Corrosive Esophagitis

A 50 year old woman was seen in emergency after ingesting a chemical substance . Esophagogastrodudenoscopy was performed and the picture is shown below.

Initial esophagoscopy. (A) Middle esophagus shows whitish discoloration. (B) Distal esophagus shows exudates with easy touch bleeding.

The case was diagnosed as Corrosive Esophagitis 

Corrosive Esophagitis Case Discussion

Introduction

Inflammation and damage to the esophagus after ingestion of a caustic chemical is called corrosive or caustic esophagitis. Similar to a burn, this injury may be temporary or lead to permanent stricture (narrowing or stenosis) of the esophagus that requires corrective surgery.
Severe injury can quickly lead to esophageal perforation, mediastinitis, and death from infection, shock, and massive hemorrhage (due to aortic perforation).

Causes
The most common chemical injury to the esophagus follows the ingestion of lye or other strong alkalies; less commonly, injury follows the ingestion of strong acids. The type and amount of chemical ingested determine the severity and location of the damage.
In children, household chemical ingestion is accidental; in adults, it’s usually a suicide attempt or gesture. The chemical may damage only the mucosa or submucosa, or it may damage all layers of the esophagus.

Pathology

Esophageal tissue damage occurs in three phases: 

1. in the acute phase, edema and inflammation; 
2. in the latent phase, ulceration, exudation, and tissue sloughing; and
3.  in the chronic phase, diffuse scarring.

Diffuse esophageal spasm (DES)

Diffuse esophageal spasm (DES) is a condition characterized by uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may causes symptoms such as chest pain, similar to heart disease.

Etiology: Etiology of esophageal spasm is unknown. Increased release of acetylcholine appears to be a factor (sensitive to cholinergic stimulation), but the triggering event is not known. Other theories include gastric reflux or a primary nerve or motor disorder. 

Pathology: Diffuse esophageal spasms occur when the propagative waves do not progress correctly. Usually, several segments of the esophagus contract simultaneously, preventing the propagation of the food bolus. In addition, diffuse esophageal spasms can be characterized by rapid wave progression down the esophagus or distinguished by a nonperistaltic response to swallowing.

Clinical Features: DES manifests as intermittent difficulty swallowing (dysphagia) for solid foods

Causes Of Ascites

Ascites is the accumulation of excess fluid in the peritoneal cavity.
A list of causes is given below:

1.  Hepatic Causes:

• Cirrhosis
• Hepatic tumors.

2. Malignant disease:

• Carcinomatosis
• Abdominal tumor
• Pelvic tumor
• Psudomyxoma peritonei
• Primary mesothelioma

3. Cardiac Causes:

• Cardiac failure
• Constrictive pericarditis.
• Tricuspid incompetence

4. Renal Causes:

Bird's Beak Sign On Barium Enema

A patient presents to the emergency room with abdominal pain. An abdominal series shows a “bird’s beak” sign.

The most likely diagnosis is

A) Intussusception
B) Volvulus
C) Pyloric stenosis
D) Malrotation
E) Acute appendicitis

Answer and Discussion
The answer is B.

Sigmoid volvulus is a rare problem seen in children and adolescents. Volvulus occurs when a floppy sigmoid loop rotates around its base, producing arterial and venous obstruction of the affected segment, followed by rapid distention of the closed loop. Because the consequences can be life-threatening, sigmoid volvulus should be included in the differential diagnosis of acute and recurrent episodes of abdominal pain or bowel obstruction in children, especially if colonic dilation is seen on
radiographs.

Black Hairy Tongue

A 60-year-old man who smokes presents to the physician’s office smelling of alcohol. He complains of a black discoloration of his tongue and a gagging sensation on occasion. He admits to smoking
1 to 2 packs per day along with drinking at least 6 to 8 beers per day. The patient brushes his teeth infrequently and has not seen a dentist for a long time.
On physical exam, his teeth are stained and his tongue shows elongated papillae with brown discoloration . See picture below:

Diagnoses include black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction.

Case Discussion:

Black Hairy Tongue: 

Black hairy tongue (BHT) is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue resulting in a hair-like appearance
Also known as : Hyperkeratosis of the tongue and lingua villosa nigra.

Risk factors include:

Approach To A Patient With Chronic Diarrhoea

A 24 year old married man presents to his general physician with a history of watery diarrhea which has sometimes blood mixed in with the stools. He has lost some weight and also complains of arthralgia.. How would you approach this case ?

Clinical Approach:
The patient in this case is most likely suffering from idiopathic inflammatory bowel disease, but it is important to exclude chronic infection and to consider other causes of chronic diarrhea. Always make sure that the patient is actually having diarrhea that is increased daily stool volume.

History of Presenting Problem:

1. Character of the stool  knowing the character of the stool is very important for the appropriate diagnosis. The questions to be asked in history include:

• Frequency of passing the motion.
• Whether there is any urgency
• Any pain on defecation

2. Rectal Bleeding: If there is any rectal bleeding or blood in stool following should be clarified:

• is the blood passed freely per rectum without any stool?
• Is it mixed with stool
• is it only present on the toilet paper when the anus is wiped.