Download Presentation The PPT/PDF document "79-YEAR OLD GENTLEMAN WITH" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
79-YEAR OLD GENTLEMAN WITHPROGRESSIVE DYSPHAGIA………………………………………………………………………………………………………………………………………………………………………………………………………………………………. FAISAL GHANI SIDDIQUI MBBS; FCPS (GENERAL SURGERY); PG DIPLOMA-BIOMEDICAL ETHICS; MCPS-HPE; FICLS; (MHPE) HEAD , SURGICAL UNIT-I PROFESSOR OF SURGERY CHAIRMAN , DEPARTMENT OF SURGERY & DIRECTOR, DEPARTMENT OF MEDICAL EDUCATION LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES faisalghani@lumhs.edu.pk
CASE REPORT A 79-year-old retired teacher was admitted in the surgery ward with H/O: Increasing difficulty in swallowing Initially could swallow soft diet but now can tolerate fluids only Weight loss of 5 kg in last one month On examination, he appears cachectic WHAT IS THE MOST LIKELY DIAGNOSIS?
DIAGNOSIS CARCINOMA ESOPHAGUS
WHAT IS THE THE DIFFERENTIAL DIAGNOSIS?
STAGES OF SWALLOWING
DYSPHAGIA - difficulty in the progression of bolus from the mouth to the stomach due to dysfunction of: oropharynx esophagus
DIFFERENTIAL DIAGNOSIS OF DYSPHAGIA OROPHARYNGEAL DYSPHAGIA ESOPHAGEAL DYSPHAGIA DISEASES OF CNS CVA PARKINSON’S DISEASES ALZHEIMER'S DISEASE MULTIPLE SCLEROSIS DISEASES OF PERIPHERAL NERVOUS SYSTEM MYASTHENIA GRAVIS OBSTRUCTIVE LESIONS IN OROPHARYNX ZENKER’S DIVERTICULUM ENT TUMOURS ESOPHAGEAL MOTILITY DISORDERS ACHALASIA CARDIA DIFFUSE ESOPHAGEAL SPASM NUTCRACKER ESOPHAGUS EXTRINSIC COMPRESSION LYMPHADENOPATHY RETROSTERNAL GOITRE OBSTRUCTIVE LESIONS PEPTIC / CORROSIVE STRICTURES FOREIGN BODY CARCINOMA ESOPHAGUS
CARCINOMA OF THE OESOPHAGUS PATHOLOGY
CARCINOMA ESOPHAGUS –INCREASE IN INCIDENCE
3 TIMES MORE COMMON IN MALES
TYPES OF CARCINOMA ESOPHAGUS 25 % 75 %
SPREAD OF CARCINOMA OESOPHAGUS ACROSS THE WALL LONGITUDINALLY THROUGH SUBMUCOSAL LYMPHATICS LIVER LUNGS BONE TO THE REGIONAL LYMPH NODES
Carcinoma Esophagus disseminates early! Symptoms are often absent until tumour becomes advanced poor prognosis at the time of diagnosis!
WHY ME? RISK FACTORS
SMOKING ALCOHOL HOT BEVERAGES CORROSIVE INJURY ACHALASIA CARDIA OBESITY --> REFLUX SMOKING
CARCINOMA OF THE OESOPHAGUS CLINICAL FEATURES
PROGRESSIVE DYSPHAGIA REGURGITATION WEIGHT LOSS ODYNOPHAGIA HOARSENESS HORNER’S SYNDROME COUGHING ON EATING LYMPHADENOPATHY HEPATOMEGALY/JAUNDICE CHEST PAIN ENLARGED CERVICAL LN
CASE REPORT A 79-year-old man admitted in the surgery ward with H/O: Increasing difficulty in swallowing Initially required soft diet but now can tolerate fluids Weight loss of 5 kg in last one month On examination, he appears cachectic HOW WILL YOU INVESTIGATE THIS PATIENT?
CARCINOMA OF THE OESOPHAGUS INVESTIGATIONS
HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 2 3
ENDOSCOPY First-line investigation Site/size/extent/ histology of lesion Disadvantage: only mucosal surfaces biopsied
SQUAMOUS CELL CARCINOMA OF THE MID ESOPHAGUS NORMAL MUCOSA OF THE ESOPHAGUS
HISTOPATHOLOGY SHOWS SQUAMOUS CELL CARCINOMA WHAT NEXT?
HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 2 3 Local tumour and regional nodes (T, N) Endoscopic ultrasound Metastases (M) CT / PET scan (lung; liver; bones; distant nodes) Laparoscopy (peritoneal metastases) Anemia Tests for malnutrition
MANAGING A PATIENT WITH SUSPICIOUS SYMPTOMS CURATIVE TREATMENT ADVANCED
EARLY DISEASE T1/T2, N0 LOCALLY ADVANCED DISEASE T3/T4, N1 INCURABLE DISEASE Any T, N2/N3, M0
RADICAL SURGERY NEOADJUVANT CHEMOTHERAPY + SURGERY PALLIATION
RADICAL SURGERY NEOADJUVANT CHEMOTHERAPY + SURGERY PALLIATION
IVOR-LEWIS TWO PHASE ESOPHAGECTOMY
IVOR-LEWIS TWO PHASE ESOPHAGECTOMY
MCKEOWN THREE PHASE ESOPHAGECTOMY
NEOADJUVANT CHEMOTHERAPY LOCALLY ADVANCED TUMOURS SQUAMOUS CELL CARCINOMA
RADICAL SURGERY NEOADJUVANT CHEMOTHERAPY + SURGERY PALLIATION
SELF-EXPANDING METAL STENT
CASE REPORT A 79-year-old man admitted in the surgery ward with H/O: Increasing difficulty in swallowing Initially required soft diet but now can tolerate fluids Weight loss of 5 kg in last one month On examination, he appears cachectic CONCLUSION: This case report demonstrated the importance of a timely upper endoscopy. It carries major impact on primary care physicians who serve as the first tier in managing patients with ‘red flag’ features.
. . . IN SUMMARYSquamous cell affects the upper two-thirds; adenocarcinoma affects the lower third Common etiological factors are tobacco and alcohol (squamous cell), GORD and obesity (adenocarcinoma) Dysphagia is the most common presenting symptom Accurate pretreatment staging is essential in patients thought to be fit to undergo ‘curative’ treatment