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Diagnostic Dilemma: GI Disease

Diagnostic Dilemma: GI Disease

Test your diagnostic skills with the following endoscopic quiz.

This 76-year-old man is being followed closely for Barrett's esophagus and documented high-grade dysplasia (HGD). The HGD involved the esophagus in a diffuse manner. Photodynamic therapy (PDT) was delivered 8 months ago after a full discussion of the therapeutic options and risks. Due to multiple medical conditions, the patient was assessed as being a high surgical risk for esophagectomy. There is no history of dysphagia, abdominal pain, or weight loss. He has a long history of heartburn that is well controlled on medications.

His past history is significant for stable angina, hypertension, mild chronic obstructive pulmonary disease (COPD), diverticulosis, and a small stable abdominal aortic aneurysm.

His medical therapy consists of high-dose proton pump inhibition and cardiac medications. There is a long history of prior smoking, and he consumes alcohol rarely. Family history is negative for malignancy and positive for heart disease.

Physical examination is unremarkable. Laboratory evaluation is also normal.

The patient has undergone repeat upper gastrointestinal endoscopies since the photodynamic therapy. Photographs were obtained during these examinations.

1) Photograph A reveals:

a) An esophageal mass

b) Evidence of residual Barrett's epithelium

c) Duodenal ulceration
d) A mid-esophageal diverticulum

e) An area of suspicious columnar lining

2) Appropriate management at this time includes:
a) Laparoscopic fundoplication
b) Surgical resection
c) Random four-quadrant biopsies every 1 to 2 cm and biopsies of abnormal areas
d) Empiric treatment for H pylori
e) Selective vagotomy

3) Photograph B demonstrates:
a) An erythematous polyp
b) A visible vessel
c) An aorto-enteric fistula
d) Endoscopic mucosal resection (EMR)
e) Endometriosis

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