Clinical Challenges & Images in Gastroenterology. A Diagnostic Guide

Description

Clinical Challenges & Images in GASTROENTEROLOGY: A Diagnostic Guide Title Page Copyright Contents Preface Abbreviations Acknowledgements Dedication Case 1 History What is your differential diagnosis? Physical examination Does this narrow your differential diagnosis? Investigations What other blood tests would you order? What do these laboratory data suggest? What imaging test would you order? Please describe what you see How would you proceed? What is your differential diagnosis for necrotising lymphadenitis? Infection Autoimmune Malignancy What is the diagnosis, and how would you proceed? Clinical pearls Impress your attending What virus is implicated as a possible cause for NK/T-cell lymphoma? What is the prevalence of extranodal NK/T-cell lymphomas in East Asia? What is the prognosis of non-nasal NK/T-cell lymphoma? What do you know about the SMILE regimen? References Case 2 History Physical examination Investigations What is your differential diagnosis? What other blood tests would you order? What do these laboratory data suggest? What other tests would you order? What imaging test would you order? Please describe what you see What is your diagnosis, and how would you proceed? What would you do next? Please describe what you see What is your differential diagnosis? How would you manage this patient? Clinical pearls Impress your attending How common is tuberculosis of the intestinal tract? What are the risk factors for tuberculosis of the intestinal tract? What is the presentation of intestinal tuberculosis? What is the duration of anti-tuberculosis treatment if the gut is affected? Do you know of any new drugs for the treatment of tuberculosis? References Case 3 History What is your differential diagnosis? Physical examination Does this narrow your differential diagnosis? What diagnosis does the physical examination suggest? Investigations What other blood tests would you order? What do these laboratory data suggest? How would you proceed? Please describe what you see What imaging test would you order? Please describe what you see What is the diagnosis, and how would you proceed? What is the next step? Clinical pearls Impress your attending What is the definition of a granuloma? How would you distinguish between Crohn’s disease and ITB (Table 3.1)? References Case 4 History Physical examination Investigations What is your differential diagnosis? What other tests would you order? How would you assess the severity of the flare? How would you manage his flare? How would you proceed? What is the first-line management? What other medical rescue therapies are available for a steroid-refractory ulcerative colitis flare? How would you proceed? Please describe what you see Clinical pearls Impress your attending What precautions are necessary to prevent the spread of the Clostridium difficile infection? References Case 5 History Physical examination Investigations What are the possible causes of his fever given his history of Crohn’s? What further investigations would you perform? Please describe what you see Later on, the ZN stain shows acid-fast bacilli. How would this affect your management? Clinical pearls Impress your attending How would you screen for TB? What are the possible causes of a false-negative Mantoux test? What can cause a false-positive Mantoux test result? What is the performance of interferon-. release assays in the diagnosis of latent TB (Table 5.1)? What would be your approach if the patient has latent tuberculosis? What are the potential side effects from the therapy? References Case 6 History Physical examination What is your differential diagnosis? What blood test(s) would you order? What further investigations would you order? Please describe what you see Does this narrow your differential diagnosis? In colonoscopy, what are the features suggestive of Behçet’s disease? On histological examination, what is the important feature that differentiates Crohn’s from Behçet’s disease? What is a pathergy test and how would you perform it? What other skin manifestations may be seen in Behçet’s disease? What are the diagnostic criteria for Behçet’s disease? What are the treatment options for Behçet’s disease? Clinical pearls Impress your attending How frequent are GI symptoms in patients with Behçet’s disease? References Case 7 History Physical examination Please describe what you see Investigations What are the potential causes for the skin lesions? How would you manage this patient? What further investigations would you request? Please describe what you see Clinical pearls Impress your attending What is pancreatic panniculitis? Which pancreatic malignancy is most strongly associated with the development of pancreatic panniculitis? What is Schmid’s triad? References Case 8 History Physical examination Please describe what you see Investigations What is your differential diagnosis? What would you do next? Please describe what you see What is the most compatible diagnosis? Clinical pearls Impress your attending What are the systemic diseases associated with pyoderma gangrenosum? How would you manage this patient? What other extra-intestinal manifestations (EIM) of inflammatory bowel disease do you know of? References Case 9 History Physical examination Investigations What is your differential diagnosis? What further investigations would you arrange? Please describe what you see Does this narrow your differential diagnosis? How would you treat this patient? Please describe what you see What is the final diagnosis? Clinical pearls Impress your attending What organ systems can be affected by IgG4-related disease (Table 9.1)? What is the treatment for IgG4-related disease? Do you know of any new biomarkers under investigation for the use in IgG4-related disease? References Case 10 History Physical examination Investigations Please describe what you see What is the likely diagnosis? How would you manage this patient? Clinical pearls Impress your attending What C. difficile toxins do you know of? What is the incidence of Clostridium difficile-associated disease? What are the risk factors for CDAD? How would you distinguish between non-severe and severe (fulminant) CDAD (Table 10.1)? How would you manage patients with CDAD (Figures 10.2 and 10.3)? Is there any evidence supporting the use of faecal microbiota transplantation (FMT) for recurrent CDAD? References Case 11 History Physical examination Investigations What is your differential diagnosis? What would you do next? Please describe what you see What is the working diagnosis? What would you do next? Clinical pearls Impress your attending What is the nature of the pain in this condition? What are the causes of haemosuccus pancreaticus? References Case 12 History Physical examination Investigations What is your working diagnosis? How would you proceed? Please describe what you see What would be the next step of management? What therapy was given to this patient? Clinical pearls Impress your attending What are the risk factors for HCC? What tests are used as surveillance for HCC in at-risk populations? Do you know of any newer biomarkers? How is HCC staged? In patients with HCC and cirrhosis, which patients are generally deemed suitable for the consideration of liver transplantation? What chemotherapeutic agents are injected during a session of TACE? What is post-embolisation syndrome? References Case 13 History Physical examination Investigations What would you do next? Please describe what you see How would you treat this patient? Clinical pearls Impress your attending What are the limitations of CA 19-9? Do you know of any poor prognostic factors for pancreatic cancer? What is the prognosis of pancreatic adenocarcinoma? What would be the choice of chemotherapy after curative resection? References Case 14 History Physical examination Investigations How would you manage this lady? What is your differential diagnosis for the mass? What imaging test would you order next? Please describe what you see What further investigations would you request? Please describe what you see What is your diagnosis? What would be your next step? Clinical pearls Impress your attending What do you know about the genetics of neurofibromatosis Type 1? What are the gastrointestinal manifestations of neurofibromatosis Type 1? How would you treat GISTs? What are good prognostic factors for GIST recurrence after surgery? Is there a role for adjuvant imatinib? How would you decide the timing of resumption of anticoagulation? References Case 15 History Physical examination Investigations What would you do next? Please describe what you see What is your differential diagnosis? How would you proceed? Please describe what you see What would you do next? Please describe what you see What is your final diagnosis? Clinical pearls Impress your attending What is the postulated pathogenesis of extranodal marginal zone lymphoma of MALT (MALT lymphoma)? What are the possible aetiologies for the development of gastric and small bowel lymphoma? What are the latest developments in the treatment of MALT lymphoma? References Case 16 History Physical examination Investigations Please describe what you see What is your differential diagnosis? What further investigations would you arrange? Please describe what you see How would you proceed? Please describe what you see What is your final diagnosis? Clinical pearls Impress your attending What cells are responsible for endocrine function in the pancreas? What are the syndromes related to this disease? How are neuroendocrine tumours graded? What are the treatment options for neuroendocrine tumours? References Case 17 History Physical examination Investigations What is your differential diagnosis? What other investigations would you perform? How would you proceed? Please describe what you see What is the likely diagnosis? Clinical pearls Impress your attending What are the types of AIH (Table 17.2)? Which histopathological features are typical of AIH? Management of this condition Immunosuppressants Screening for malignancy What is post-infantile giant cell hepatitis? How long should immunosuppressants be given in patients with AIH? References Case 18 History Physical examination Investigations How would you proceed? Please describe what you see What is your diagnosis? Clinical pearls Impress your attending What is the histology of GAVE? What other diseases is this condition associated with? How would you treat this patient? Is APC effective in the treatment of GAVE? What are the complications of APC? References Case 19 History Physical examination Investigations What is your clinical diagnosis? What further investigations would you request? Please describe what you see What would be your next step? How would you proceed? What would be your next step of management? Please describe what you see Clinical pearls Impress your attending What are the risk factors for stomach cancer? How would you treat stomach cancer? What is trastuzumab? What are the newer modalities of treatment on the horizon for advanced gastric cancer? References Case 20 History Physical examination Investigations Please describe what you see What is your differential diagnosis? What further investigations may be helpful? What is the likely diagnosis? Clinical pearls Impress your attending What is the postulated pathogenesis in chronic intestinal pseudo-obstruction? How would you classify the causes of CIPO (Table 20.1)? What is Hirschsprung’s disease? References Case 21 History Physical examination Investigations What would you do next? Please describe what you see What is your differential diagnosis? How would you proceed? Clinical pearls Impress your attending Which gene is affected in FAP? How is classic FAP diagnosed? Which types of multiple colorectal adenoma syndromes do you know of? Classic FAP (>100 adenomas) Attenuated FAP MYH-associated polyposis What are the clinical presentations of classic FAP? Which eponymous syndromes are related with FAP? What are the latest recommendations for colorectal cancer (CRC) screening for patients with FAP? References Case 22 History Physical examination Investigations What other physical examinations would you like to perform? What further investigations would you request? Please describe what you see How would you manage this gentleman? Please describe what you see Clinical pearls Impress your attending Are there any specific foreign bodies where endoscopic removal should not be attempted, and why? What factors would you take into account when considering timing of endoscopy? References Case 23 History Physical examination Investigations What is your working diagnosis? How would you proceed? What would you do next? Please describe what you see What would be your diagnosis? Clinical pearls Impress your attending What are the typical cholangiographic findings? How would you manage these patients in the long term? References Case 24 History Physical examination Investigations What is your differential diagnosis? What would you do next? Please describe what you see What is the likely diagnosis? Clinical pearls Impress your attending What is the definition of polycystic liver disease? What are the genetic diseases and corresponding genes associated with this condition? What are the risk factors for the growth of liver cysts? What are the treatment strategies that can be implemented for symptomatic PCLD? Do you know of any pharmacological options that may be useful in this condition? References Case 25 History Physical examination Investigations Please describe what you see What is your differential diagnosis? How would you proceed? Please describe what you see Does this narrow the differential? What would you do next? What is the final pathological diagnosis? Please describe what you see What is your final diagnosis? Clinical pearls Impress your attending How would you interpret cyst fluid analysis in pancreatic cysticlesions (Table 25.1)? When is resection indicated for pancreatic cystic lesions? References Case 26 History Physical examination Investigations What further investigation would you perform? Please describe what you see What would you do next? Please describe what you see How would you proceed? Please describe what you see How would you manage this patient? Clinical pearls Impress your attending What is the prognosis of oesophageal carcinoma? What is trimodality therapy? Are there any promising therapies on the horizon that you know of? References Case 27 History Physical examination Investigations What is your differential diagnosis for her dysphagia? What other tests will you order? Please describe what you see How would you manage the acute medical condition? After stabilisation, what would be the next investigation for her dysphagia? What further investigation should be performed? Please describe what you see What are the treatment options for achalasia? Clinical pearls Impress your attending What are the causes of pseudoachalasia? What is POEM? What is the performance of POEM compared with that of a Heller myotomy? References Case 28 History Physical examination Investigations What is your differential diagnosis? What would you do next? How would you proceed? Please describe what you see How would you proceed endoscopically? What would you do next? Clinical pearls Impress your attending What are the common organisms implicated in acute cholangitis? What are the treatment options for large biliary stones which fail conventional techniques? How is mechanical lithotripsy performed? What is the limitation of mechanical lithotripsy? How is electrohydraulic lithotripsy performed? How is cholangioscopic-guided laser lithotripsy performed? References Case 29 History Physical examination Investigations What is your differential diagnosis? What are the causes of elevated serum amylase? How would you make a diagnosis of acute pancreatitis? What are the causes of acute pancreatitis? How would you further investigate the patient to elucidate the aetiology? Calculate the Ranson score of this patient Please describe what you see How would you manage this patient? Clinical pearls Impress your attending What is the predictive value of the Ranson score? How would you classify acute pancreatitis? References Case 30 History Physical examination Investigations What is the differential diagnosis of jaundice? What is the pattern of liver function abnormality? Does this narrow down your differential diagnosis? What is Courvoisier’s law? What are the exceptions to Courvoisier’s law? What further imaging would you order? Please describe what you see What condition is associated with ampullary adenoma? How would you proceed further regarding the management of the ampullary adenoma? Clinical pearls Impress your attending What is the success rate of endoscopic papillectomy for ampullary adenoma? What are the factors predicting the success of papillectomy? References Case 31 History Physical examination Investigations What is your differential diagnosis? Would you arrange an oesophagogastroduodenoscopy (OGD) for this patient? Please describe what you see How would you report the Prague classification in this case? How would you take biopsies? How would you further manage the patient? Clinical pearls Impress your attending What is the definition of Barrett’s oesophagus? Is universal screening for Barrett’s oesophagus recommended? If not, who should be screened? Would the presence of oesophagitis affect your management in a patient with Barrett’s oesophagus? Is surveillance endoscopy recommended for patients with confirmed Barrett’s oesophagus? What is the risk for cancer in patients with high-grade dysplasia in Barrett’s oesophagus? How would you manage patients who have biopsy-confirmed Barrett’s oesophagus with high-grade dysplasia? What is the role of EMR in the treatment of high-grade dysplasia in Barrett’s oesophagus after EUS assessment? References Case 32 History Physical examination Investigations What is the differential diagnosis? How would you investigate the patient further? Please describe what you see What is the most likely diagnosis? How would you manage this patient? How would you advise your patient to reduce the risk of recurrence of oesophageal candidiasis? Clinical pearls Impress your attending What is the predictive value of oral candidiasis for oesophageal candidiasis in immunocompromised patients? What is the prevalence of oesophageal candidiasis among patients treated with inhaled corticosteroids? References Case 33 History Physical examination Investigations What is your differential diagnosis? What further investigations would you perform? Please describe what you see What is the most likely diagnosis? What are the causes of chronic pancreatitis? What further testing would you perform to find out the aetiology? How would you manage the patient? Clinical pearls Impress your attending Which of the causes of chronic pancreatitis are associated with pancreatic calcifications? Why is hypoglycaemia common in patients with chronic pancreatitis? How should chronic pancreatitis associated with a dominant stricture of the main pancreatic duct be managed? How should pancreatic stones associated with chronic pancreatitis be managed? References Case 34 History Physical examination Investigations What are the risk factors for colorectal neoplasm in this patient? In general, when should colorectal cancer screening commence? What are the sensitivities of colorectal cancer screening tests? In view of the positive family history with one first-degree relative affected at age