Clinical Challenges & Images in Gastroenterology: A Diagnostic Guide

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 <60, screening is offered. What screening test would you recommend for this patient?
		Please describe what you see
	In addition to white light endoscopic assessment, what further technique can be employed to characterise the lesion?
		Please describe what you see
	What would you do next?
	Clinical pearls
	Impress your attending
		What is CEA? Would you recommend checking CEA in this patient?
		What is ESD? What are the common complications?
		What are the rates of possible complications of colorectal ESD?
	References
Case 35
	History
	Physical examination
	Investigations
	What is your differential diagnosis?
	What further investigations would you order?
		Please describe what you see
	What treatment should be given next?
	Supportive transfusion is given. What is the target level of haemoglobin?
	What would you do next?
		Please describe what you see
	A rapid urease test (RUT) was negative at the index endoscopy. Does the patient require additional testing for Helicobacter pylori?
	How would you advise the patient on the use of NSAIDs in the future?
	Clinical pearls
	Impress your attending
		What is the role of Hemospray® in the treatment of upper gastrointestinal bleeding?
	References
Case 36
	History
	Physical examination
	Investigations
	What is the differential diagnosis?
	How would you assess the severity of the liver failure?
	How would you perform the work-up for the cause of the liver failure?
	With the above information, what is the most likely cause of the liver failure?
	What should be done next?
	Clinical pearls
	Impress your attending
		What is the definition of occult hepatitis B?
		What is the risk of hepatitis B reactivation in patients with occult hepatitis B (HBsAg-negative, anti-HBc-positive) receiving rituximab?
		What is the current recommendation of antiviral prophylaxis in patients receiving immunosuppressive therapy?
		What is the preferred agent to be used?
		How long should antiviral prophylaxis be continued for?
	References
Case 37
	History
	Physical examination
	Investigations
	What is your differential diagnosis of his epigastric discomfort?
	What would be the next investigation?
		Please describe what you see
	What are the different diagnostic tests for Helicobacter pylori?
	What will affect the accuracy of a urea breath test?
	What would be your next step in the management of this patient?
	What are the first-line regimens of Helicobacter pylori eradication?
	What is the recommended dosing for a PPI in a Helicobacter pylori eradication regime?
	What are the potential side effects of clarithromycin?
	Clinical pearls
	Impress your attending
		What are the possible ways to increase the efficacy of PPI clarithromycin-containing triple therapies?
		What is sequential therapy?
		What is rifabutin? What is the potential role of rifabutin in Helicobacter pylori eradication?
		What are the side effects of rifabutin?
	References
Case 38
	History
	Physical examination
	Investigations
	What is the differential diagnosis of microcytic anaemia?
	What are the typical features of the CBC and iron profile for the possible causes of microcytic anaemia?
	With the above results, what is the most likely cause of microcytic anaemia in this patient?
	What would be the next investigation?
	What should be done next?
	What would you do next?
		Please describe what you see
	What is the treatment for tapeworm infection?
	Clinical pearls
	Impress your attending
		What are the common capsule endoscopic findings in patients with unexplained iron deficiency anaemia after a negative OGD and colonoscopy?
		What are the different types of tapeworm infection?
		What is the epidemiology of tapeworm?
		What do you know about the life cycle of tapeworms?
	References
Case 39
	History
	Physical examination
	Investigations
	What is your differential diagnosis?
	What further history would you enquire?
	What further blood tests would you order for the workup of the underlying aetiology of deranged liver function?
	What other tests would you order?
		Please describe what you see
	What is the most likely unifying diagnosis?
	Clinical pearls
	Impress your attending
		What is ketamine?
		What are the effects of ketamine?
		What is the mechanism of biliary injury by ketamine?
		What is the prevalence of liver dysfunction in ketamine abusers?
		What other potential damage is caused by ketamine misuse?
	References
Case 40
	History
	Physical examination
	Investigations
	What is the differential diagnosis of per rectal bleeding?
	What is the next investigation?
	What should be done next?
	What is the sensitivity of a 99mTc-pertechnetate Meckel’s scan?
		Please describe what you see
	What is your diagnosis?
	Clinical pearls
	Impress your attending
		What is a Meckel’s diverticulum?
		What is the ‘rule of two’ in Meckel’s diverticulum?
		What is the complication rate and the most common complication of a Meckel’s diverticulum?
		What are the causes of false-positive and false-negative results of 99mTc-pertechnetate Meckel’s scans in patients with a Meckel’s diverticulum?
	References
Case 41
	History
	Physical examination
	Investigations
	What are the common causes of increased ALP?
	How would you evaluate the origin of ALP?
		Please describe what you see
	What is the most likely diagnosis, given the background of the patient?
	In addition to cholangiocarcinoma, what are the other cancers that the patient is at risk of?
	Clinical pearls
	Impress your attending
		What is the association of PSC with IBD?
		What are the characteristics of IBD in patients with PSC?
		What is the role of ursodeoxycholic acid in the treatment of PSC?
	References
Case 42
	History
	Physical examination
	Investigations
	What is your differential diagnosis specific to her situation?
	What other tests would you request?
		Please describe what you see
	What is the diagnosis?
	What is a pseudocyst?
	What is the risk of pancreatic fluid collection progressing into the formation of pseudocysts after an episode of pancreatitis?
	Which type of pseudocyst can be managed conservatively?
	What are the possible complications of a pseudocyst?
	In view of the large size of the pseudocyst and the complication (abdominal pain), drainage of the cyst is warranted. What are the possible ways of drainage?
	Clinical pearls
	Impress your attending
		What is the efficacy of endoscopic as compared with surgical cystogastrostomy?
		Is antibiotic prophylaxis needed before EUS-guided pseudocyst drainage?
	References
Case 43
	History
	Physical examination
	Investigations
	What are the possible causes of generalised abdominal distension?
	What are the organic causes of constipation?
		Please describe what you see
	Given the history and the imaging findings, what is the diagnosis?
	What is the management?
	Clinical pearls
	Impress your attending
		What is the pathophysiology of stercoral proctitis?
	References
Case 44
	History
	Physical examination
	Investigations
	What further investigations would you request?
		Please describe what you see
	What is your differential diagnosis?
	What would you do next?
		Please describe what you see
	How would you treat this patient?
	Clinical pearls
	Impress your attending
		What would be a possible cause for this patient’s immunosuppressed state?
		What is Good’s syndrome?
		How would you minimise the risk of recurrent infection?
	References
Case 45
	History
	Physical examination
	Investigations
	What is your differential diagnosis of his epigastric discomfort?
		Please describe what you see
	What is the differential diagnosis?
	Which of the above is more likely, and why?
	How would you differentiate ectopic pancreas from the other differential diagnoses?
	What is the appearance of an ectopic pancreas on EUS?
	What is the role of EUS-guided fine needle aspiration (FNA) or endoscopic removal of lesions in the diagnosis?
	How would you manage this patient?
	Clinical pearls
	Impress your attending
		What is an ectopic pancreas?
		What are the common sites for an ectopic pancreas?
		What are the possible complications of an ectopic pancreas?
	References
Case index
Index
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