Male Patient with Chronic GERD

Thursday, March 25, 2010 14 comments

This is the Upper GI Endoscopy of 61 years old male ,showing the lower part of the Oesophagus  who has been suffering from heartburn and reflux of stomach acid into the mouth for several years.

What is the Diagnosis?
How would you confirm it?


ANSWER

Barrett's esophagus or Barrett's syndrome due to Chronic GERD.
Barrett's oesophagus is a condition in which there is gastric or intestinal metaplasia of the mucosa of the distal oesophagus thought to be caused by damage from chronic acid exposure, or reflux esophagitis


It is considered to be a premalignant condition because it is associated with an increased risk of esophageal cancer (more specifically, adenocarcinoma)


Barrett's oesophagus is most common in elderly adults

CLINICAL FEATURES

There is a relationship between chronic heartburn and the development of Barrett's esophagus
Sometimes people with Barrett's esophagus will have no heartburn symptoms at all.
Barrett's esophagus does not cause any particular symptoms.But WARNING SIGNS are
Dyspepsia
Dysphagia
Vomiting
Haemetemesis
Melaena
Retrosternal pain that radiates to the neck

DIAGNOSIS

Barrett's oesophagus is defined as columnar metaplasia of the oesophageal mucosa which ranges more than 2 cm from the gastro-oesophageal junction.
Endoscopic visualisation and biopsy are diagnostic.
Colonic metaplasia is usually identified by finding goblet cells in the epithelium
For the defenitive identification of globlet cells
Histochemical stain Alcian blue pH 2.5
Immunohistochemical analysis with antibodies to CDX-2 can be used

TREATMENT

In pre malignant stage
Regular endoscopy monitoring and biopsy
If two endoscopies and biopsy sessions performed within 12 months are negative for dysplasia then surveillance can be performed every 3 years
Intensive anti-reflux measures (long term proton pump inhibitor therapy)


High grade dysplasia - laser ablation of the site of metaplasia


Malignancy may require surgery, radiation therapy, or systemic chemotherapy

Cyanotic 2 months old baby

Tuesday, March 23, 2010 28 comments

Here shows the Frontal Radiography  of a 2 months old infant  who was brought to the hospital by the mother because this baby had become bluish and difficulty in breathing while mother was bathing the baby.Mother noticed that bluish color was increasing as child cries vigorously.



On examination this baby there was marked central and peripheral cyanosis.But finger clubbing was absent.Baby was tachypnoeic.
His precordial Examination revealed 
  • Bulge  left anterior hemithorax 
  • Systolic thrill is felt along the left sternal border 
  • Loud  systolic murmur most intense at the left sternal border
  • Systolic ejection murmur at the upper sternal border
What are the differential diagnosis of cyanosis??
What are the Abnormalities seen in this Xray??
What  is the Defenetive diagnosis??

37 year old male patient was admitted to the Surgery ward complaining of abdominal and loin pain and haematuria for 2 days duration.No fever or Dysuria.
He was not pale.His blood Pressure was 180/110mmhg.On abdominal examination this patient,two ballotable masses found in both sides.
Ultrasonography of the patient is given here.



What is the Diagnosis?


ANSWER

AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE


Polycystic kidney disease (PKD)also known as polycystic kidney syndrome is a genetic disorder characterized by the growth of numerous cysts in the both kidneys


PKD cysts can profoundly enlarge the kidneys while replacing much of the normal structure, resulting in reduced kidney function and leading to kidney failure.


PKD can also cause cysts in the liver ,the pancreas,blood vessels in the brain(intracranial berry aneurysms) and heart


Two major inherited forms of PKD exist:


Autosomal recessive PKD 
  • Is a rare inherited form. 
  • Symptoms of autosomal recessive PKD begin in the earliest months of life, even in the womb.




AUTOSOMAL DOMINANT PKD


  • Is the most common inherited form.
  • About 90% of all PKD cases are autosomal dominant PKD.
  • Important cause of renal failure
  • Mutations in either the PKD-1 or PKD-2 gene
  • Cyst formation begins in utero
  • Cysts arise from the tubules throughout the nephrons but initially, involve only a portion of them
  • Symptoms usually develop between the ages of 30 and 40, but they can begin earlier, even in childhood.
  • Autosomal dominant PKD is asymptomatic for several tears and hence it is often called “adult polycystic kidney disease"

CLINICAL FEATURES

  1. Abdominal pain and early satiety and gastroesophageal reflux symptoms - due to mass effect of enlarging kidneys
  2. Loin and back pain
  3. Gross Hematuria
  4. Symptoms of UTI
  5. Hypertension
  6. Features of uraemia
  7. Palpable, bilateral abdominal masses

COMPLICATIONS

* Urinary tract infections—specifically, in the kidney cysts


* Liver and pancreatic cysts


* Abnormal heart valves


* High blood pressure


* Kidney stones


* Ureamia


*Intracranial berry aneurysms - subarachnoidal hemorrhage


* Diverticulosis—small pouches bulge outward through the colon


*Thoracic aortic aneurisms

INVESTIGATIONS

Ultrasonography - highly sensitive


Before the age of 30 years, CT scan or T2-weighted MRI is more sensitive


  • Diagnostic Criteria


In younger patients


  1. Two or more cysts in one kidney
  2. At least one cyst in the contralateral kidney
  3. With a positive family history of the disease
In older patients -four or more cysts


Genetic tests

TREATMENT

Treatment is largely supportive, as there is no single therapy that has been shown to prevent the decline in kidney function


Blood Pressure control(ACE inhibitors or angiotensin II receptor blockers )


Pain management (percutaneous aspiration, sclerotherapy with alcohol or, rarely, surgical drainage)


Lipid-soluble antimicrobials for UTI


End-stage renal disease - Dialysis or Transplantation


In patients with ESRD optimizing nutritional status is important.


This is  a non contrast(T1 Weighted) sagital MRI of a 3days old male baby who developed apnoea and respiratory distress in the baby care unit who had prominent occiput .This condition was prediagnosed during the antenatal period.


What are the Abnormalities that can be visualized in this MRI?
What is the Diagnosis?


ANSWER

ANSWER - Dandy-Walker Syndrome




Dandy-Walker Syndrome is a rare congenital abnormality in which there is usually an absence of the foramina of Magendie and Luschka.




Occurs more frequently in females than in males.




Dandy-Walker malformation is characterized by
  1. Agenesis or hypoplasia of the cerebellar vermis
  2. Cystic dilatation of the fourth ventricle
  3. Dilatation of the third and lateral ventricles
  4. Enlargement of the posterior fossa with a high tentorium cerebelli and transverse sinuses
  5. Brainstem compression and hypoplasia
  6. Thinning and bulging of the occipital bones
  7. Approximately 70-90% of patients have hydrocephalus, which often develops postnatally


Other Causes of posterior fossa cystic malformations are Dandy-Walker variant, mega cisterna magna, and posterior fossa arachnoid cyst


Predisposing factors for Dandy-Walker malformation include gestational exposure to rubella (in the first trimester), cytomegalovirus, toxoplasmosis, warfarin, alcohol, and isotretinoin.

CLINICAL FEATURES

  • Enlarged head circumference
  • Developmental delay
  • Signs of cerebellar dysfunction
  • Signs and symptoms of hydrocephalus
  • Interference with respiratory control centers in the brainstem may cause respiratory failure
  • Seizures
  • Hearing or visual difficulties
  • Intellectual impairment has been observed in patients with agenesis of the corpus callosum

INVESTIGATIONS

Ultrasonography - routinely used during the antenatal period as a screening method, and it is particularly used for postnatal follow-up studies of hydrocephalus.
CT scan
MRI for detailed evaluation of Dandy-Walker malformation lesions

TREATMENT

Dandy Walker Syndrome is treated by excision of the cyst or with a cystoperitoneal shunt.

PROGNOSIS

Prognosis depends upon the extent of neurological impairment prior to treatment and the presence of other developmental abnormalities.
Overall mortality rates of 12-50%


This is a sagital T2 weighted MRI of a 28 years old worker who came to the Neurology unit complaining of headache in the back of head and the nape associated  with paresthesia and weakness of the  hands and limbs.
On examination cerebellar signs were elicited but there was no significant muscle wasting.
 


What is the Diagnosis?


ANSWER

ARNOLD-CHIARI MALFORMATION TYPE 1


The Arnold-Chiari malformation is a congenital malformation of the base of the skull with varying degrees of herniation of cerebellum and medulla into the spinal canal.
Mainly three types
  • type I - cerebellar ectopia
  • type II
  • type III


Arnold-Chiari malformation TYPE 1 is the most common form.It is generally asymptomatic during childhood.


In symptomatic patients, it is associated with:
spinal diseases - 50% of cases: syringomyelia
cranial disorders - 10% of cases: obstructive hydrocephalus

CLINICAL FEATURES

Symptoms and Signs of Brain Stem,Cranial nerves and cerebellar compression
  • Gait ataxia
  • Spastic quadraparesis
  • Downbeat nystagmus or rotatory nystagmus
  • Bulbar symptoms
Occipital headaches - induced by coughing and straining


The blockage of CSF flow may also cause a syrinx to form, eventually leading to syringomyelia and eventually patient will develop symptoms of cord compression

INVESTIGATIONS

  1. MRI - the investigation of choice
  2. CT - best with contrast

TREATMENT

In symptomatic patients
  • Decompression surgery - removes the lamina of the first cervical vertebrae and part of the occipital bone of the skull to relieve pressure
  • Ventricular peritoneal shunting if there is evidence of hydrocephalus or raised intracranial pressure.

This is a Barium Swallow taken from 71 years old man who was complaining of  a sensation that foods sticking in the throat and regurgitation of unchanged food few hours after eating which was lasting for about 2 months.His neurological examination was uneventful.

Identify this Barium Swallow?


ANSWER

Zenker Diverticulum or Pharyngoesophageal Diverticulum 


It is a outpouching of the mucosa of the posterior pharyngeal wall through Killian's triangle(also known as Laimer's triangle, and the Killian-Laimer triangle)an area of weakness between the two parts of the inferior pharyngeal constrictor - the thyropharyngeus and the cricopharyngeus - at their posterior margin.Zenker diverticulum has male predominence and is observed almost exclusively in older individuals.


Mechanisms
  • Uncoordinated swallowing
  • Impaired relaxation and spasm of the cricopharyngeus muscle


Zenker diverticula extend into the left neck 90% of the time

CLINICAL FEATURES

  • Dysphagia
  • Palpable swelling in the neck in two-thirds of cases
  • Involuntary gurgling noises when swallowing
  • Halitosis
  • Regurgitation of undigested food hours after eating
  • Sensation of food sticking in the throat
  • Coughing after eating
  • Aspiration of organic material
  • Episodes of pulmonary infection
  • Unexplained weight loss


COMPLICATIONS
  • Aspiration
  • Bleeding from the mucosa
  • Esophageal obstruction
  • Tracheal Fistulation
  • Squamous cell carcinoma - but very rare

INVESTIGATIONS

Barium swallow with videofluoroscopy

TREATMENT

If small and asymptomatic, no treatment is necessary
In symptomatic cases
Excision of the pouch combined with myotomy (longitudinal division - of the cricopharyngeus)
Approaches at the level of the cricoid cartilage or obliquely through the left sternomastoid have been used to excise the pouch
Risks of surgery such as fistula formation, mediastinitis, inhalation pneumonia and recurrent laryngeal nerve damage
Endoscopic stapling performed through a fibreoptic endoscope

A 30-year-old young man came to the ENT clinic complaining of  increasing tinnitus in his left ear with a tendency to fall to the left. He has no significant previous medical history and on examination he has left sided ataxia, a gaze paresis to the left and audiogram shows sensorineural deafness on that side.


 What is the most propable Diagnosis?




ANSWER

ANSWER - LEFT SIDED ACOUSTIC NEUROMA
An acoustic neuroma(or vestibular schwannoma), is a slow growing benign primary intracranial tumor of the myelin-forming cells of the vestibular portion of the 8th cranial nerve.
It comprises about 6% of all intracranial tumors
lesions are usually located in the internal auditory canal or the cerebellopontine angle causing compression of the vestibular nerve and resulting eventually in deafness
Bilateral acoustic neuromas are the hallmark in patient with type 2 neurofibromatosis

CLINICAL FEATURES

1. Occipital pain on the side of the tumour
2. VIII nerve damage - unilateral sensorineural deafness developing gradually over a period of months or years. vertigo with associated nausea and vomiting,tinnitus.Caloric paresis may be demonstrable.
3. V nerve damage - depression of corneal reflex occurs early. Facial pain, paraesthesia and numbness develop.
4. VII nerve damage - facial weakness is unusual.If involved it may lead to ipsilateral facial weakness, sensory impairment, impairment of glandular secretions and loss of taste sensation in the anterior two-thirds of the tongue
5. IX, X, XI nerve damage - rare; presents as dysphagia, change in voice, palatal weakness.
6. Compression effects of large tumours:

* cerebellum - ataxia, loss of co-ordination on ipsilateral side, nystagmus
* pons - contralateral hemiparesis,gaze palsies
* aqueduct and 4th ventricle - raised intracranial pressure, e.g. headache

INVESTIGATIONS

Neuro-otological
Pure tone audiometry - demonstrates unilateral sensorineural hearing loss
Brainstem audiometry - to distinguish cochlear deafness from retrocochlear disease

Caloric test - expect depressed or absent response

Contrast CT scan as acoustic neuromas are often isodense

MRI with gadolinium enhancement - especially for small intracanalicular tumours

TREATMENT

Conservative management - due to the risk of interventions, small asymptomatic tumors may be managed by a "watch, wait and rescan" approach. This is more suitable in elderly patients with co morbid diseases

Stereotactic radiotherapy

Microsurgery - is useful in treating large acoustic neuromas. three surgical methods are used in approaching the CP angle

1. retrosigmoid approach
2. translabyrinthine approach
3. middle fossa approach




This Is a Xray (Xray taken after injecting water soluble contrast in to the Knee  Joint)showing the knee joint  of  a man who was  complaining sudden onset of calf pain and swelling of the Calf ,  after came home finishing his works.Since 2 months back , before the onset of calf pain he has had some tightness behind the knee and paresthesia of the feet.
His Back of  the knee joint was  swallen,tender and reddish.

Identify this Xray?
What is your Diagnosis?






ANSWER



RUPTURED BAKER'S CYST(PSEUDOTHROMBOPLEBITIS SYNDOME)
Baker's cyst(popliteal cyst), a collection of synovial fluid which has escaped from the knee joint or a bursa and formed a new synovial-lined sac in the popliteal space.The term 'cyst' is a misnomer because it is in fact a synovial sac bulging from the back of the joint.Baker's cysts arise between the tendons of the medial head of the gastrocnemius and the semimembranosus muscles.

CAUSES

It can be caused by virtually any cause of arthritis
Eg : Osteoarthritis, juvenile arthritis of the knee, rheumatoid arthritis
Baker's cysts can be associated with Lyme disease also.
Cartilage (particularly the meniscus) tear

CLINICAL FEATURES

Asymptomatic or asssociated with knee joint pain tightness behind the knee, especially when the knee is extended or fully flexed
If it is large it becomes palpable particularly on standing ,soft and minimally tender
Ruptured Baker's cyst can produce acute pain behind the calf and knee,redness and swelling of the calf that may mimic thrombophlebitis or a potentially life-threatening deep vein thrombosis (DVT)

INVESTIGATIONS

  1. Diagnosis is confirmed by Ultrasonography
  2. Arthrogram
  3. MRI

TREATMENT

  1. Rest and leg elevation
  2. Removal of excess knee fluid in conjunction with cortisone injection.
  3. Surgical excision is reserved for cysts that cause a great amount of discomfort to the patient


This is  a PA chest Xray Of a 67 years old man who has been suffering from a Stroke for 2years admitted to the hospital having  Fever , Productive cough and stabing pain in the right  side of the chest for 6weeks duration.He further told that sputum was foul smelling.No history of hemoptysis.
On general examination he was febrile,emaciated and had finger and toe clubbing.
Oh his respiratory sytem examination  there was decreased breath sounds, dullness to percussion, and course inspiratory crackles in the lower region of the right chest.

Identify the Chest Xray annd What is the Dx?


ANSWER

LUNG ABSCESS IN THE LOWER LOBE OF THE RIGHT LUNG DUE to ASPIRATION


A lung abscess is a confined area of suppuration within the lung parenchyma. It is more common in alcoholics and in elderly, debilitated patients who are prone to aspiration, and in intravenous drug abusers. Males are affected slightly more often than females.The incidence of lung abscess has declined in the recent past due to the greater efficacy of antibiotics in the treatment of lower respiratory tract infection.


Organisms
* Anaerobic bacteria: Peptostreptococcus, Bacteroides, Fusobacterium species,
* Microaerophilic streptococcus : Streptococcus milleri
* Aerobic bacteria: Staphylococcus, Klebsiella, Haemophilus, Pseudomonas, Escherichia coli, Streptococcus, Mycobacteria
* Fungi: Candida, Aspergillus
* Parasites: Entamoeba histolytica

CAUSES

Aspiration of gastric secretion
Septic emboli
Necrotizing pneumonia
Vasculitis: Wegener's granulomatosis
Necrotizing tumors:primary squamous carcinoma of the lung is the commonest

MORPHOLOGY

Abscesses due to aspiration are more common on the right, due to the more vertical right bronchus, and most often, are single.
In pneumonia or bronchiectasis are usually multiple, basal and diffusely scattered
Septic emboli and pyemic abscesses are usually multiple and may affect any region of the lung

CLINICAL FEATURES

Symptoms and signs of a pneumonitis:
  • shivers
  • fever
  • pleuritic chest pain
  • malaise and fatigue


Discharge of the abscess into a bronchus:
  • cough
  • the sputum is copious and foul smelling
  • the sputum is initially blood-stained but may become green or brown with time


Finger clubbing
Signs of a pleural effusion or consolidation
Pleural rub

INVESTIGATIONS

Leucocytosis
High ESR, CRP
Sputum or Transtracheal of Transbronchial aspirates can also be cultured
Chest radiography:may reveal one or more circular lesions of almost any size which may cavitate and show fluid levels Chest ultrasound:can identify a fluid collection
Fibre-optic bronchoscopy:permits sampling for bacteriology and for histological diagnosis of any obstructive lesions

TREATMENT

Broadspectrum antibiotic
      gentamicin,benzylpenicillin,metronidazole
Pulmonary physiotherapy
postural drainage
Percutaneous drainage of a lung abscess
Lung resection in selective patients

COMPLICATIONS

Bronchial:
  • bronchiectasis
  • bronchial stenosis
  • rupture with spread of infection
  • haemorrhage and a bronchopleural fistula
Parenchymal:
  • overdistension of the alveoli
  • collapse
  • secondary infection
Empyema
Distant spread: sepsis, brain abscesses, mediastinitis

PROGNOSIS

Usually excellent unless there is a debilitating underlying condition
Mortality from lung abscess is about 5%


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