clinical cases in gastroenterology and hepatology

Clinical Cases In Gastroenterology and

HepatologyAhmed Adel Abdelhakeem Amin

Internal Medicine DepartmentGI & Hepatology Unit

Assiut University Hospitalahmed_adel_1984@yahoo.com

Case 1

 53-year-old male complaining of difficult swallowing for the past 3 years, not so progressive, for both liquids and solids, no weight loss, with nocturnal regurgitation.How do you start work up? Endoscopy Barium swallow

Case 1

As a rule in dysphagia:If suspected mechanical cause (to solids) : start with endoscopy.If suspected motility disorder (to fluids) : start with barium swallow.BUTIn all cases, endoscopy is a must !

Case 1

 53-year-old male complaining of difficult swallowing for the past 3 years, not so progressive, for both liquids and solids, no weight loss, with nocturnal regurgitation.How do you start work up? Endoscopy Barium swallow

Barium swallow was made..

What is the most likely diagnosis?

Achalasia Esophageal stricture Esophageal cancer Diffuse esophageal spasm

What is the most likely diagnosis?

Achalasia Esophageal stricture Esophageal cancer Diffuse esophageal spasm

A case of dysphagia

• It is always about the History.• Choking or coughing while swallowing: neurologic cause

(oropharyngeal)• Pain on swallowing (odynophagia): pill esophagitis or infection

(mostly opportunistic).• Liquids more: motility disorder• Progressive solid: stricture or malignancy• Intermittent solid: lower esophageal ring.

A case of dysphagia

• Always needs a work up – never give PPI and wait!• Always perform endoscopic evaluation, but if you have to

choose which one to start with: EGD: if dysphagia to solids (mechanical cause is

suspected). Barium swallow: if more to fluids (motility disorder is more

likely).

Motility disorders of esophagus

Achalasia Diffuse esophageal spasm Scleroderma

Achalasia

Degeneration of myenteric plexus of nerves Failure of relaxation of LES Dysphagia to both liquids and solids Regurgitation, aspiration Dry cough, chest pain No weight loss Nocturnal cough

Achalasia

Always start with Barium swallow (dilated oesophagus – bird peak), followed by EGD (rule out tumours), and motility studies (high pressure LES and no organized peristalsis) for total confirmation.

Pseudo-achalasia: AKA secondary achalasia, older age, progressive weight loss, short duration of symptoms and due to malignancy. Endoscopy is diagnostic.

Treatment: pneumatic dilation – laparoscopic myotomy.

Diffuse oesophageal spasm

usually young patient, intermittent dysphagia to cold liquids – atypical chest pain – barium swallow – sometimes no abnormalities in diagnostic tests.

Mechanical causes of dysphagia

Lower oesophageal ring Cancer oesophagus Oesophageal stricture Oesophagitis

Lower oesophageal ring

Intermittent solid dysphagia

Often relieved by regurgitation

Diagnosed by endoscopy and barium swallow

Treated by dilation followed by PPI therapy

Case 2

24-year-old male, presents with symptoms of oesophageal food impaction, for 2 hours after eating chicken. He is salivating and spitting frothy secretions. This is his 4th episode. he denies any heartburn. His physical examination is normal, and he only gives history of bronchial asthma.

What is the next step?• Consult endoscopist to perform EGD• Consult surgery• CT chest• Barium swallow

Case 2

24-year-old male, presents with symptoms of oesophageal food impaction, for 2 hours after eating chicken. He is salivating and spitting frothy secretions. This is his 4th episode. His physical examination is normal, and he only gives history of bronchial asthma.

What is the next step?• Consult endoscopist to perform EGD• Consult surgery• CT chest• Barium swallow

Case 2

24-year-old male, presents with symptoms of oesophageal food impaction, for 2 hours after eating chicken. He is salivating and spitting frothy secretions. This is his 4th episode. His physical examination is normal, and he only gives history of bronchial asthma.

What is the most likely cause?

Eosinophilic oesophagitis

Young males Recurrent food impaction – solid History of bronchial asthma or allergy Diagnosed by endoscopy: ringed oesophagus Treatment: PPI – ingested fluticasone

Case 3

18-year-old male presented to the ED with sudden onset of pain with any attempt to swallow either solids or liquids. He points to mid-chest as the area that hurts. It just started in the morning, and he denies any reflux symptoms or prior dysphagia. His past history is negative. He is taking some medications for acne but he cannot remember the name.What is the most likely diagnosis?

Case 3

18-year-old male presented to the ED with sudden onset of pain with any attempt to swallow either solids or liquids. He points to mid-chest as the area that hurts. It just started in the morning, and he denies any reflux symptoms or prior dysphagia. His past history is negative. He is taking some medications for acne but he cannot remember the name.What is the most likely diagnosis?Pill-induced oesophagitis

Odynophagia

Pill-induced: NSAIDS, doxycycline, KCl, FeSO4, aspirin. Infection: mostly opportunistic (Herpes, candida,

CMV). Rarely: with other common causes of dysphagia as

Schatzki ring. History is crucial – EGD confirms diagnosis.

Case 4

45-year-old male, presenting to the outpatient clinic with dry cough for 4 months now, not responding to OTC drugs. He reports that he saw a chest physician last week and told him that he has to see a gastroenterologist to check for the possibility of acid reflux. What is the best diagnostic test to rule out GERD in this case?

• Upper endoscopy• Barium swallow• 24-hour PH monitoring• Motility studies

Case 4

45-year-old male, presenting to the outpatient clinic with dry cough for 4 months now, not responding to OTC drugs. He reports that he saw a chest physician last week and told him that he has to see a gastroenterologist to check for the possibility of acid reflux. What is the best diagnostic test to rule out GERD in this case?

• Upper endoscopy• Barium swallow• 24-hour PH monitoring• Motility studies

GERD

Typical symptoms: heartburn – dyspepsia – regurgitation.Atypical symptoms: chronic cough especially nocturnal – recurrent upper respiratory infections – recurrent asthma – atypical chest pain.Alarming symptoms: dysphagia – weight loss – bleedingComplications: Barrett's oesophagus > adenocarcinoma – peptic stricture – upper GI bleeding.

GERD

Typical symptoms + no alarming symptoms + duration of symptoms less than 10 years: no need for endoscopy unless there are refractory symptoms.

Atypical symptoms: 24-hour PH monitoring is the main diagnostic option if endoscopy is normal. Treatment in these patients should be aggressive and prolonged.

Alarming symptoms: endoscopy is a must.

Case 5

35-year-old female, presenting to the ED with history of hematemesis of fresh blood twice in the past 3 hours. She feels light-headedness, and her blood pressure is 80/50, her pulse is 110 b/m. she gives history of taking ibuprofen for 2 weeks now for back pain. What is the initial management?

• Urgent endoscopy• IV fluids and blood crossmatch• Start IV PPI infusion• Surgical consultation

Case 5

35-year-old female, presenting to the ED with history of hematemesis of fresh blood twice in the past 3 hours. She feels light-headedness, and her blood pressure is 80/50, her pulse is 110 b/m. she gives history of taking ibuprofen for 2 weeks now for back pain. What is the initial management?

• Urgent endoscopy• IV fluids and blood crossmatch• Start IV PPI infusion• Surgical consultation

Upper GI bleeding

Common causes:• Bleeding peptic ulcer• Bleeding varices• Simple severe gastritis• Mallory Weiss syndrome• Malignancy Other less common:• Angiodysplasia• Aorto-enteric fistula• Osler-Weber-Rendu , Peutz-Jegher syndrome.

Upper GI bleeding

► Management:• Always start with ABC, resuscitation is the most important first line of

management. Blood is the best volume expander to be used.• NGT and aspiration is indicated especially in peptic ulcer disease.• If NGT does not show blood, this can’t exclude upper GI source of

bleeding.• Drugs: according, PPI if ulcer is suspected, Vasopressin analogues if

varices.• Upper endoscopy after stabilization of patients.

Upper GI bleeding

► Pharmacologic therapy:• IV PPI infusion for bleeding peptic ulcers, followed by continuous

infusion for 72 hours after endoscopic treatment if high risk ulcer (visible vessel or blood clot). If the ulcer has clean base in endoscopy, the patient can be given oral PPI and discharged safely.

• IV infusion of octreotide or Glypressin for cases of bleeding varices. This should be continued for 3-5 days after endoscopic treatment. Long term prevention is done by regular EVL and beta blockers.

Upper GI bleeding

► Endoscopic therapy:

• Peptic ulcer: adrenaline injection – endo-clips. Risk assessment is crucial about deciding the route of treatment and decision about discharge.

• Oesophageal varices: Band ligation.• Gastric varices: histoacryl injection.• Angiodysplasia: argon photocoagulation (APC).

Case 6

► A 40-year-old woman, has suffered from chronic heartburn and diarrhea for the past 2 years. She takes Omeprazole, which gives some relief of heartburn, but not the diarrhea which is 5-6 loose stools per day. She has some epigastric discomfort. Upper endoscopy showed grade III lower oesophagitis, shallow ulcers in the duodenal bulb and minute duodenal ulcers in the second part.

► What do you recommend?

Case 6

► Continue Omeprazole but add sucralfate.

► Continue omeprazole but add metoclopramide.

► Order H Pylori ELISA

► Order serum fasting gastrin

Case 6

► Continue Omeprazole but add sucralfate.

► Continue omeprazole but add metoclopramide.

► Order H Pylori ELISA

► Order serum fasting gastrin

Zollinger Ellison Syndrome

► Don’t forget: consider ZE syndrome whenever you have a patient with chronic diarrhea and chronic heartburn with pan inflammatory process in upper endoscopy.

► Always remember: it may be part of MEN I syndrome (20%).► Diagnosis: • serum fasting gastrin level – you should stop any PPI for at least 7 days

before the test. Why?• EUS is ideal for localizing gastrinomas.• Surgical exploration might be needed as diagnostic and therapeutic option.

Case 7

► 25-year-old female presented with 3 years history of chronic diarrhea and abdominal cramps. She was told that she had IBS and maintained on high fibre diet. Now she has the same symptoms which awakes her at night. Her PMH and family history are negative. She reports that she lost 4 Kg in the past four months. Examination is normal except slight tenderness in right iliac fossa. What do you recommend?

• Reassure. It is IBS and only add a spasmolytic.• Order stool analysis and give empirical antibiotics for a week.• Do colonoscopy• Give her mesalamine

Case 7

► 25-year-old female presented with 3 years history of chronic diarrhea and abdominal cramps. She was told that she had IBS and maintained on high fibre diet. Now she has the same symptoms which awakes her at night. Her PMH and family history are negative. She reports that she lost 4 Kg in the past four months. Examination is normal except slight tenderness in right iliac fossa. What do you recommend?

• Reassure. It is IBS and only add a spasmolytic.• Order stool analysis and give empirical antibiotics for a week.• Do colonoscopy• Give her mesalamine

Case 7

► Colonoscopy was done to the patient and showed multiple shallow ulcers in the ascending colon. Biopsies were taken and showed non specific chronic inflammation.

► What is the best treatment to start with?• Metronidazole• Oral steroids• Oral azathioprine• Oral mesalamine• Infliximab

Case 7

► Colonoscopy was done to the patient and showed multiple shallow ulcers in the ascending colon. Biopsies were taken and showed non specific chronic inflammation.

► What is the best treatment to start with?• Oral steroids• Oral azathioprine• Oral mesalamine• Infliximab

IBD

► Always suspect IBD rather than IBS if there is any of: bleeding – high inflammatory markers – anaemia – low vitamin B12 – nocturnal diarrhea. So ALWAYS do CBC and ESR in every suspected case of IBS. If abnormal proceed for colonoscopy.

► Biopsy is diagnostic but not always conclusive. Differentiation is mainly made by clinical scenario and endoscopic findings.

IBD

Crohn’s diseases Ulcerative colitisClinical features Chronic non bloody

diarrhea Rt iliac fossa mass Rectal sparing

Bleeding per rectum and bloody diarrhea

Lt iliac fossa pain Tenesmus

Extraintestinal Gall stones Oxalate renal stones

PSC 

Complications Obstruction Fistulae and perforation Intestinal obstruction

Colorectal cancer Massive bleeding

IBD

Crohn’s diseases Ulcerative colitisEndoscopy Deep ulcers

Skip lesions Cobble stone mucosa

Shallow ulcers Continuous widespread

lesions Pseudo polyps

Radiology (Barium) Fistulae and strictures Rose thorn ulcers Proximal bowel dilatation

Loss of haustrations Drain-pipe colon

IBD

Crohn’s diseases Ulcerative colitisPathology From mouth to anus

Skip lesions 

Starts from rectum and upwards but never affects beyond ileocecal valve

Continuous lesionsHistology Affects all layers from

mucosa to serosa Granulomas Excess goblet cells

Affects only mucosa and submucosa

Granulomas are infrequent

Depletion of goblet cells Crypt abscesses

IBD

► Treatment is mainly aiming at: induction of remission followed by maintenance therapy.

► For inducing remission: In UC mesalamine (5-ASA) is effective in mild to moderate cases. While in CD steroids is essential (Ivor oral according to severity), as 5-ASA are not so effective (usually as an add-on therapy if there is evidence of colonic disease).

► Systemic IV steroids is a must in both diseases in severe cases.► Infliximab only in fistulising or perianal disease (CD), or in severe

resistant cases (both). You should exclude TB first.

Cancer risk in UC

2 % after 10 years 15 % after 20 years Pancolitis has greater risk than localized

disease Factors that predicts cancer development:

Age of onset < 15 years Pancolitis Disease duration > 10 years Unremitting disease Poor compliance to treatment

Cancer screening: Duration > 10 years : every 2

year Duration > 20 years : every 1

year.

IBD

Loss of haustrations and pipe-like colon in a case of ulcerative colitis.

Case 8

► 25-year-old male, recently diagnosed with ulcerative colitis, with about 2 months history of bleeding per rectum, 3 times per day, and urgency. His colonoscopy showed typical picture of UC involving both rectum and sigmoid colon. All the way around beyond that is normal, and the ileocecal junction is normal as well. What is the best initial treatment?

• Oral mesalamine• Mesalamine enema• Oral steroids• Infliximab

Case 8

► 25-year-old male, recently diagnosed with ulcerative colitis, with about 2 months history of bleeding per rectum, 3 times per day, and urgency. His colonoscopy showed typical picture of UC involving both rectum and sigmoid colon. All the way around beyond that is normal, and the ileocecal junction is normal as well. What is the best initial treatment?

• Oral mesalamine• Mesalamine enema• Oral azathioprine• Infliximab

UC – Treatment by extent

► Proctitis: suppositories► Proctosigmoiditis: enema► More extensive: oral therapy

Case 8

► 30-year-old female with long history of loose bowel movements for about 3-4 years presented to you with slight fatigue. She denies any history of bleeding per rectum, and her menstruation is normal. O/E she is slightly pale. Her Hb level is 8 g/dl and MCV is 64. she has an itchy rash on extremities.

► What do you plan for this patient?• IBS, give her antispasmodics and antidiarrheal agents.• Reassure and increase fibre in diet• Order tissue transglutaminase• Order stool analysis

Case 8

► 30-year-old female with long history of loose bowel movements for about 3-4 years presented to you with slight fatigue. She denies any history of bleeding per rectum, and her menstruation is normal. O/E she is slightly pale. Her Hb level is 8 g/dl and MCV is 64. she has an itchy rash on extremities.

► What do you plan for this patient?• IBS, give her antispasmodics and antidiarrheal agents.• Reassure and increase fibre in diet• Order tissue transglutaminase• Order stool analysis

Coeliac disease

► Always falsely diagnosed as IBS (sounds like IBS but anaemic).► Again, any case of IBS that has anaemia, dermatitis or manifestations

of malabsorption (iron deficiency or macrocytic anaemia, hypocalcaemia, osteoporosis) should be investigated for coeliac disease.

► Diagnosis: TTG Abs + Upper endoscopy and biopsy from duodenum that shows villous atrophy.

► Associated conditions: Osteoporosis, dermatitis herpitiformis, unexplained raised LFTs.

► Treatment: Gluten-free diet (Wheat, barley and rye) الشعير و القمح

Dermatitis herpitiformis

Coeliac disease

► Villous atrophy in coeliac disease

Case 9

► 2/ A 25-year-old man who is known to have diabetes mellitus and suffers from recurrent chest infections is referred to the gastroenterology team with chronic diarrhoea. The letter from his GP states the patient has had persistently abnormal liver function tests over the last three months and an abdominal ultrasound scan showed a fatty liver and gallstones.

► What is the most likely diagnosis?

Cystic fibrosis

► Cystic fibrosis (CF) is an autosomal recessive disorder that affects secretory epithelia, where patients have dry protein-rich secretions which lead to complications of the pulmonary and gastrointestinal systems. It also affects pancreatic exocrine and endocrine functions (malabsorption and diabetes mellitus).

► Twenty per cent have a fatty liver, and gallstones are seen in 15% of young adults with the disease. Patients may also develop secondary biliary cirrhosis with mucus plugging of bile ducts and portal hypertension.

Case 10

► A 41-year-old woman comes to the gastroenterology clinic for review. She underwent extensive resection of her distal small bowel for Crohn's disease around three months earlier. She is still suffering from diarrhoea and is worried that her Crohn's disease is still active. On examination her BP is 105/70 mmHg with a pulse of 80. Her abdomen is soft and non-tender. Investigations show:

► Hb: 10, Wbc: 4.5, Plt: 195, Na: 138, K: 3.8, CRP: 9 (<10).► What is the most likely diagnosis?• Short bowel syndrome• Bile acid diarrhea• Bacterial overgrowth• Active crohn’s disease• Ischemic colitis

Case 10

► A 41-year-old woman comes to the gastroenterology clinic for review. She underwent extensive resection of her distal small bowel for Crohn's disease around three months earlier. She is still suffering from diarrhoea and is worried that her Crohn's disease is still active. On examination her BP is 105/70 mmHg with a pulse of 80. Her abdomen is soft and non-tender. Investigations show:

► Hb: 10, Wbc: 4.5, Plt: 195, Na: 138, K: 3.8, CRP: 9 (<10).► What is the most likely diagnosis?• Short bowel syndrome• Bile acid induced diarrhea• Bacterial overgrowth• Active crohn’s disease• Ischemic colitis

Case 10

► In patients with extensive small bowel resection for CD there are different causes for diarrhea:

• Active crohn’s: tenderness, raised WBCs, raised CRP, systemic manifestations

• Short bowel syndrome: mostly voluminous amounts of fluid, > 5 litres per day, through ileostomy opening.

• Bile acid diarrhea: due to lack of reabsorption of bile acids from ileum.• Bacterial overgrowth: mostly associated with scleroderma more than

CD, and associated with excessive bloating.

Case 11

► A 50-year-old woman is seen in the clinic because of deranged liver function tests (LFTs). She drinks at most 4 units of alcohol weekly. On examination she is obese with a BMI of 45kg/m2 and her LFTs show: ALT 140, AST 150, bilirubin 14 umol.

► What is the most likely cause?• Diabetes mellitus• Drug induced• Chronic alcoholic hepatitis• Hypothyroidism

Case 11

► A 50-year-old woman is seen in the clinic because of deranged liver function tests (LFTs). She drinks at most 4 units of alcohol weekly. On examination she is obese with a BMI of 45kg/m2 and her LFTs show: ALT 140, AST 150, bilirubin 14 umol.

► What is the most likely cause?• Diabetes mellitus• Drug induced• Chronic alcoholism• Hypothyroidism

NASH

► For a patient to be considered at risk of chronic alcoholic hepatitis he should consume at least 40 units per week. Which is not present in this case.

► The presence of morbid obesity suggests that this is a case of NASH, and the most common cause in these patients is diabetes mellitus.

► NASH is a disease that is diagnosed by exclusion, and sometimes a liver biopsy is indicated to confirm the diagnosis. Good glycaemic control and weight loss is the corner stone in management of patients with NASH.

NASH

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