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Showing posts with the label Gastroenterology

Image Challenge ! Please follow next week for answer

Clinical scenario:
     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 two  weeks her  pain  would get  aggravated  by food  intake. and she described this phenomenon for   the past  2 weeks only .She denied any alarming symptoms  in the form of  loss of  appetite and weight   loss . There was no history of vomiting or  melena .
Clinical examination and Investigations :
Her clinical examination was normal
Evaluation, her hemoglobin levels were 14 gm/dl . She had a normal leuckoucyteic count, and tests on  Lliver function , and renal  function  were  normal . Serum  Llipase and Aamylase levels were not elevated .
 An ultrasound of her abdomen did not  show presence of gall stones and all other organs were normal.
She underwent upper gastrointestinal (GI) endoscopy keeping in view her severe symptoms and to rule…

The answer to last weeks image challenge!

Clinical scenario
An 80 year old female presented to our clinic with history of post prandial fullness, nausea and intermittent postprandial vomiting of 3 weeks duration without any history of anorexia or weight loss.

On examination she was conscious oriented hemodynamically stable with no pallor,lymphadenopathy cyanosis or jaundice. Her systemic examination was normal .
On laboratory evaluation she had hemoglobin of 15.3gm/dl. normal liver and kidney function tests.
Her gastroscopic examination revealed normal esophagus. gastric fundus and body.Antrum showed 1.5 cm size head polyp with 3cms long stalk freely mobile moving inside the pyloric ring with the two parts of head (Fig.1,,)
. Polypectomy snare was used and the polyp was resected close to the base with no significant bleeding. Two clips were applied (fig2) to the polypectomy base and polyp was removed out of
stomach with endoscopy net. Patient was observed overnight and later discharged home without any
complications. The biop…

Image challenge !

Clinical scenario  An 80 year oldfemale presentedto our clinic with history of post prandial fullness, nausea and intermittent  postprandial   vomiting of 3 weeks duration without any history of anorexia or weight loss.  Examination she was conscious oriented hemodynamically stable with  no pallor, lymphadenopathy cyanosis or jaundice.  Her systemic examination was normal . Investigations :
On laboratory evaluation she had hemoglobin of 15.3gm/dl. normal WBC and platelet count. liver and kidney function tests were normal  Upper GI endoscopic examination showed normal esophagus , body of the stomach was normal and there was a lesion in Antral area of stomach as shown in Fig below 

What is your diagnosis ?  follow next week for answer .

The sad story of Pancreatitis !

A 30-year-old male patient was admitted in our hospital with history of epigastric pain radiating to the back, which was of 4 days’ duration. The pain was associated with recurrent vomiting on the first day. The patient had been a chronic abuser of alcohol for the previous 4 years. He did not have jaundice, abdominal distension, or constipation. There was no history of previous abdominal pain or diabetes mellitus.
On examination:
      Patient was stable hemodynamically; he had epigastric tenderness and no organomegaly or free fluid in the abdominal cavity.Clinical exam was normal otherwise.
Investigations  :
The investigation revealed a hemoglobin of 11 gm/dL  total leukocyte count of 17,300/mm and serum amylase of 400 IU/mL (up to 100 IU/mL), and results of serum biochemistry and chest radiograph were normal.
A contrast-enhanced CT (CECT) revealed an edematous pancreas with multiple areas of necrosis in the head and tail regions. There was peripancreatic fluid collection extending to l…

Recurrent pain abdomen in a young male !

Clinical scenario: 
A 27-year-old Egyptian male with no significant comorbidities presented with history of episodic, recurrent abdominal pain of 4 years duration .Patient described pain as colicky, remaining for 1–2 hours necessitating intravenous analgesics predominantly in the upper abdomen. His abdominal pain had no reference or radiation and there was no jaundice associated with it. Patient had been admitted four times in various hospitals during this period and every time basic laboratory evaluation including liver function tests and serum amylase were within normal limits. His ultrasound examination had been within normal limits on each occasion he was hospitalized for his abdominal pain. Patient denied any high risk behavior or drug abuse. Over this period he had stable appetite and constant weight. On examination he was conscious oriented and he had stable vitals. There was no icterus, or lymphadenopathy. His systemic examination was unremarkable. 
Evaluation and course : 

He was wrongly diagnosed as a case of Chronic liver disease !!!

Clinical scenario :
               A 19-year-old male was referred to our hospital with breathlessness on exertion and fatigue for 1 year and a history of gastrointestinal bleeding. Three months ago, he had three episodes of painless hemetemesis when he  was admitted to another hospital and was found to have variceal bleeding. He was transfused with four units of blood and was subjected to two sessions of variceal band ligation.
He started having progressive abdominal distension and pedal edema a month later for which he was put on diuretics. He did not complain of jaundice or altered sensorium. There was no history of diarrhea during childhood and his physical growth was normal.He was labelled as a case of chronic liver disease  in that hospital.
                  On examination, in our hospital he had pallor, mild icterus, no pedal edema; his blood pressure was 124/ 80 mm Hg. Abdominal examination showed hepatomegaly (3 cm below right costal margin), splenomegaly (4 cm), …

Fatal hemetemesis due to sudden rupture of esophagial tumor

Clinical scenario:
          A 51 year old male presented with history of progressive mechanical dysphagia of three months duration, without any history of anorexia, weight loss, offending drug intake .There were no features of transfer dysphagia.
        He was  conscious, hemodynamically stable without any pallor, palpable lymphadenophathy, jaundice or organomegaly
        He had  hemoglobin of  12 gm/dl .His biochemical parameters were normal. The patient underwent  upper GI endoscopy  which  revealed submucosal lesion in mid-part, 25-35 cm from incisors, with luminal compromise and scope was passable with moderate resistance into stomach. (Fig 1).
 A contrast enhanced-CT scan abdomen revealed a heterogenous, soft tissue density mass in relation to mid- and distal esophagus with nonvisualized mid thoracic segment of azygos vein and mediastinal lymphadenopathy. A provisional diagnosis of leiomyoma/leiomyosarcoma was made (Fig 2).
He was planned for an electi…

Where did the gall stone 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…

Fish bone migration : an unusual cause of recurrent liver abscess

Clinical scenario :A 48 yr old male  presented with h/o Fever and abdominal pain of 10 days duration  On examination he was conscious oriented  and had stable vitals , temp 38° C ,he had mild hepatomegaly , rest of clinical examination was unremarkable  Investigation: WBC 12,0000  Liver function test normal       An ultrasound revealed  Liver abscess .Patient was given  Antibiotics and abscess was drained .He became a febrile and was discharged home Symptoms recurredafter 1 month and he was admitted again . 2nd admission : He had high grade fever and labs showed WBC count of 16000. Liver function tests showed  normal Bilirubin , elevated alkaline phosphatase  .CT scan abdomen was done which showed presence of a foreign body in the liver and residual liver abscess (Fig 1).Patient was operated and the foreign body was removed which proved to be fish bone  (Fig 2) Patient became a febrile after surgery .

       On repeated questioning patient admitted intake of  Fish in a restaurant 5 month…

Pain abdomen and Jaundice in a young male

Clinical scenario :
A 27 yr old male was admitted with epigastric  pain of 3 days duration associated with vomiting .There was no viral prodrome or any offending drug intake . His father has noticed yellowish discoloration of eyes
Patient was conscious oriented and hemodynamically stable.There was Jaundice and no lymphadenopathy 
Abdomen was soft , non tender ,mild hepatomegaly no ascites.
 Complete blood count (CBC),NORMAL
 serum Amylase levels 390 IU , serum lipase 290
Liver function tests
 Bilirubin, 4.5mg/dl
 ALP was 320 KA units and SGOT /SGPT were 56, 62 respectively .
Coagulation parameters and Albumin levels were normal.
All viral markers were negative and CT scan abdomen was done .What is your diagnosis ?
Let us analyse the index case .
Patient has presented with sudden onset of acute abdominal pain associated with vomiting . Even though there is no further clue in the history acute pancreatitis must be ruled out by proper history which includes history of gall …

Pain abdomen in a young male

Case No 1 
A 30 year old male non smoker presented with abdominal pain of 2 weeks duration .Clinical examination was normal .His Liver function tests and CBC were also normal . UGI endoscopy revealed no abnormality and he was diagnosed as Dyspepsia .
Q 1 What is Dyspepsia ?
Answer : Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise.
Q2 who are the patients where EGD is required ?  Answer :
Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD). In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an em…

Complication during any procedure is part of the game but in timemanagement can make the difference !

Clinical scenario:  A 65-year-old female with no comorbidities presented to the emergency room of King Fahad Medical City, a tertiary care center in Riyadh, Saudi Arabia, with chief complaints of right upper quadrant pain and vomiting for 5 days.
She was conscious, oriented, jaundiced and hemodynamically stable; she was afebrile and had an oxygen saturation of 94% on room air. She had mild right hypochondriac tenderness, no organomegaly, no palpable lump or free fluid on abdominal examination. Her other systemic examinations were unremarkable.
Laboratory investigations revealed hemoglobin of 13g/dl , leukocyte count of 14.0 x 10³,predominantly neutrophilic (polymorphs 92%). The liver function tests showed totalbilirubin of 21.6 umol/L, direct bilirubin of 9.7 umol/L, ALT 317 umol/L, AST 300
umol/L, alkaline phosphatase 488 umol/L, GGT 498 umol/L, and amylase 94umol/L. Her renal function test and electrolytes were normal. Abdominal ultrasound revealed a prom…