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  • A 47-year-old man presents to the emergency department complaining of retrosternal pain. The patient states that for the past 2 weeks he has had pain with swallowing and now the pain is almost constant. His medical history is significant for a renal transplant 5 months ago, for which he is on immunosuppressive therapy. Physical examination is unremarkable. An upper endoscopy reveals multiple, discrete, shallow ulcerations of the esophagus. (Herpes simplex virus esophagitis)
Introduction
  • Introduction
    • clinical definition
      • inflammation of the esophageal lining
    • pathogenesis
      • eosinophilic
      • corrosive
      • infectious
        • Candida
        • herpes virus
        • cytomegalovirus (CMV)
      • gastroesophageal reflux disease (GERD)
      • medication-induced
  • Differential
    • esophageal stricture
      • distinguishing factors
        • trouble with swallowing solids only
        • strictures observed on endoscopy
      • can itself be a complication of esophagitis
    • achalasia
      • distinguishing factors
        • dilated esophagus that terminates in “bird-beak” narrowing on barium esophagram
        • incomplete lower esophageal sphincter relaxation on esophageal manometry
    • systemic scleroderma
      • distinguishing factors
        • progressive dysphagia to both solids and liquids
        • evidence of other symptoms of systemic scleroderma (i.e., skin thickening)
        • positive serologic tests (i.e., antitopoisomerase)
Corrosive Esophagitis
  • Corrosive esophagitis
    • pathogenesis
      • ingestion of strongly acidic or basic chemical
        • alkali (usually pH 11.5-12.5)
          • i.e., lye or batteries
          • causes liquefaction necrosis
        • acids (usually pH < 2)
          • i.e., hydrochloric acid
          • causes coagulation necrosis
    • demographics
      • 50% of toxic exposures occur in children 5 years or younger
    • risk factors
      • pediatric population
      • suicide attempts
  • Presentation
    • odynophagia
    • retrosternal pain
    • dysphagia
    • drooling
    • hematemesis
  • Studies
    • endoscopy
      • indicated if
        • symptomatic
        • evidence of oral burns
        • ingested substance is very caustic
      • contraindicated if
        • respiratory compromise
  • Treatment
    • observation
      • if asymptomatic and does not require endoscopy
    • nasogastric tube or gastrostomy tube
      • if endoscopy reveals extensive circumferential burns
    • prophylactic antibiotics
      • if perforation suspected
      • if there are severe burns
    • use of neutralizing agents, diluting agents, or activated charcoal is not recommended
  • Complications
    • esophageal perforation
      • pathogenesis
        • especially within 10 days during which granulation tissue formation causes weakening of the esophageal wall
      • presentation
        • respiratory distress (i.e., stridor, hoarseness, nasal flaring, or wheezing)
        • persistent severe retrosternal or back pain
        • fever
      • imaging
        • chest radiograph
          • indicated if presenting with respiratory symptoms
          • to assess for complications of ingestion
            • pneumomediastinum
            • widened mediastinum
            • subcutaneous emphysema in neck
      • complications
        • can lead to mediastinitis or development of a tracheoesophageal fistula
    • esophageal stricture formation
      • pathogenesis
        • usually around 3 weeks as fibrogenesis occurs
      • risk factors
        • more severe or circumferential burns
      • presentation
        • progressive dysphagia
      • studies
        • barium contrast
          • indicated 2-3 weeks post-chemical ingestion or sooner if progressive dysphagia develops
          • contraindicated if
            • perforation suspected
              • water-soluble contrast agents can be used instead
      • treatment
        • esophageal dilation
Candida Esophagitis
  • Candida esophagitis
    • pathogenesis
      • most secondary to C. albicans
    • risk factors
      • human immunodeficiency virus (HIV) with advanced immunosuppression (CD4 count < 100/mm3)
      • use of inhaled corticosteroids
      • cancer patients
  • Presentation
    • odynophagia 
    • dysphagia
    • may have oral thrush
  • Studies
    • endoscopy
      • indicated especially if no improvement in symptoms after empiric antifungal therapy for 72 hours
      • white or yellowish mucosal plaque-like lesions
  • Treatment
    • azoles (i.e., fluconazole, voriconazole, or posaconazole)
      • for HIV patients can trial before confirmation with endoscopy
    • echinocandins (i.e., caspofungin and micafungin)
      • if hospitalized
      • if refractory to azoles
    • amphotericin B
      • if refractory to azoles and echinocandins
Herpes Simplex Virus Esophagitis
  • Herpes simplex virus (HSV) esophagitis
    • risk factors
      • solid organ and bone marrow transplant
  • Presentation
    • odynophagia
    • dysphagia
    • retrosternal chest pain
    • fever
    • may have coexistent oropharyngeal ulcers
  • Studies
    • endoscopy
      • vesicles
      • well-circumscribed and “punched-out” ulcers
    • biopsy
      • multinucleated giant cells with ground-glass nuclei and eosinophilic inclusions
  • Treatment
    • acyclovir
Cytomegalovirus Esophagitis
  • Cytomegalovirus (CMV) esophagitis
    • risk factors
      • transplant patients
      • long-term dialysis patients
      • HIV-infected patients
      • long-term steroid treatment
  • Presentation
    • odynophagia
    • fever
    • nausea
    • retrosternal burning pain
  • Studies
    • endoscopy
      • single, large, shallow, and linear ulcer
    • biopsy
      • intranuclear or intracytoplasmic inclusion bodies
  • Treatment
    • ganciclovir
    • foscarnet
Eosinophilic Esophagitis
  • Eosinophilic esophagitis
    • demographics
      • men > women
      • average age 20-30s
    • associated conditions
      • atopic dermatitis
      • asthma
      • chronic seasonal allergies
  • Presentation
    • dysphagia to solid food
    • retrosternal chest pain
    • nausea
    • vomiting
    • weight loss
    • may present with history of other atopic conditions
  • Studies
    • endoscopy
      • corrugated mucosa
      • longitudinal mucosal furrows
      • fixed esophageal rings
      • narrowed lumen
      • mucosal fragility
    • biopsy
      • extensive eosinophils infiltrated esophageal mucosa
    • immunoglobulin levels
      • may have mildly elevated serum IgE
  • Treatment
    • dietary modifications
      • if specific allergen is found
    • trial of proton pump inhibitors
    • oral aerosolized steroids (i.e., fluticasone or budesonide)
    • systemic steroids
      • if refractory to aerosolized steroids
  • Complications
    • esophageal strictures
Medication-Induced Esophagitis
  • Medication-induced esophagitis
    • demographics
      • women > men
      • average age 40s
    • associated medications
      • antibiotics
        • tetracyclines, doxycycline, and clindamycin
      • aspirin
      • other non-steroidal anti-inflammatory drugs (NSAIDs)
      • bisphosphonates
      • potassium chloride
      • iron
    • risk factors
      • taking pills without water
      • taking pills right before lying down
    • pathogenesis
      • direct irritant effect
      • disruption of cytoprotective barrier
  • Presentation
    • retrosternal pain
    • odynophagia
    • dysphagia
    • hematemesis
  • Studies
    • endoscopy
      • indicated if symptoms are severe or persist > 1 week after discontinuation of suspected medication
      • discrete ulcer with normal surrounding mucosa
    • biopsy
      • to rule out other causes
  • Treatment
    • discontinue culprit medication or switch to liquid formulation if available

·         Introduction

o   clinical definition

§  inflammation of the esophageal lining

o   pathogenesis

§  eosinophilic

§  corrosive

§  infectious

·         Candida

·         Herpes

·         Cytomegalovirus (CMV)

§  gastroesophageal reflux disease (GERD)

§  medication-induced

 

·         Differential

o   esophageal stricture

§  distinguishing factors

·         trouble with swallowing solids only

·         strictures observed on endoscopy

§  can itself be a complication of esophagitis

o   achalasia

§  distinguishing factors

·         dilated esophagus that terminates in “bird-beak” narrowing on barium esophagram

·         incomplete lower esophageal sphincter relaxation on esophageal manometry

o   systemic scleroderma

§  distinguishing factors

·         progressive dysphagia to both solids and liquids

·         evidence of other symptoms of systemic scleroderma (i.e., skin thickening)

·         positive serologic tests (i.e., antitopoisomerase)

 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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