A 72-year-old woman notices progressive dysphagia to solids and liquids. There is no history of alcohol or tobacco use, and the patient takes no medications. She denies heartburn, but occasionally notices the regurgitation of undigested food from meals eaten several hours before. Her barium swallow is shown.
Which of the following is the cause of this condition?
The barium swallow shows the dilated baglike proximal esophagus and tapered distal esophageal ring characteristic of achalasia. This is a motor disorder of the esophagus and classically produces dysphagia to both solids and liquids. Structural disorders such as cancer and stricture usually cause trouble swallowing solids as the first manifestation. In achalasia, manometry shows elevated pressure and poor relaxation of the lower esophageal sphincter. In classic achalasia the contractions of the esophagus are weak, although a variant called vigorous achalasia is associated with large-amplitude prolonged contractions. Medications (nitrates, calcium channel blockers, botox injections into the LES) or physical procedures (balloon dilatation or surgical myotomy) that decrease LES pressure are the recommended treatments. Squamous cell carcinoma would not cause esophageal dilation and would be associated with ratty rather than smooth tapering of the esophagus. Achalasia is not associated with gastroesophageal reflux disease. Although anxiety can cause dysphagia and a globus-like sensation in the cricoid region, it would not cause the anatomical changes seen on this barium swallow.
A 37-year-old woman presents for evaluation of abnormal liver chemistries. She has long-standing obesity (current BMI 38) and has previously taken anorectic medications but not for the past several years. She takes no other medications and has not used parenteral drugs or had high-risk sexual exposure. On examination, her liver span is 13 cm; she has no spider angiomas or splenomegaly. Several sets of liver enzymes have shown transaminases two to three times normal. Bilirubin and alkaline phosphatase are normal. Hepatitis B surface antigen and hepatitis C antibody are normal, as are serum iron and total iron-binding capacity.
Which of the following is the likely pathology on liver biopsy?
This woman likely has nonalcoholic fatty liver (NAFL), which is associated with macrovesicular accumulation of fat in the liver. If hepatocellular necrosis is present, the condition is termed nonalcoholic steatohepatitis (NASH). This condition is histologically similar to alcoholic hepatitis, and increasing evidence suggests that it too is a precirrhotic condition. With the increasing incidence of obesity in Western societies, NASH may become the commonest cause of cirrhosis and end-stage liver disease. Microvesicular fat is seen in the acute life-threatening conditions of acute fatty liver of pregnancy and Reye syndrome. Portal triaditis and piecemeal necrosis of cells in the hepatic lobule are associated with several disorders, including autoimmune and chronic viral hepatitis. Cirrhosis, characterized by bands of fibrous tissue, regenerating nodules, and disruption of the hepatic architecture, is the final common pathway of various chronic insults to the liver. Copper deposition is seen in Wilson disease.
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