correlate to his heartbeat but not his respirationsWhich of the following approaches to management is most appropriate?
A patient presents with a 24-hour history of periumbilical pain, now localized to the right lower quadrant. An abdominal CT scan is obtained in the ER, which is shown in Figure.Which of the following is considered a physical sign often associated with this diagnosis?
The diagnosis of acute appendicitis can often be made based on the history and physical findings. The sequence of symptoms classically begins with anorexia followed by periumbilical pain that localizes to the right lower quadrant after 612 hours. The onset on nausea and emesis occur after the development of abdominal pain. If the patient has an appetite or if bouts of vomiting begin before the onset of abdominal pain, the diagnosis should be reconsidered. In this patient, the acute appendicitis has progressed to a rupture resulting in a localized right lower quadrant abscess (marked with arrow in Figure below)The signs of acute appendicitis are also characteristic. On examination, tenderness is often maximal at McBurney's point, located approximately one-third the distance from the anterior superior iliac spine to the umbilicus. Other physical signs include Rovsing's sign (pain initiated in the right lower quadrant upon palpation in the left lower quadrant), Dunphy's sign (increased pain with coughing), the obturator sign (pain on internal rotation of the hip), and the psoas sign (pain during extension of the right hip). Dance's sign (concave and empty right lower quadrant) is associated with ileocecal intussusception. Grey-Turner's sign is bruising of the flanks and may occur in severe, acute pancreatitis due to subcutaneous tracking of inflammatory, peripancreatic exudate along the retroperitoneum. Murphy's sign is defined as inspiratory arrest secondary to pain when palpating under the right costal margin. It is associated with a diagnosis of acute cholecystitis
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