Causes of dysphagia: differential diagnosis based on patient history

Dysphagia, or difficulty swallowing, can have various causes, including structural abnormalities, functional disorders, and neoplastic conditions. Based on the patient’s history, several possibilities can be considered. For example, a benign oesophageal stricture may develop in patients with acid gastro-oesophageal reflux disease and can be treated with endoscopic dilation and reflux management. Diffuse oesophageal spasm, on the other hand, may cause dysphagia for both solids and liquids and be accompanied by chest pain. A lower oesophageal web can produce episodic dysphagia when food gets stuck in the distal oesophagus. Oesophageal squamous carcinoma is less likely in a young non-smoking patient, but should not be ruled out entirely. Scleroderma, a connective tissue disorder, may also cause dysphagia along with Raynaud’s phenomenon and skin changes. Therefore, a thorough evaluation and appropriate diagnostic tests are necessary to determine the underlying cause of dysphagia and guide the treatment plan.

Investigating Perforated Peptic Ulcers: Imaging Modalities

When investigating a possible perforated peptic ulcer, there are several imaging modalities available. However, not all of them are equally effective. The most appropriate first-line investigation is an erect chest X-ray, which can quickly and cost-effectively show air under the diaphragm if a perforation has occurred.

A supine chest X-ray is not effective for this purpose, as lying down changes the direction of gravitational effect and will not show the air under the diaphragm. Similarly, an ultrasound of the abdomen is not useful for identifying a perforated ulcer, as it is better suited for visualizing soft tissue structures and blood flow.

While a CT scan of the abdomen and pelvis can be useful for investigating perforation, an erect chest X-ray is still the preferred first-line investigation due to its simplicity and speed. An X-ray of the abdomen may be appropriate in some cases, but if the patient has vomited coffee-ground liquid, an erect chest X-ray is necessary to investigate possible upper gastrointestinal bleeding.

In summary, an erect chest X-ray is the most appropriate first-line investigation for a possible perforated peptic ulcer, as it is quick, cost-effective, and can show air under the diaphragm. Other imaging modalities may be useful in certain cases, but should not be relied upon as the primary investigation.

Investigating Perforated Peptic Ulcers: Imaging Modalities

Possible Causes of Obstructive Jaundice: A Case Analysis

The patient’s symptoms suggest that the most probable cause of obstructive jaundice is gallstones lodged in the common bile duct. Recurrent episodes of biliary colic and/or cholecystitis may have caused the intermittent abdominal pain, which has now worsened and led to hepatic obstruction. Cholecystitis, inflammation of the gallbladder due to gallstones, would not cause obstructive jaundice unless the gallstones leave the gallbladder and become lodged in the common bile duct. Alcohol-induced pancreatitis is a common cause of acute pancreatitis in the UK, but it will not cause obstructive jaundice. Hepatitis C may cause cirrhosis and subsequently jaundice, but there is no evidence that the patient is an intravenous drug user. Pancreatic carcinoma, particularly if located in the head of the pancreas, can cause obstructive jaundice, but it is usually painless in origin. Courvoisier’s law states that a non-tender palpable gallbladder accompanied by painless jaundice is unlikely to be caused by gallstones.

Oral Lesions: Differential Diagnosis and Characteristics

Oral lesions can present in a variety of forms and have different characteristics. In this case, a patient with a history of immunosuppression presents with a white mass on the lateral aspect of the tongue that cannot be scraped off with a tongue blade. This is most consistent with oral hairy leukoplakia, a non-premalignant Epstein-Barr virus-mediated mucocutaneous manifestation that often presents in immunosuppressed patients. Treatment involves antivirals.

Other possible oral lesions include oral discoid lupus erythematosus, which is the oral manifestation of systemic lupus erythematosus and typically presents as punched-out lesions with surrounding erythema. Aphthous ulcers are round or oval-shaped lesions with surrounding erythema that typically occur on the inside of the mouth and can be treated with topical steroids. Oral candidiasis can be scraped off with a tongue blade, making it an unlikely diagnosis in this case. Oral lichen planus is a chronic inflammatory condition that can present as white, lacy patches or erosions on the gingival margin.

In summary, a thorough examination and consideration of the patient’s medical history are necessary to accurately diagnose and treat oral lesions.

Diagnostic Biopsy Findings for Various Intestinal Conditions

When conducting a biopsy of the small intestine, various changes may be observed that can indicate the presence of certain conditions. However, it is important to note that these changes are not always specific to a particular disease and may be found in other conditions as well. Therefore, additional diagnostic tests may be necessary to confirm a diagnosis.

Coeliac disease is one condition that can be suggested by biopsy findings, which may include infiltration by lymphocytes and plasma cells, villous atrophy, and crypt hyperplasia. However, positive serology for anti-endomysial or anti-gliadin antibodies is also needed to confirm gluten sensitivity.

Abetalipoproteinemia, Mycobacterium avium infection, Whipple’s disease, and intestinal lymphangiectasia are other conditions that can be diagnosed based on biopsy findings alone. Abetalipoproteinemia is characterized by clear enterocytes due to lipid accumulation, while Mycobacterium avium infection is identified by the presence of foamy macrophages containing acid-fast bacilli. In Whipple’s disease, macrophages are swollen and contain PAS-positive granules due to the glycogen content of bacterial cell walls. Finally, primary intestinal lymphangiectasia is diagnosed by the dilation of lymphatics in the intestinal mucosa without any evidence of inflammation.

Gastrointestinal Conditions: Understanding Oesophageal Varices, Hiatus Hernia, Mallory-Weiss Tear, Barrett’s Oesophagus, and Oesophageal Stricture

Gastrointestinal conditions can cause discomfort and even life-threatening complications. Here are five conditions that affect the oesophagus:

Oesophageal Varices: These are enlarged veins in the lower third of the oesophagus that can rupture and cause severe bleeding. They are often caused by portal hypertension, which is associated with chronic liver disease.

Hiatus Hernia: This condition occurs when the diaphragmatic crura separate, causing the stomach to protrude above the diaphragm. There are two types: axial and non-axial. Bleeding with a hiatus hernia is usually not severe.

Mallory-Weiss Tear: This condition is characterized by tears in the oesophageal lining caused by prolonged vomiting. It presents with bright red haematemesis.

Barrett’s Oesophagus: This condition is associated with reflux, inflammation, and possible ulceration. Bleeding is not usually severe.

Oesophageal Stricture: This condition results from scarring, typically caused by reflux or scleroderma. It is a chronic process that does not usually cause severe bleeding.

Understanding these conditions can help individuals recognize symptoms and seek appropriate medical attention.

Understanding Achalasia: Symptoms, Diagnosis, and Differential Diagnosis

Achalasia is a motility disorder that affects the lower esophageal sphincter, causing difficulty swallowing both liquids and solids. This condition is characterized by the failure of the sphincter to relax in response to peristalsis during swallowing, which can lead to chest pain after eating and regurgitation of food. The cause of achalasia is unknown, but it is thought to be due to degeneration of the myenteric plexus.

To diagnose achalasia, a barium swallow may reveal a dilated esophagus with a bird’s beak tapering of the distal esophagus. Manometry can confirm the high-pressure, non-relaxing lower esophageal sphincter. Endoscopy should also be carried out to exclude malignancy.

Differential diagnosis for achalasia includes oesophageal carcinoma, pharyngeal pouch, benign oesophageal stricture, and caustic stricture. Oesophageal carcinoma is less likely in a relatively young patient without history of weight loss, and the barium swallow findings are more suggestive of achalasia than malignancy. A pharyngeal pouch would be visualized on a barium swallow, while a benign oesophageal stricture is more common in older people with a history of gastro-oesophageal reflux disease. Caustic stricture would also be visualized on a barium swallow, but there is no history of caustic damage in this case.

The patient is suspected to have acute cholecystitis, and a confirmation of the diagnosis will rely on an ultrasound scan of the abdomen. To manage the patient’s symptoms and prevent sepsis, it is essential to administer intravenous antibiotics and fluids. Antiemetics may also be necessary to prevent dehydration from vomiting. It is recommended to keep the patient ‘nil by mouth’ until the scan is performed and consider prescribing analgesia for pain relief. An NG tube is not necessary at this stage, and an OGD or ERCP may be appropriate depending on the scan results. The NICE guidelines recommend cholecystectomy within a week of diagnosis.

When it comes to distinguishing between ulcerative colitis and Crohn’s disease, one key factor is the presence of crypt abscesses. These are typically seen in ulcerative colitis, which is the more common of the two inflammatory bowel diseases. In ulcerative colitis, inflammation starts in the rectum and spreads continuously up the colon, whereas Crohn’s disease often presents with skip lesions. Patients with ulcerative colitis may experience left-sided abdominal pain, cramping, bloody diarrhea with mucous, and unintentional weight loss. Colonoscopy typically reveals diffuse and contiguous ulceration and inflammatory infiltrates affecting the mucosa and submucosa only, with the presence of crypt abscesses being a hallmark feature. In contrast, Crohn’s disease is characterized by a transmural inflammatory phenotype, with non-caseating granulomas and stricturing of the bowel wall being common complications. Patients with Crohn’s disease may present with right-sided abdominal pain, watery diarrhea, and weight loss, and may have a more systemic inflammatory response than those with ulcerative colitis. Barium enema and colonoscopy can help to differentiate between the two conditions, with the presence of multiple linear ulcers in the bowel wall (rose-thorn appearance) and bowel wall thickening being suggestive of Crohn’s disease.

Diagnostic Tests for Achalasia: Oesophageal Manometry Study and Other Modalities

Achalasia is a motility disorder of the oesophagus that causes progressive dysphagia for liquids and solids, accompanied by severe chest pain. While it is usually idiopathic, it can also be secondary to Chagas’ disease or oesophageal cancer. The diagnosis of achalasia is confirmed through oesophageal manometry, which reveals an abnormally high lower oesophageal sphincter tone that fails to relax on swallowing.

Other diagnostic modalities include a barium swallow study, which may show a classic bird’s beak appearance, but is not confirmatory. A CT scan of the thorax may show a dilated oesophagus with food debris, but is also not enough for diagnosis. Upper GI endoscopy with biopsy is needed to rule out mechanical obstruction or pseudo-achalasia.

Treatment for achalasia is mainly surgical, but botulinum toxin injection or pharmacotherapy may be tried in those unwilling to undergo surgery. Drugs used include calcium channel blockers, long-acting nitrates, and sildenafil. Oesophageal pH monitoring is useful in suspected gastro-oesophageal reflux disease (GORD), but is not diagnostic for achalasia.

In summary, oesophageal manometry is the best confirmatory test for suspected cases of achalasia, and other diagnostic modalities are used to rule out other conditions. Treatment options include surgery, botulinum toxin injection, and pharmacotherapy.