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Showing posts with the label Gastroenterology

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.


Hemogram, RFT, LFT, INR, ECGMonitoring of Blood sugars Arterial blood gasArterial ammonia  Blood culture Workup for Malaria /Typhoid/Leptospira/Rickettsial infection-if  suspicion of ALF mimickers Routine Viral hepatitis serology,sIgM 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 treatment  Infection: Surveillance  & Prompt treatment Coagulopathy : (Al…

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 NH3 : >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/E : Oculocephalic reflex, unresponsiveness to noxious stimuli Management ·Grade I/II HE

Non variceal Upper GI bleed

Non variceal Upper GI bleed

·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    

·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 scoring system

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 clinically evident…

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 antibiotics (Le…

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 hemoglobin of 14gm/d…

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.
       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.

         He had normal levels of hemoglobin(…

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.
     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.
      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.

CT scan of the abdomen did not demonstrate any vascular calcification or any other abnormality.
Colonoscopic examination up to term…

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 hernia. Th…

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 : 
The bl…

Answer to last weeks image challenge!

Clinical scenario :
      A 77-year-old female presented to our hospital with history of lower GI bleed and colonoscopic examination showed multiple lesions in sigmoid colon and in transverse colon . Fig 1 and Fig 2
Biopsy was taken .

The biopsy revealed features of monotonous sheets of Lymphocytes as shown in figure 3 .The immuno staining was positive for Cyclin D+ and CD 2 positive Fig 4 and 5 below
The overall features were suggestive of MANTLE CELL LYMPHOMA  (MCL)

Further reading :
   Extra nodal lymphomas commonly occur in the GI tract. They account for 2% of primary GI tract lymphomas . Non-Hodgkin’s lymphoma of the colon is rare .
MCL is a discrete entity, unrelated to small lymphocytic or small-cleaved-cell lymphomas .
Abdominal pain is the most common symptom and obstruction is unusual;however, reports of intussusception  are known. The majority of patients are elderly as in the index case and have multiple polypoidal lesions ranging from 0.1 to 4 cm with central ulcerations.

Image challenge !

Clinical scenario :
A 77-year-old female presented to our hospital with history of lower GI bleed and colonoscopic examination showed multiple lesions in sigmoid colon and in transverse colon . Fig 1 and Fig 2
Biopsy was taken .

Follow for the answer next week. 

The Answer to last weeks image challenge!

                               The answer is PANCREATIC REST 

Details of the case are as under :
A 37-year-old female presented with a history of epigastric pain of 8 weeks duration. The pain had an intensity of 7/10 and was a burning type of pain with no reference or radiation. She stated that for the previous 2 weeks her pain was aggravated by food intake. She denied any alarming symptoms in the form of loss of appetite and weight loss. There was no history of vomiting or melena. Her clinical examination was normal  Evaluation: Her hemoglobin levels were 14 g/dl. She had a normal leukocyte count, and liver function and renal function were normal. Serum lipase and amylase levels were not elevated. An ultrasound of her abdomen did not indicate the presence of gallstones and all other organs were normal. She underwent upper gastrointestinal (GI) endoscopy to rule out a gastric ulcer due to the pain being aggravated by food. An upper gastroscopic examination revealed normal esophagus. Ther…