What is the next step in management for an adult female with a history of unintentional corrosive ingestion, severe esophageal strictures, and ongoing regular dilatation for 3 months with a feeding jejunostomy?

From the Guidelines

For a patient with a history of toxic nodular goiter who is not taking antithyroid drugs regularly and presents with palpitations, tachycardia, and suppressed TSH, the best management is total thyroidectomy. This provides definitive treatment for toxic nodular goiter, which typically doesn't respond well to long-term medical therapy and has low remission rates with antithyroid drugs alone 1.

Some key points to consider in the management of such patients include:

• The importance of regular medication adherence, which the patient has not been doing, indicating a need for a more definitive treatment approach.
• The symptoms of palpitations and tachycardia, which are indicative of hyperthyroidism and suggest the need for prompt and effective management.
• The suppressed TSH level, which confirms the diagnosis of hyperthyroidism and necessitates intervention.

For Graves' disease with exophthalmos not responding to antithyroid drugs for 10 months, near total thyroidectomy is the appropriate management. This approach provides rapid control of hyperthyroidism while preserving a small amount of thyroid tissue to potentially reduce the risk of permanent hypoparathyroidism. Radioactive iodine is generally avoided in patients with significant ophthalmopathy as it may worsen eye symptoms.

When discovering a problem with an energy device that also affects other hospitals, you should report it to the Ministry of Health. This allows for system-wide notification and potential recall if necessary, protecting patients across multiple facilities.

The most commonly used drugs for peptic ulcer disease are proton pump inhibitors (PPIs) for long-term management. They effectively suppress gastric acid production and promote healing of ulcers with excellent safety profiles for extended use.

For an adult with severe esophageal strictures from corrosive ingestion who has undergone regular dilation for three months with a feeding jejunostomy in place, continuing endoscopic dilation is the appropriate next step. Persistent dilation therapy often requires 6-12 months before considering more invasive surgical options, and many patients can eventually achieve adequate swallowing function with continued dilations, as supported by guidelines on oesophageal dilatation in clinical practice 1.

Key considerations in the management of esophageal strictures include:

• The need for repeated dilatation sessions, which may be required weekly or biweekly based on symptoms and stricture resolution.
• The importance of reassessing stricture diameter and adjusting the dilator size as necessary to achieve optimal results.
• The goal of achieving easy passage of a ≥15 mm dilator along with symptomatic improvement, as recommended by clinical guidelines 1.

From the Research

Management of Toxic Nodular Goiter

• The patient has a history of toxic nodular goiter and is not taking antithyroid drugs regularly, presenting with palpitations and tachycardia, and a TSH of 0.2.
• According to the study 2, surgical treatment results in rapid, reliable resolution of hyperthyroidism and removal of the nodular goiter with low morbidity and no mortality.
• The study 3 suggests that total thyroidectomy (TT) and near-total thyroidectomy (NTT) are safe and effective approaches in the treatment of toxic multinodular goiter, preventing recurrence of thyrotoxicosis and reoperation for incidentally found thyroid cancers.
• Therefore, the management of this patient could be total thyroidectomy or near-total thyroidectomy.

Management of Graves’ Disease with Exophthalmos

• The patient has Graves’ disease with exophthalmos that is not responding to antithyroid drugs for the past 10 months.
• According to the study 4, radioiodine is increasingly used as first-line therapy and is the preferred choice for relapsed Graves’ hyperthyroidism.
• The study 2 also mentions that radioiodine treatment is safe and effective, usually requiring a single dose.
• Therefore, the management of this patient could be radioiodine therapy.

Reporting of Problems in Energy Devices

• The problem in an energy device was also found in other hospitals.
• It is not specified in the provided studies who to report this problem to.
• However, it would be logical to report this problem to the manufacturing company or the Ministry of Health.

Most Commonly Used Drugs for Peptic Disease

• The most commonly used drugs for peptic disease are not specified in the provided studies.
• However, the options given are long-term PPI, H pylori eradication, H2 blockers, and antacids and prokinetics.

Management of Corrosive Ingestion with Severe Oesophageal Strictures

• The patient has a history of unintentional corrosive ingestion followed by severe oesophageal strictures and is currently undergoing regular dilatation for 3 months with feeding jejunostomy.
• The next step in management is not specified in the provided studies.
• However, the options given are continue endoscopic dilatation, oesophageal resection, stent placement, and oesophageal bypass.