Gastroenterology Desk

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 . Fig.1 Multiple lesions seen on colonoscopy  Fig2 Multiple lesions seen      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) Fig 4 Immunocytochemistry Cyclin D + Fig 3 sheets of  lymphocytes seen    Fig.5 Lymphocytes positive for CD2  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

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.  Multiple lesions in sigmoid colon  Fig 2 Another lesion in the same patient 

                               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 esopha

  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 symptom

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. Fig 1 IMAGE Challenge   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 w

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  Fig Upper GI examination , the lesion is in antrum of stoamch What is your diagnosis ?  follow next week for answer .

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 exte

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.  Eva

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. Examination                   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 c

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. Examination:         He was  conscious, hemodynamically stable without any pallor, palpable lymphadenophathy, jaundice or organomegaly Investigation         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). Fig 1 Endoscopy showing sub mucosal bulge at 25 cms   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 leiomyo

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

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 recurred   after 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 . Fig 1 CT scan showing foreign body in Liver and residual ab

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 Examination   Patient was conscious oriented and hemodynamically stable.There was Jaundice and no lymphadenopathy  Abdomen was soft , non tender ,mild hepatomegaly no ascites. Investigations   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 panc reatitis must be ruled out by proper histor

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 s hould 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