Saturday, November 17, 2007

the doctor is in 5

just learned something about odiogo audio - i need to use different titles. it associated this post with an older one. so i am deleting and reposting. will use doctor is in 5 ... then 6 ...

Today we are presented with a 68 year-old. We’ll get to his story in a few. First, the pics …

Oh my! Looks like the dude swallowed somebody’s scrotum! That’s gross. I mean, nuts still wrapped up like a couple mini-pillows just-for-to-sleep-on-honey-oh-no-thank-you! seem to be lodged in this guy’s throat. Wanna have some fun? Take your browser slider and move it up and down a bit – the old chin strap seems to move around as if it were riding free in a pair of Levi’s and we are frolicking in a meadow feeling free and pretty like those girls that wear panti-liners. Hey, wait a sec … look at that kinda sorta line of white under the scrotal package. Odd. Wonder what it is. Better look at the next pic.


This boy better have a good story. Ain’t never no reason no-how to go chomping down on the spanker, and in particular … AAHH!! AAAHHHH!!!! THE DUDE HAD HIS LOVE PUMP LOVING IN SOME OTHER DUDE’S MOUTH AND GOT BIT BIG TIME! AAHH!! AAAHHHH!!!! And then this low-down geriatric sexual purveyor of “Dick: The Other White Meat” couldn’t stop there – he had to take the lil buddies, too? Damn, man, what is you thinking?

You better have a DAMN fine story, or I am going toss HIPAA right out that window, track down your sorry ass, and perform a stomach stapling without anesthesia. You won’t eat another thing, son, for the rest of your days. You done had your last meal!

Alright – cough, I want the story. I’m listening.


A 68-year-old (sixty-eight, 68! You should know better, son! Ain’t your dick still attached? You like it there? You tinkle on a regular basis? What is wrong with you?), previously healthy white man (I knew he was white, just by viewing the crime scene – I knew it. Yeah, “previously healthy” until you started chomping. I oughta kick your ass right through this cyber-diagnosis) presents to his primary care physician’s office with a complaint of 2 years of progressive dysphagia (Two years, my ass! That dick still dripping momma’s milk! You lie so bad). He reports that he has lost about 15-20 lb and that he is not following any diet or regimen to lose weight (unsafe sexual practices can lead to weight lose, too, grampaw. I don’t see no rubber on that rascal. You surfing bareback. Why you surprised you losing weight? Probably fit into a size 9 cocktail dress now, don’t you?). Although he can drink liquids without difficulty, he has lately felt a “sticky sensation” in the middle of his throat (it’s still dripping – can’t you people see that? Of course it’s sticky! It’s gots to stick to the egg – it’s designed that way! HEY – THE DUDE BIT OFF AND SWALLOWED SOMEBODY’S DICK THEN WENT AFTER THE MUD FLAP! YEAH – STICKY – SURPRISED? You want to know what is even more sticky? When the now-flapless-and-dickless partner goes home to his WIFE and has to EXPLAIN where his DICK went – and STILL is!) when he eats any solid food (I think our friend has had enough solid food for one lifetime). He also regurgitates food particles from a particular meal for up to 2 days after he has eaten it (I am positive this is true. Yes, whatever he eats comes back up. Yes. I have no problem believing this).

On physical examination, the patient’s vital signs are within the normal range. The examination of the oropharynx yields unremarkable findings. The patient has no neck mass or other abnormality. Examination of the thorax and the abdomen also yield unremarkable results. (Blah, blah blah. The formerly attached dick lost its erection. You would, too, with a good bite-down. So of course you don’t feel anything in there. It’s sticky – but soft.)

Observe the saclike structure in the esophagus. (Scrotal fun buns, dick. Saw them. Thanks.)

Zenker (so that’s his name. Better write that down. I can find him. No problem. I’ll do the Whistle Test. Little known fact: Dicks lodged in throats prevent whistling. Something about the way air moves in the diaphragm. I’ll find every 68 year-old Zenker in America and make them whistle. When one can’t – I’ll have my man!) (pharyngoesophageal) diverticulum: The frontal (see Image 1) and lateral (see Image 2) barium-swallow images of the upper esophagus demonstrate a large outpouching (what a great medical term, “outpouching.” I prefer “lodged spanker.”) at the posterior aspect of the pharyngoesophageal junction that retains barium (arrows) (I think “barium” is code for “seminal fluid”). This finding is consistent with a Zenker diverticulum (Latin for “pervert.” Zenker, Pervert. Now I have a complete name. This dude is so toast).

A Zenker diverticulum, also called a pharyngoesophageal diverticulum, is a pseudodiverticulum (note, “pseudo” – this answer is full of code only us internet docs can read) consisting of esophageal mucosa and submucosa (read, “seminal fluid”) that herniate (“the buddies”) posteriorly between the cricopharyngeus and the inferior pharyngeal constrictor muscles (like a pirate map to show you where to find your nuts if your wife said, “go back and get them! And don’t return until you do!”) and through an area of potential weakness referred to as the Killian dehiscence (the first clue as to the victim’s identity – a Mr. Killian). The pathogenesis of this condition is not well known (this means that they don’t have much information on Mr. Killian – must have been a chance encounter in a bar, mayeb a glory hole). Patients with a Zenker diverticulum are thought to have a discoordination of the swallowing mechanism that increases pressure on the mucosa of the pharynx (this “discoordination” means that he didn’t want to bite the guy’s dick off – but got the “mucosa” thing happening, which means he did bite the guy’s dick off). Over time, this pressure leads to herniation of the esophageal mucosa through the Killian dehiscence (“Over time … herniation” – Mr. P. Zenker bite off the dick of one Mr. Killian, and then bit off and removed the remainder of the male package).

The condition occurs most commonly in elderly women (this should come as no surprise), with peak incidence in the seventh to ninth decades of life (OK, good information. No wonder older men tend to be so quiet – fear of being Zenkered). The most common presenting feature in a Zenker diverticulum is upper-esophageal dysphagia, which occurs in as many as 98% of patients (this means that the dick get lodged pretty high up). Other common symptoms are halitosis (you’ve got a dick in your throat, probably been there for days – of course your breath stinks), regurgitation of undigested food, aspiration, noisy deglutition, and changes in voice (eg, hoarseness) (yeah, what about the change in voice in the bitee?). Weight loss, possibly resulting from limited caloric intake (tough to get calories around that thing in your throat, eh, grammaw?) and recurrent pulmonary infection from aspiration, occurs in approximately one third of patients.

(Blah, blah, blah. Read the rest of the pseudo-answer if you like. Here’s the bottom line. Diagnosis: Dick and Scotty lodged in throat. Recommended treatment: Shoot him right between the legs, then between the eyes. Put his crime on prune juice containers for all prospective criminals to see – face, facts, final disposition – under the caption, “Don’t be a Zenker!”)

In patients with a Zenker diverticulum, the physical findings are usually normal. Fluoroscopic barium-swallow studies are the mainstay of diagnosis and demonstrate the characteristic outpouching that arises from the midline of the posterior wall of the distal pharynx near the pharyngoesophageal junction. This finding is best identified during swallowing, and it is typically seen on lateral images, on which the diverticulum is observed at the C5-C6 vertebral level. If the diverticulum is large, it may protrude laterally, most often to the left side. After the bolus of contrast agent passes the upper esophagus, the diverticulum is typically seen extending posterior to the cricopharyngeus muscle, and the contrast material that was retained in the diverticulum may be regurgitated into the hypopharynx. The lumen of the diverticulum should be carefully observed for irregularities or filling defects because squamous cell carcinoma can develop in a small percentage of cases.

When incidentally imaged on computed tomography (CT) scans or magnetic resonance imaging (MRI) scans, a Zenker diverticulum appears as a structure that arises posteriorly from the hypopharynx and is filled with air, fluid, or oral contrast material. Zenker diverticula may also be found on endoscopy. Care must be taken during endoscopic procedures, because passage of the endoscope into the diverticulum may result in perforation.

Small, asymptomatic diverticula may be followed up by monitoring the progression of symptoms. Surgical management should be considered in patients with clinically significant dysphagia, weight loss, pulmonary aspiration with recurrent lung infections, and complications related to bleeding. Surgical options for treatment include myotomy of the cricopharyngeus muscle, with or without diverticulopexy, and endoscopic division of diverticular wall with stapling. The success rate (ie, the relief of symptoms as measured in most studies) is approximately 93%.

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