CPC.ppt

CPC 01.12.10 John O. Clarke, M.D. Assistant Professor of Medicine Director of Esophageal Motility Johns Hopkins University Questions to Address What were the patient’s risk factors for bleeding? How does HIV affect the differential? What is the most likely diagnosis? Differential Diagnosis of Upper GI Bleed Ulcerative or erosive Idiopathic Drug-induced H. pylori Other Infectious Stress-induced Zollinger-Ellison Syndrome Esophagitis Peptic Infectious Pill-induced Portal hypertension Varices Portal hypertensive gastropathy Vascular Idiopathic angiomas Osler-Weber-Rendu syndrome Dieulafoy’s lesion Gastric antral vascular ectasia Radiation-induced telangectasia Blue rubber bleb nevus syndrome Traumatic or post-surgical Mallory-Weiss tear Surgical anastomosis Aortoenteric fistula Post-polypectomy Tumors DDx of Massive Upper GI Bleed Ulcer Idiopathic Drug-induced H. pylori Other infections Esophagitis Infectious Portal hypertension Varices Vascular Dieulafoy’s lesion Traumatic Mallory-Weiss tear Aortoenteric fistula Tumors What affect does HIV have? All items on the prior slide are still possible Infection and tumors become more likely Relationship of CD4 Count to Infection Tumor Wilcox C M. Gut 2008;57:861-870 What Were This Patient’s Risk Factors? (1) Esophageal ulcer (5-6cm but clean-based) (2) Esophageal varices (though small) (3) Gastric polyp (possible neoplasm) (4) Bluish lesion at GEJ (vascular, infection or tumor) Esophageal Ulcer “An ulcer was found in the mid esophagus 5-6cm in length . . . not bleeding” What is the differential diagnosis? (1) Pill-induced (2) Infectious - HSV (IgG +) - CMV (PCR +) - Primary HIV - Other (no indication from history) (3) Neoplasm - Adenocarcinoma - Squamous cell - Lymphoma - Kaposi’s sarcoma Unlikely to be the primary source unless it eroded into a varix/artery or rapidly grew in size Esophageal Varices “There were 2-3 small associated esophageal varices . . . 2 bands were placed” Esophageal v