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Spot Diagnosis - Endoscopy Clip

Discussion in 'Spot Diagnosis' started by neo_star, Feb 15, 2013.

  1. neo_star

    neo_star Moderator

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    This patient has an unresolved cough ( mostly nocturnal ) with chronic bronchitis and rhinosinusitis ruled out.


    on Endoscopy....


    [​IMG]

    Kindly suggest the possible cause of his cough.
     

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    Last edited: Feb 15, 2013

  2. Emergency medicine Mike

    Emergency medicine Mike Bronze Member

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    Barrets esophagitis.
     

  3. DALIMEN48

    DALIMEN48 Young Member

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    oesophage candidose
     

  4. DALIMEN48

    DALIMEN48 Young Member

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    post nasal drip syndrome with buccal candidose or metaplasie(biopsie
     

  5. bb100

    bb100 Bronze Member

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    Gastroesophageal reflux and reflux oesophagitis

    aspiration of gastric acid cause to chemical pneumonia
     

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  6. kittychan

    kittychan Well-Known Member

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    gastroesophageal reflux disease
     

  7. neo_star

    neo_star Moderator

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    Answer: Likely cause of the persistent cough is - pharyngitis and or laryngitis secondary to GERD.

    Discussion
    barret's esopagus is a histologic diagnosis ( not a gross / endoscopic diagnosis ) and there is no endoscopic criteria for this diagnosis. So to avoid any raised eyebrows, i will just call it esophagitis ( the red areas. pls. note - the white areas is normal sq. epithelium )

    Let's compare the normal GE junction with the clip above


    GI441.jpg

    so we can definitely say that our patient has gross inflammatory changes which given his persistent cough could be suggestive of reflux esophagitis.


    We still have to rule out other causes of non-reflux esophagitis which are mostly medications ex. potassium chloride tablets, doxycycline, tetracycline, quinidine gluconate, ferrous sulfate, vitamin C, NSAIDs, aspirin, oral contraceptives, and alendronate (Fosamax) ..becos for any severe med. issue the causes could be ( goes without saying ) - multifactorial.

    The areas that appear red and velvetty usually just show inflammatory changes, rather than actual metaplasia which is the defining feature of Barrett's esophagus. The white / paler areas are normal squmous epithelium and most of us mistake that for being the pathognomic "Barrett's columnar Epithelium". Coupe of images to clarify this..

    some more images.JPG

    The potential consequences of severe reflux esophagitis are bleeding, development of stricture, and Barrett esophagus, with its predisposition to malignancy.


    Histopath Charecteristics of inflmmatory changes

    Mild esophagitis may appear macroscopically as simple hyperemia, with virtually no histologic abnormality.

    In contrast, the mucosa in severe esophagitis shows confluent epithelial erosions or total ulceration into the submucosa.

    Three histologic features are characteristic of uncomplicated reflux esophagitis, although only one or two may be present:
    (1) eosinophils, with or without neutrophils, in the epithelial layer;
    (2) basal zone hyperplasia; and
    (3) elongation of lamina propria papillae. Intraepithelial neutrophils are markers of more severe injury.

    Charecteristics of metaplastic changes which define Barrett's esophagus are of 3 types:

    (1) Gastric type with chief and parietal cells
    (2) Intestinal type with goblet cells is most common. This mmucosa is smooth ( unlike gastric folds )
    (3) Junctional type - has mucus glandsand resembles gastric cardia

    Clinical types
    (1) long segment - metaplastic changes involving more than 2 cms
    (2) short segment - metaplastic changes involving less than 2 cms

    long segment is more likely to progress to dysplasia and mandates aggressive Mx including anti-reflux surgery.

    the metaplastic changes calls for incresed surveillence to look for dysplasia and advocates aggressive MX to prevent progression to dysplasia

    Histopath charecteristics of Dysplasia

    Ӣ Low-grade lacks clearly definable criteria and is therefore associated with considerable interobserver variation; difficult to distinguish from reactive changes
    Ӣ High-grade dysplasia: clear criteria exist and the interobserver variation is less: the presence of a severe cytologic abnormality and complete loss of nuclear polarity and/or gland complexity characterized by luminal bridging and cribriform change.

    For those who think the white areas represent Candidiasis....

    esophageal candidiasis.JPG

     

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