Today's highlighted
some of the areas of medicine less commonly featured in morning report.
The case involved a
38-year-old woman with a history of GERD and a motor vehicle collision several
years prior to her admission. She presented with a 5-month history of
progressive dysphagia, first to solids then to liquids with globus sensation. She had lost a significant amount of
weight. There were no systemic features
to suggest a connective tissue disorder such as systemic sclerosis. There were also no bulbar or cranial nerve
features to suggest a central nervous system cause. Finally, she had no fatigability suggestive
of a myasthenic cause. As the case
progressed, an extensive number of ‘outside’ investigations was revealed
including an esophagogastroduodenoscopy, motility study, and barium swallow
which effectively ruled out an intraluminal cause of dysphagia. It was then revealed that there were
substantial psychosocial stressors and, when the psychiatry consult-liason team
was involved, her presentation was consistent with a somatoform disorder.
Important learning
points from today:
-Dysphagia is a common
symptom with a wide differential diagnosis
-It is helpful to
divide dysphagia into obstructive
(extrinsic/intrinsic mass, peptic strictures) and propulsive (achalasia, neuromuscular disorders, central nervous
system/coordination) causes
-We discussed salient
historic features that can help differentiate them – these include a
progressive dysphagia from solids to liquids (more consistent with an obstructive
cause) compared to dysphagia which begins with solids and liquids (consistent
with a neuromuscular cause)
-We briefly discussed
the infections in an immunocompromised host that would lead to esophageal
dysphagia including opportunistic infections with Herpes group viruses, or
esophageal candidiasis
-We discussed features
of brainstem and bulbar disease and the importance about acquiring those
symptoms when taking a dysphagia history (dysphonia, dysarthria, nasal vocal
changes, hoarseness, etc.)
-Importantly, we
discussed the concept of psychiatric or somatoform disease as a diagnosis of exclusion and that it can
be challenging to deem someone having been ‘investigated enough’ for ‘organic’
causes of symptoms
Further Reading:
Mathog, R. H., & Fleming, S. M. (1992). A clinical approach to dysphagia. American journal of otolaryngology, 13(3), 133-138.
No comments:
Post a Comment