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Showing posts with the label Gastroenterology

Her last ice cream

Greetings of the day !      Mrs Radha (name changed) a 28 year old female was admitted with a history of recurrent vomiting and  Jaundice of one  day duration to our hospital. She had no  history of viral prodrome , fever or any offending drug intake .She was conscious oriented,  and had  mild icterus . Her systemic examination was normal. An Ultrasound of the abdomen did not reveal any obstruction in the  biliary system .All routine investigations required were sent and the patient was started on supportive treatment. Although she had  mild elevation of Bilirubin and Liver enzymes,  her INR (coagulation profile ) was 4 times the upper limit of  normal.  While peeping into her liver cell function tests  , it was obvious that her liver was failing .She was managed as a fulminant liver cell failure in the Intensive Care Unit of the hospital.   What led to her Jaundice and high INR left all of us clueless.   In the evening at around  8pm the resident doctor on duty got an alert call from

Good clinical examination clinched the diagnosis

Greetings of the day  Down the track of Memories Another  story  from PGIMER Chandigarh Years back , while working as a DM student. Mr. Paul  Singh (name changed) a 49 year old thin built person presented to our  clinic at PGI Chandigarh with pain abdomen off and on for  the past 12 months .Pain was   intermittent and diffuse. He had lost around 14  kilograms of weight during this period.For these complaints he had consulted a lot of doctors. Apart from baseline investigations he had undergone UGI endoscopy twice, Colonoscopy once and all other investigations  required for evaluation of an unintentional weight loss. Based on a few small lymph nodes in his CT scan abdomen , Anti tubercular treatment  had been started by some doctor .The patient had continued treatment for 2 months without any  relief and  stopped it in despair. Ultimately Mr.  Paul Singh had been  started on anti depressants   as no definite cause  could be  ascertained by the doctors.Finally he came to PGI. That day Pr

A good clinical examination clinched the diagnosis

Greetings of the day  Down the track of memories Today story from Sir Ganga Ram hospital New Delhi Years back while working as senior resident in Medicine, a young business man Mr Raj  (name changed) was admitted for evaluation of swelling of feet of 3 weeks duration.  On evaluation he was found to be losing proteins in urine (Nephrotic range proteinuria)  A kidney biopsy was planned by the dept for this patient to know the cause of protein loss through kidneys. Sadly on the day of kidney biopsy Mr Raj  developed high grade fever and the procedure was cancelled. The treating team send all  investigations required to know the cause of fever. But there was not a single  clue from any of the  investigation sent. Mr Raj continued to drench in fever .  Finally they send a refrence to internal medicine for advice. "Ibrahim! Let us see the patient", said Dr S P Byotra  and together we went to see Mr Raj on the 3rd floor  ( the semi nursing home) of the hospital. " Hello  ji&quo

Look beyond the obvious - II

Greetings of the day! Dear Friend. Today another story from Saudiarabia Down the track of Memories King Abdul Aziz specialist hospital Taif Saudi Arabia On another occasion, Mr Zahrani (name changed), a 43 year old business man  presented with right upper abdominal pain  associated with loss of appetite of ten  days duration. Clad in long Abaya, the anxious wife of Mr. Zahrani  kept her dazzling, branded ladies purse aside and pulled the CT scan report of her beloved husband and a referral note. "Daktoor( doctor) we are worried" ,she said. The  CT scan abdomen was suggestive of a hyper dense  lesion in the segment V  of liver and the concerned radiologist had mentioned lot of differentials below for further studies. The differentials varied  from  a benign to malignant lesions of the  liver. Loss of appetite was a worrying clinical symptom in this patient and Mr Zahrani was admitted for further evaluation. The family was counselled about fine needle aspiration of this hy

Dysphagia in a young male

 Clinical scenario  A 35-year-old male presented with a history of difficulty of swallowing solids and liquids of 4 weeks duration. He denied weight loss and loss of appetite. Clinical examination was normal. Baseline investigations were normal   UGI endoscopy revealed no mass lesion in the oesophagus. Barium meal follow-through was done as shown below    The barium meal shows parrot beak appearance suggestive of Achalasia cardia. Failure of  relaxation of lower end of the oesophagus  This condition can be managed with Endoscopic methods or by Surgery previously was manged by medications alone   

Acute Liver Failure

Diagnosis : AASLD guidelines : Criteria for Diagnosis in Adults  1. Jaundice < 26 weeks  2.Coagulopathy (INR>1.5 3.Hepatic encephalopathy 4.No evidence of chronic liver disease. Investigations Hemogram, RFT, LFT, INR, ECG Monitoring of Blood sugars  Arterial blood gas Arterial ammonia   Blood culture  Workup for Malaria /Typhoid/Leptospira/Rickettsial infection-if  suspicion of ALF mimickers Routine Viral hepatitis serology,s IgM anti HAV,HBsAg,anti-HBc ,IgM,anti HEV,anti HCV   If Wilson suspected: Ceruloplasmin levels, KFRing/Urinary copper   Brain imaging (CT/MRI) if there is a clinical suspicion  Pregnancy test in females  Severity assessment : Poor clinical prognostic indicators   Age >50 years  Jaundice -encephalopathy interval >7 days  Hepatic encephalopathy grade 3 & Higher  Presence of cerebral oedema  Creatinine >1.5mg/dl Presence of any 3 ----indicates Poor prognosis  Management  : ICU admission  Supportive tr

Management of hepatic encephalopathy

Diagnosis ·         Known or suspected CLD presenting with altered sensorium ·         ALF ·         No neurological cause on examination or imaging Investigations         ·        Neurological examination to rule out focal cause ·        Hemogram RFT,LFT,INR, Sugar, ECG ·        Arterial NH 3  : >200ug/dl is associated with cerebral herniation , >75ug/dl is associated with Hepatic encephalopathy ·        USG abdomen ·        Brain imaging in relevant cases Severity assessment ·        West Haven Grades Minimal HE : Normal examination , subtle changes in working /driving                        Abnormal visual perception , Psychometric  or number test   Grade !:Personality changes , attention deficits , depressed state or irritability Grade II: Change in sleep -wake cycle , lethargy , mood changes Flap+ Grade  III: Altered level of consciousness , disorientation , O/E Muscular rigidity, clonus, hyporeflexia  Grade IV: Stupor and coma  O/

Non variceal Upper GI bleed

Non variceal Upper GI bleed Diagnosis ·         History of Hemetemesis or Melena /Hematochezia ·         H/O NSAIDS use /Anti coagulants/antiplatelets/steroids /Peptic ulcer Examination : Hemodynamic status , vitals Look for Vascular lesions on the skin Consider variceal if : Splenomegaly /ascites /Features of CLD     Investigations ·         Hemogram , RFT,LFT INR Sugar, ECG, X -ray chest   ·         USG to rule out CLD ·         Serology :HBSAg, anti HCV , HIV ·         Plan UGI endoscopy   ·         May need CT angiography   Severity assessment ·         Endoscopic Findings.      Classification ·         Active bleeding               Ia Brisk bleeding  1b Oozing ·         Non bleeding visible vessel  IIa (visible vessel ) ·         Adherent clot                     IIb ·         Flat spot                              IIc ·         Clean base                         III Click to Calculate  Rockall score:  Rockall scor

Management of ascites in cirrhosis

Management of ascites  in cirrhosis Grading of ascites: Grade I Detected by USG only , Grade II moderate ascites , Grade III gross ascites Characteristics of ascites in CLD: wide gradient SAAG >1.1 Recommendations  1. A diagnostic paracentesis should be performed in all patients with new-onset grade 2 or 3 ascites, and in all patients hospitalized for worsening of ascites or any a complication of cirrhosis (Level A1). 2. Neutrophil count and culture of ascitic fluid (by inoculation into blood culture bottles at the bedside) should be performed to exclude bacterial peritonitis (Level A1). 3. It is important to measure ascitic total protein concentration since patients with an ascitic protein concentration of less than 15 g/L have an increased risk of developing spontaneous bacterial peritonitis (Level A1) and may benefit from antibiotic prophylaxis (Level A1). 4. Measurement of the serum–ascites albumin gradient may be useful when the diagnosis of cirrhosis is not c

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis EASL Recommendations  1.A diagnostic paracentesis should be carried out in all patients with cirrhosis and ascites at hospital admission to rule out SBP. A diagnostic paracentesis should also, be performed in patients with gastrointestinal bleeding, shock, fever, or other signs of systemic inflammation, gastrointestinal symptoms, as well as in patients with worsening liver and/or renal function, and hepatic encephalopathy (Level A1).  2. The diagnosis of SBP is based on neutrophil count in ascitic fluid of >250/mm3 as determined by microscopy (Level A1).  3. Blood cultures should be performed in all patients with suspected SBP before starting antibiotic treatment (Level A1).  4. Some patients may have an ascitic neutrophil count less than 250/mm3 but with a positive ascitic fluid culture. This condition is known as bacterascites. If the patient exhibits signs of systemic inflammation or infection, the patient should be treated with

Where did the Gallstones go?

Clinical scenario:              An 88-year-old  male with no co morbid illness  presented to the emergency department at King Fahad Medical City , Riyadh, with chief complaints of postprandial fullness and on-and-off vomiting of  one month duration.              One year back he had developed pain abdomen and was diagnosed to have  cholecystitis Ultrasound at that time showed two   gall stones without biliary dilatation . He had been managed in a local hospital and discharged home at that time .  The patient denied having had any abdominal surgery  or endoscopic procedure prior to current  presentation. On examination:   The patient was thin built  mildly dehydrated with normal vitals. Abdominal examination revealed no surgical scar.There was  fullness in the upper abdomen but abdomen was  soft, not tender and there was no organomegaly or ascites.  Succession splash   was positive. Bowel sounds were normal  Systemic  exam was unremarkable.  Laboratory investigations  revealed a

Abdominal mass in a young male

Clinical scenario:             A 35-year-old male farmer had noticed a swelling of the left side of his hypochondrium that persisted for six months. He had no history of severe abdominal pain, jaundice or fever. There was no history of loss of appetite or weight loss. Examination:        The patient was conscious and oriented. Icterus, lymphadenopathy, and edema were absent. The examination of his abdomen revealed a swelling that measured 5x6 cm. The swelling was smooth and cystic. In order to confirm the origin of this swelling different maneuvers were used. The swelling disappeared while raising his head suggesting an intraabdominal nature of the swelling. The patient was asked to assume the knee-elbow position and the swelling was palpated in this position. The said swelling disappeared confirming the retroperitoneal nature of this swelling. There was no bruit on auscultation. The results of the systemic examination were normal. Evaluation:           He had normal levels of he

The mystery of colonic calcification!

Clinical scenario :       A 22-year-old female presented to our with a history of intermittent abdominal pain of 4 weeks duration. She described the pain as mild (score of 3/10), dull aching,in the whole abdomen with no reference or radiation. She denied abdominal distension, constipation or vomiting. Examination      Her vitals were stable. Her abdomen was not distended, soft and there was no tenderness or guarding. There was no organomegaly or free fluid and her bowel sounds were normal. Her other systemic examination was unremarkable. Evaluation       Her hemogram, erythrocyte sedimentation rate (ESR), renal function tests, serum amylase, lipase and liver function tests were normal. Abdominal CT scan (Figure 1) revealed diffuse colonic calcification starting from rectum to splenic flexure, sparing transverse colon and involving the whole ascending colon. Fig 1 CT scan abdomen showing diffuse colonic calcification. CT scan of the abdomen did not demonstrate any vascular

And the polyps in the stomach disappeared !

Clinical scenario:          A 30 year old male presented to our clinic with history of on and off epigastric pain of 4 years duration without any alarming symptoms. The patient had no history of offending drug intake. He had been taking proton pump inhibitors Tab. Esomeprazole 20 mg twice daily continuously for 4 years with partial relief. He has been a non smoker and denied any drug abuse or alcohol intake. His systemic examination was unremarkable. Evaluation :          He was evaluated on outpatient basis. He had haemoglobin of 14 g/dl with normal leucocytic count and normal platelet count. He had normal liver and kidney function tests. Serum amylase was within normal limits. Abdominal ultrasound showed a normal size of the liver with its normal echo texture. There were no gall stones, the common bile duct was normal and other abdominal viscera were also normal.The patient underwent upper gastrointestinal (GI) endoscopy which revealed a normal esophagus and a small hiatal herni

He felt all the time fatigued !

Clinical scenario:           A 54 yr old male was admitted with history of fatigue and generalized malaise of 3 weeks duration . He also complained of postprandial fullness and an episode of non bilious vomiting .Patient denied history of fever , night sweats but had weight loss of 3 kgms over this period.       Prior to this presentation he was admitted in a different hospital one month ago with history of epigastric pain of 3 days duration and was managed as acute pancreatitis based on high levels of Amylase and lipase and an ultrasound evidence of gall stones at that time .After necessary treatment his pain had settled and was  discharged home with an advice for follow up. Patient has been known case of Diabetes mellitus for last 5 years on oral hypoglycemic agents. Clinical Examination :   On examination  he was conscious , oriented in time place and person with stable vitals . There was no icterus , pallor or lymphadenopathy Systemic examination was normal. Investigations :