GIT Cases: Achalasia Diagnosis and Treatment

Lab 1: GIT Cases

• Topic: Gastrointestinal Tract (GIT) cases
• Lecturer: Dr. Safy Salah
• University: Nahda University, Beni Suef

Case 1

• Patient: 75-year-old woman
• Presenting complaint: Losing weight, difficulty swallowing solids and liquids, regurgitation of undigested food, feeling of fullness, chest pain, coughing, and aspiration
• Physical exam: Normal
• X-ray: Enlarged, fluid-filled esophagus, air-fluid interface
• Barium esophagography: Esophageal dilation, loss of peristalsis, poor esophageal emptying
• Endoscopic exam: Normal, no carcinoma
• Esophageal manometry: Complete absence of esophageal peristalsis
• Diagnosis: Achalasia
• Treatment: Dilation of sphincter, incision, or botulinum toxin injection into the Lower Esophageal Sphincter (LES).

Case 1 Questions

• What is the most probable diagnosis? Achalasia
• Which structure limits retrograde entry of food into the esophagus? Lower Esophageal Sphincter (LES)
• Explain the mechanisms of movement of swallowed food through the esophagus? Primary peristalsis and secondary peristalsis
• Which symptom directed you to think about this diagnosis? Weight loss, difficulty swallowing, regurgitation of undigested food, fullness, and pain in the chest.
• How to treat this condition? Dilation of sphincter, incision, or botulinum toxin injection into the LES

Case 2

• Patient: 33-year-old man

• Presenting complaint: Mid-epigastric pain, burning sensation in the chest, worse after eating and when lying flat, also woken up from the pain, sore throat, hoarse voice.

• Relieved by: Sitting position and over-the-counter medication (Zantac)

• History: aspirin and ibuprofen use

• Treatment: Omeprazole (proton pump inhibitor) and reduced dose of aspirin/ibuprofen

• Diagnosis: Gastroesophageal reflux disease (GERD)

Case 2 Questions

• What is your possible diagnosis? Gastroesophageal Reflux Disease (GERD)
• How is acid produced and controlled within the gastrointestinal tract? Acid is produced by parietal cells in the stomach. Secretions are stimulated by acetylcholine, histamine, and gastrin, and inhibited by somatostatin. Phases include cephalic, gastric, and intestinal.
• Etiology of GERD? Factors affecting LES pressure, including neural control, acetylcholine, nitric oxide (NO)/VIP, other factors (like smoking, some foods, medications, or hormone gastrin).
• Patient's signs/symptoms: Mid-epigastric pain, burning sensation in chest, worse after eating, lying flat, sore throat, hoarse voice, partial relief with sitting and Zantac
• How do aspirin and NSAIDs affect gastroesophageal disease? Aspirin and NSAIDs promote reflux.
• What class of medication is omeprazole? Proton pump inhibitor. Blocks H+ and K+ ATPase enzyme (a component of HCL production).

Case 3

• Patient: 52-year-old man
• Presenting complaint: Burning epigastric pain, right after eating, subsides after some time, reappears in two hours. Relieved by antacids, not NSAIDs.
• History : Smoker, 5 cups coffee daily, 9 pounds weight loss without dieting
• Physical exam: Epigastric tenderness on palpation
• Lab findings: Positive occult blood in stool, Positive Helicobacter pylori antigen
• Endoscopic findings: Ulcer confirmed by biopsy
• Diagnosis: Peptic Ulcer

Case 3 Questions

• What is the most probable diagnosis? Peptic ulcer.
• Explain the mechanisms developing such a diagnosis in this case? Breakdown of gastric mucosal barrier, cigarette smoking, nervous.
• Discuss acid secretion in the stomach. Parital cells produce HCL. Stimulation by Ach, histamine and gastrin, inhibited by somatostatin. 3 phases: Cephalic, Gastric, and Intestinal phases.
• factors increasing gastric acid secretion? Histamine, acetylcholine, and gastrin
• Treatment? Blockade of H2 histamine receptors (e.g., cimetidine), Inhibit H+/K+ ATPase (e.g., omeprazole), Eradication of Helicobacter pylori with antibiotics, Stop smoking and NSAIDs, Surgical removal of gastrin secreting tumors.