Topics in Gastro: Trouble Swallowing and Chronic Diarrhea Explained


Ciaran P. Kelly, Associate Professor, Harvard Medical School discusses common and uncommon issues related to swallowing.

In his presentation, “Doctor, I have Trouble Swallowing,” Ciaran P. Kelly, presented three specific patient cases related to swallowing in an effort to discuss the common issues and not so common issues related to swallowing.

Kelly is a professor of medicine at Harvard University and a gastroenterologist.

Among the cases presented was one that involved a 34-year-old woman, who was brought to the emergency department at midnight due to having food stuck in her esophagus. The patient had experienced multiple episodes of food blockage beginning at age 19 and tolerated endoscopy poorly. She had been told in the past that her esophagus was “congenitally narrow,” he said.

While patients with her symptoms are usually diagnosed with acid reflux disease, he said, the patient has actually been suffering from Eosinophilic (allergic) esophagitis, a condition that has risen in the last 20 years, he said.

It is associated with allergies and atopy, mild peripheraleosinophilia, and eosinophilic gastroenteritis. It is more commonly found in men. And treatment may involve the use of flucticasone, a systemic steroid and the identification of food allergies.

The second case presented involved dysphagia & heartburn in a 55-year-old woman. The patient had chest discomfort and dysphagia, and experienced weekly episodes for three years that lasted up to 15 minutes. She was a non-smoker. She usually had issues with carbonated drinks especially, he said. After an evaluation it was clear that the patient had lower esophageal sphincter dysfunction GERD, he said.

To treat the patient, Kelly placed her on high dose Proton Pump Inhibitors for six weeks and then switched to standard dose once her symptoms were reduced.

Kelly also gave a second presentation, titled “Chronic Diarrhea: An Approach to Diagnosis.”

He began by distinguishing the difference between acute diarrhea and chronic diarrhea. Acute diarrhea usually takes place for as long as three weeks, he said. With Chronic Diarrhea it necessary to assess whether it’s the real thing or pseudo diarrhea, he said.

The first step is asking the previous question (is it real), next the clinician should asses if there are any special risks groups involved, such as: is there diarrhea with blood?, is it obscure watery diarrhea, or is there malabsorption involved.

In determining whether the condition is truly chronic diarrhea, Kelly said the clinician can compare the common symptoms of irritable bowel syndrome as a possible alternative. IBS is characterized by “visceral hypersensitivity, which includes cramping, exaggerated gastro-colic reflex, and tenesmus, and dysmotility, which affects the frequency and urgency.

Another alternative may be that the patient is lactose intolerant, she said. In lactose intolerant patients, the ingestion of lactose can result in diarrhea, abdominal cramping, and flatulence. Chron’s disease may also be another alternative.

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