Differentials
Esophagitis
SIGNS / SYMPTOMS
Can occur concurrently with MWT. History of esophageal reflux, systemic disease (e.g., telangiectasias, psoriasis), and recent intake of medications that can induce esophagitis: for example, immunosuppression, corticosteroid, antibiotics (tetracycline, doxycycline), ferrous sulfate, and ascorbic acid.
Physical exam may include skin, looking for evidence of immunosuppression or systemic disease (e.g., telangiectasias, psoriasis), and oropharynx, looking for ulcers, thrush, and leukoplakia.
Although patient may be asymptomatic, typical symptoms include odynophagia, dysphagia, retrosternal chest pain, and heartburn, together with "coffee ground" emesis, anorexia, weight loss, cough, fever, and sepsis.
INVESTIGATIONS
CBC: may show anemia.
HIV test: may be positive in high-risk patients.
Esophagogastroduodenoscopy (EGD) is the diagnostic test of choice because it allows mucosa visualization showing irritation/inflammation, brushing, and biopsy of the lesions.
Spontaneous esophageal perforation (Boerhaave syndrome)
SIGNS / SYMPTOMS
Classic presentation is an episode of retching or vomiting followed by severe retrosternal pain and/or epigastric pain (not truly spontaneous).
History of alcohol intake is obtained in 40% of patients.
During physical evaluation, it is important to look for subcutaneous emphysema, which may be absent in 10% to 30% of patients.
Other common symptoms and signs include dyspnea, tachypnea, cyanosis, sepsis, and shock.
INVESTIGATIONS
Conventional radiography of the chest may reveal free mediastinal, peritoneal, or prevertebral air. Pleural effusion, with or without pneumothorax, widened mediastinum, as well as subcutaneous emphysema may be seen in late presentations.
Pleural fluid amylase measurement is indicative of esophageal rupture.
Confirmatory tests include water-soluble contrast, which is helpful to localize the lesion.
CT scan may also be used as a confirmatory test; - findings include esophageal wall edema, periesophageal fluid with or without bubbles, and widened mediastinum.
Cameron erosions
SIGNS / SYMPTOMS
In the acute setting, there is no way to differentiate both entities. However, patients with Cameron erosions may present with symptoms of persistent and recurrent iron deficiency anemia (weakness, fatigue, dyspnea). Manifestations of chronic iron-deficiency anemia include angular cheilitis, glossitis, koilonychia (spoon nails), and pallor.
INVESTIGATIONS
CBC: may show anemia.
EGD is the diagnostic test of choice because it allows mucosa visualization and biopsy of the lesions. Endoscopic diagnosis of Cameron erosions or ulcers is made when linear erosions or ulcers are seen inside of the sliding hiatal hernia.
Peptic ulcer disease
SIGNS / SYMPTOMS
Patients may present with upper gastrointestinal (GI) bleeding or melena, without other symptoms. However, most patients describe a history of gnawing, burning, or hunger-like abdominal pain 40 to 60 minutes after eating, or, less often, before eating; patients also report nausea, vomiting, weight loss, and fatigue.
History of medication use such as aspirin and nonsteroidal anti-inflammatory drugs.
Helicobacter pylori is involved in about 60% to 70% of patients with gastric ulcer disease.[58]
INVESTIGATIONS
EGD is the diagnostic test of choice because it allows mucosa visualization, identification of the ulcer, and biopsy of the lesions.
Urea breath test or H pylori stool antigen test (HpSA) may help in the diagnosis of H pylori infection. Histology and biopsy urease testing (rapid urease test) are invasive and reserved for patients where endoscopy is indicated.
Erosive gastropathy
SIGNS / SYMPTOMS
Patients may present with upper GI bleeding or melena and a chronic history of gnawing, burning, or hunger-like abdominal pain accompanied by nausea and vomiting.
History of smoking, alcohol intake, and/or medication use, such as aspirin or nonsteroidal inflammatory drugs is usually present.
INVESTIGATIONS
EGD is the diagnostic test of choice because it allows mucosa visualization and biopsy of the lesions. Erosive gastropathy is characterized endoscopically by diffuse hyperemic mucosa with multiple, small superficial areas of denuded mucosa called erosions.
Urea breath test or Helicobacter pylori stool antigen test (HpSA) may help confirm H pylori infection as a cause of the gastritis. Histology and biopsy urease testing (rapid urease test) are invasive and reserved for patients where endoscopy is indicated.
Esophageal or gastric neoplasms
SIGNS / SYMPTOMS
Patients may present with or without upper GI bleeding (hematemesis, "coffee ground" emesis, with or without melena, and in rare cases, hematochezia); progressive dysphagia initially for solids, and then also for liquids; weight loss, early satiety; unspecific abdominal discomfort; and symptoms of persistent and recurrent iron-deficiency anemia.
INVESTIGATIONS
CBC: may show anemia.
LFT: may detect liver metastasis.
Amylase: usually normal.
Lipase: usually normal. Elevated in acute pancreatitis; however, lipase is not completely specific for pancreatitis. Lingual, gastric, intestinal, and hepatic isolipases have been isolated.
Radiologic evaluation may include esophagogram, upper GI series, or CT scan, each demonstrating an esophageal or gastric mass.
EGD is the diagnostic test of choice because it allows mucosa visualization of the mass, brushing, and biopsy of the lesions.
Esophageal varices
SIGNS / SYMPTOMS
Should be suspected in those with history of heavy alcohol intake and/or history of chronic liver disease who present with upper GI bleeding. Physical exam should reveal signs of chronic liver disease (i.e., asterixis, ascitis, pedal edema, jaundice, splenomegaly, spider angiomas, gynecomastia, Dupuytren contractures, leukonychia, discoloration of the nails indicating hypoalbuminemia).
INVESTIGATIONS
CBC: microcytic anemia and/or thrombocytopenia.
LFT: may be elevated in coexisting liver disease.
PT/INR: may be elevated in cirrhosis of the liver or liver failure.
EGD is the diagnostic and therapeutic test of choice because it allows visualization of the dilated veins in the lower esophagus as well as treatment of the varices.
Arteriovenous malformations
SIGNS / SYMPTOMS
Usually massive bleeding, and should be suspected in patients with history of abdominal aneurysm or those with a paraprosthetic-enteric fistula, who may give a history of a previous episode of mild "coffee ground" hematemesis or melena, usually self-limited, weeks or months earlier (which is called the initial herald or sentinel bleeding).
INVESTIGATIONS
CBC: may show anemia.
LFT: may be deranged in patients with hereditary hemorrhagic telangiectasia of the liver.
PT/INR: abnormal value may indicate less favorable course of the disease.
EGD should probably be the first test to be considered to rule out other causes of upper GI bleeding when the diagnosis of aortoenteric fistula is not clear. However, CT scan with contrast is probably the test of choice when aortoenteric fistula is highly suspected.
Exploratory laparotomy may allow definitive aortoenteric fistula repair.
Duodenitis
SIGNS / SYMPTOMS
Most patients report chronic, unspecific abdominal pain, which is described as a dull ache, throbbing, burning, or cramping pain that usually comes and goes. Symptoms can be partially relieved with antacids. Eating may help or may increase symptoms. Weight loss due to lack of appetite, nausea, and vomiting are common findings.
INVESTIGATIONS
EGD is the diagnostic test of choice because it allows mucosa visualization showing inflammation, and biopsy of the lesions.
Serology tests, urea breath test, Helicobacter pylori stool antigen test (HpSA), and gastric biopsy may help in the diagnosis of H pylori infection.
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