Jieli%20Li

1
MORNING REPORT

• Jieli Li
• 12/29/05

2
Chief Complaint

• Pain and difficulty on swallowing

3
HPI

• 54 y/o AAM with hx of syphillis, htn, OSA and
  Langerhans Cell Sarcoma with spinal cord
  compression s/p steroids and XRT now c/o pain and
  difficulty upon swallowing. Pt was originally
  admitted on 11/18 to MICU for spinal chord
  compression, treated with decadron (11/18 to
  12/05) and transferred to GMED on 11/22, now has
  completed 2 full wks of palliative XRT
  (11/23-12/7) to the area of T9-12 on TCU.

4
HPI cont.

• Pt noticed that food was getting stuck, soon
  after that he developed a burning/spasm-like pain
  in his throat when swallowing. Liquid or solid
  food makes no difference to him. Pt was started
  on viscous lidocaine without much improvement.
  constipation, denies diarrhea, hematochezia,
  melena, hematemesis, SOB.
• Per pt he was tested at outside facility for HIV
  within the last 6 months and was negative. He
  reports hx of syphillis gt 10 yrs ago s/p
  treatment.

5
PMH

• Langerhans Cell Sarcoma with spinal compression
  s/p decadron and palliative XRT
• Syphillis
• Htn
• Erectile Dysfunction
• OSA

6
Medications

• Omeprazole 20 po bid
• Lidocaine viscous 20 q3 prn swish and spit
• Dilaudid 2mg q3 prn
• Cyclobenzaprine 10 tid prn back spasms
• Albuterol 2 puffs qid
• Es-Maalox prn
• Docusate
• Senna 2 tabs qhs prn

7
History cont.

• All
• Codeine ? dizziness
• SH
• Denies hx of etoh, tobacco and illicit drug use
• FH
• NC

8
Physical Exam

• VS 97.6, 109/61, 83, 18, 7/10 pain
• Gen NAD, AAO x 4, slim AAM sitting in bed,
  speaks with a faint voice
• Skin no rash
• HEENT PERRLA, o/p clear, no oral ulcers/lesions,
  no thrush, no erythema of posterior pharynx or
  uvula
• Neck supple, no LAD
• Heart rrr, s1s2, no murmurs

9
Physical Exam cont.

• Lungs cta bilaterally, no wheezes
• Abd soft, mild epigastric tenderness,
  non-distended, na bs, no HSM
• Ext no edema/cellulitis/clubbing
• Neuro CN II-XII grossly intact, sensory and
  motor function intact, DTR 2/2

10
Laboratory

• 12.5
• 2.3 116
• 36.2
• MCV 92
• 69 neutrophils, 15 lymphs, 14 monos, 1
  eosinophils
• Anion gap panel normal, Cr 1.0

11
EGD (12/14/05)

• There are multiple ulcers in the distal esophagus
  with a large linear line of ulcers tracking up
  the mid esophagus. Bx and brushing done. The
  stomach and duodenum were normal.

12
Follow up

• ID was consulted to decide whether emperic
  antiviral tx is advisable while awaiting bx/viral
  cx results to return
• Ddx included XRT-induced esophagitis, HSV and
  CMV. Time course and location of the ulcers were
  suspicious for radiation induced ulcers. Since
  pts pain symptoms were already improving on its
  own without any specific tx by the time of the ID
  consultation, no empiric antiviral tx was
  recommended.
• Pts symptoms resolved on its own 1.5 wks later.
  
• Bx results came back negative for HSV and CMV.

13
ODYNOPHAGIA
14
Overview

• Odynophagia painful swallowing
• Suggests disruption of the esophageal mucosa
• Any inflammatory process involving the mucosa of
  the oropharynx or esophagus or its muscle may
  cause odynophagia
• Odynophagia is a common symptom of pill-induced
  esophagitis or infection of the esophagus
• A muscle spasm may also lead to muscle pain
  odynophagia

15
Differential Dx of Odynophagia

• Pill esophagitis
• Infection
• Crohns involvement of the esophagus (uncommon)
• Reflux esophagitis (usually not acute)
• Caustic ingestion
• Radiation esophagitis
• Ulcerated neoplasm (usually not acute)

16
Differential Dx of Odynophagia in AIDS patients

• Candidiasis
• Herpes simplex
• CMV
• Idiopathic HIV ulcers
• GERD
• Pill-induced

17
Differential Dx of Dysphagia

• Extrinsic pressure on the esophagus
• Thyromegaly, left atrial enlargement
• Aortic arch aneurysm
• Zenkers diverticulum
• Cervical lymphadenopathy
• Anomalous right subclavian artery
• Cephalad extension of gastric cancer

• Intrinsic narrowing of the esophageal lumen
• Esophageal tumors
• Esophageal strictures
• Disorders of esophageal motility
• Achalasia
• Esophageal spasm
• scleroderma

18
Infectious Esophagitis

• Bacteria rarely cause primary esophageal
  infection, although secondary involvement by
  direct extension from the lung is possible
• Two most common forms of infectious esophagitis
• Candida
• HSV
• Other viruses and fungi can cause esophagitis,
  but usually associated with immunosuppression
• CMV
• HIV

19
Candida Esophagitis

• The most common form of infectious esophagitis
• Predisposing conditions
• DM
• Abx therapy
• Immunocompromise
• Alcoholism
• Malnutrition
• Advanced age
• Occasionally seen in otherwise healthy
  individuals
• Presentation usually involves odynophagia,
  dysphagia, chest pain or upper GI bleeding

20
Diagnosis of Candida Esophagitis

• Esophagogram
• Irregular granular or even cobblestone or
  shaggy appearance
• 25 will have a normal barium esophagogram
• EGD
• Required to make the diagnosis
• Small raised whitish plaques
• Underlying mucosa is erythematous and friable
• Biopsy or brush cytology
• Pseudohyphae

21
Candidiasis on EGD
22
Complications of Esophageal Candidiasis

• Ulceration and hemorrhage
• Mycetoma (fungus ball)
• Formed by necrotic mucosal debris
• Causes obstruction
• Strictures
• Perforation
• Fistulas
• Tracheobronchial
• Aortoesophageal

23
Treatment of Esophageal Candidiasis

• Oral nystatin
• Ketoconazole or fluconazole for more extensive
  involvement or if pt is immunocompromized
• Amphotericin B if evidence of systemic spread

24
Herpes Simplex Esophagitis

• Second most common form of infectious esophagitis
• Presentation is similar to candida esophagitis
• Esophageal symptoms may be preceded by viral URI
  type symptoms
• Herpetic mouth or skin lesions may also develop
• Usually found in immunocompromized pts, but also
  sporadically seen in healthy young adults

25
Diagnosis of Herpes Esophagitis

• Esophagogram
• Multiple, small, superficial ulcers in the upper
  or mid esophagus
• Severe herpes esophagitis may produce extensive
  ulceration and plaque formation, mimicking the
  appearance of Candida esophagitis
• EGD with biopsy and brush cytology are required
  to confirm the diagnosis
• Brush cytology
• Epithelial cells at the edge of the ulcers are
  characterized by multinucleation, ground-glass
  nuclei and pathognomonic eosinophilic Cowdrys
  Type A intranuclear inclusion bodies

26
Herpes Esophagitis on EGD
27
Cowdry A Intranuclear Inclusion Body in a
herpetic ulcer
28
Treatment of Herpes Esophagitis

• Self-limiting disease in immunocompetent
  individuals, so symptomatic tx only
• Viscous Xylocaine and PPI
• In severely immunocompromised pts
• IV acyclovir

29
CMV Esophagitis

• Asymptomatic CMV infection is common worldwide
• The first clinical case of CMV esophagitis was
  reported in 1985
• Unlike herpes esophagitis, CMV esophagitis almost
  never occurs in immunocompetent patients
• Vast majority of affected individuals are found
  to have AIDS
• Evidence of CMV infection may be present in other
  organs such as the retina, liver, and colon
• Occasionally, odynophagia may become so severe pt
  develop sitophobia (fear of eating) and require
  TPN

30
Diagnosisof CMV Esophagitis

• Esophagogram
• Typically shows 1 or more giant and relatively
  flat ulcers, sometimes with associated satellite
  ulcers
• EGD with biopsy and brush cytology are required
  to confirm the diagnosis
• Brush Biopsy
• Infected cells contain eccentrically placed
  intranuclear inclusion bodies with surrounding
  halos mainly found near the base of the ulcers

31
CMV Esophagitis under Microscopy
32
Treatment of CMV Esophagitis

• Antiviral agents
• Ganciclovir
• Bone marrow toxicity
• Foscarnet
• Renal toxicity

33
HIV Esophagitis

• Believed to be caused by HIV
• Electron microscopy confirm presence of HIV-like
  viral particles in these lesions
• Most pts are found to have chronic AIDS with CD4
  counts lt 100
• HIV esophagitis can form giant esophaageal ulcers
  indistinguishable from CMV esophagitis
• Account for 40 of all esophageal ulcers in AIDS
  pts

34
HIV Esophagitis continued.

• Diagnosis
• EGD and biopsy are again required to distinguish
  it from CMV esophagitis
• Treatment
• Oral steroids

35
Esophagitis Associated with Immune-Mediated
Disease

• Crohns disease
• Behçets syndrome
• Pemphigoid
• Pemphigus
• Epidermolysis bullosa
• Sarcoidosis
• Eosinophilic gastroenteritis

• Chronic graft-versus-host disease after bone
  marrow transplantation
• Generalized epithelial desquamation of the upper
  and middle esophagus, sometimes with ring-like
  narrowings
• A nonspecific esophageal motor disorder may also
  develop resulting in superimposed reflux
  esophagitis

36
Acid/Alkali Ingestion

• Acid ingestion
• Superficial coagulation necrosis and eschar
  formation
• immediate chest pain and odynophagia
• Oral burns may produce local pain and drooling
• Respiratory symptoms (stridor, dyspnea and
  hoarseness) if the airway is contaminated
• Alkali ingestion
• Tends to be more injurious to the esophageal
  mucosa
• Liquefaction necrosis
• Thermal burns

37
Acid/Alkali Ingestion cont.

• Symptoms alone do not permit accurate prediction
  of the presence or absence of esophageal injury
• Early diagnostic endoscopy should be considered
  (but not if there is evidence of esophageal
  perforation)
• Adequate airway is imperitive
• NPO and IVF
• Empiric tx involves abx and corticosteroids, but
  no good evidence documenting the efficacy
• Survivors tend to develop strictures because of
  collagen deposition during healing.
• Often requires repeated esophgeal dilation

38
Lye-Induced Injury

• Lye-induced injury increases the risk of squamous
  cell cancer of esophagus
• Typically there is a 30- to 50-year lag time
• Any pt with previous lye inury and new esophageal
  symptoms should be promptly investigated
• However periodic endoscopic surveillance is not
  indicated

39
Pill-Induced Esophagitis

• Common culprits
• Antibiotics
• Tetracyclines (particularly doxycycline)
• NSAIDS
• Highest number of reported cases is with ASA
• Others
• KCl
• Quinidine preparations
• Iron compounds
• alendronate

40
Pill-Induced Esophagitis cont.

• Pts typically take meds with small amount of
  water and then immediately go to bed, then wake
  up hrs later with severe retrosternal CP and
  odynophagia
• Typical lesion shows a small punched out ulcer in
  a limited area that was conceivably in contact
  with a high concentration of medication released
  from a dissolving pill
• Usually ulceration is superficial and heals in
  weeks Rarely, can see deep esophageal ulcer with
  perforation
• Late stricture formation may occur
• Pts with esophageal motility disorders are
  particularly prone

41
Radiation-Induced Esophagitis

• Seen in up to 80 of pts receiving XRT to the
  chest
• Use of cytotoxic chemo has an additive effect
• Typically chest pain, dysphagia and odynophagia
  occur shortly after the initiation of therapy
• Late stricture formation is a common complication
  
• Usually self-limited, treatment is symptomatic