50 Gastrointestinal Cases and Associated Imaging

156 Pages·2013·5.5 MB·English

by  Abdullah A. Shaikh

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Medical students and junior doctors are integral to the healthcare system. On an academic 5
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gastroenterology service, they often initially evaluate patients before the arrival of the consulting physician. a
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For all clinical specialties, acquisition of medical knowledge is required to gain expertise. Several resources are
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available for this purpose, including textbooks and evidence‐based articles. This highly illustrated book, st
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inspired by patient care, offers a fresh approach to clinical teaching. l
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50 Gastrointestinal Cases and Associated Imagingcontains a gamut of cases for which gastroenterologists n
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are commonly consulted in the hospital and outpatient settings. Each case is presented from the initial history s
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and work‐up, including imaging (various modalities, including endoscopy), followed by a brief discussion on ia
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d CASES AND ASSOCIATED IMAGING
management. Questions are presented to the reader in each case, immediately followed by the answer. Since

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each case is unique, the pertinent teaching points are tested in a question format within the case narrative. g
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Similar to real‐life scenarios, this helps the reader retain the most important information.
Why buy this book? Unlike most review texts that just list the facts, this volume integrates teaching points
into realistic clinical cases. Medical students through to residents or registrars in internal medicine, emergency
medicine, gastroenterology and surgery will benefit from reading the cases presented. Secondary audiences
include radiologists who want to understand the presentation of common gastrointestinal cases, and general
practitioners and nurses who are looking for a unique teaching tool and a way to review imaging. Finally, this
book will make an excellent prerequisite for any individual prior to starting a gastroenterology rotation.
Abdullah A. Shaikh
Syed M. Hussain
David J. Desilets
ISBN 978-1-903378-85-4 Tara M. Catanzano
tfm
9 781903 378854
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50
GASTROINTESTINAL
CASES AND ASSOCIATED IMAGING
Abdullah A. Shaikh
Syed M. Hussain
David J. Desilets
Tara M. Catanzano
i
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50 Gastrointestinal Cases and Associated Imaging
tfm Publishing Limited
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Harley
Shrewsbury
SY5 6LX
UK
Tel: [phone]
Fax: [phone]
E-mail: [email protected]
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Design and layout: Nikki Bramhill BSc (Hons) Dip Law
First Edition © 2013
Paperback ISBN: 978-1-903378-85-4
E-book editions: 2013
ePub ISBN: 978-1-908986-96-2
Mobi ISBN: 978-1-908986-97-9
Web pdf ISBN: 978-1-908986-98-6
The entire contents of 50 Gastrointestinal Cases and Associated Imagingis copyright tfm Publishing Ltd. Apart
from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the
Copyright, Designs and Patents Act 1988, this publication may not be reproduced, stored in a retrieval system or
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Whilst every care is taken by the authors and the publisher to ensure that all information and data in this book are
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The authors and publisher gratefully acknowledge the permission granted to reproduce the copyright material
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notified of any corrections that should be incorporated in future reprints or editions of this book.
Printed by Gutenberg Press Ltd., Gudja Road, Tarxien, PLA 19, Malta.
Tel: [phone]; Fax: [phone].
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Contents
Page number
v
Foreword
vi
Abbreviations
1
Case 1
4
Case 2
7
Case 3
9
Case 4
12
Case 5
15
Case 6
18
Case 7
22
Case 8
25
Case 9
28
Case 10
31
Case 11
34
Case 12
37
Case 13
40
Case 14
43
Case 15
45
Case 16
48
Case 17
50
Case 18
53
Case 19
56
Case 20
59
Case 21
62
Case 22
iii
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50 Gastrointestinal Cases and Associated Imaging
65
Case 23
68
Case 24
72
Case 25
75
Case 26
78
Case 27
81
Case 28
83
Case 29
85
Case 30
89
Case 31
91
Case 32
95
Case 33
98
Case 34
101
Case 35
104
Case 36
106
Case 37
109
Case 38
112
Case 39
115
Case 40
119
Case 41
122
Case 42
125
Case 43
128
Case 44
130
Case 45
133
Case 46
135
Case 47
137
Case 48
139
Case 49
142
Case 50
145
Index
iv
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Foreword
This book is a unique collaborative effort from physicians trained in medicine, gastroenterology, and radiology. It
is the brainchild of two former internal medicine residents: Abdullah Shaikh and Syed Hussain. Abdullah is currently
a radiology resident with an interest in gastrointestinal imaging, and Syed is a GI fellow specializing in hepatobiliary
disease. This book would not have been possible without the mentorship of David Desilets, who has kept a stack
of interesting endoscopic images and cases over several decades, and provided expert guidance and oversight.
Tara Catanzano, a radiologist with a multispecialty imaging background, provided expertise and was an integral part
of this project. Incidentally, three of the authors are graduates of the Royal College of Surgeons in Ireland, and have
incorporated aspects of their Irish education into this book.
We hope that you, the reader, will fall in love with GI imaging as we have done. Perhaps it will spark your interest
in GI diseases. Each individual case stands alone, requires no other chapter to support it, and provides a few
clinical pearls that may come in handy on rounds. The book will possibly help you in caring for your patients, or will
be recalled with a smile when you are sitting for board exams. The cases are best read one at a time, in your spare
time, so that a few clinical pearls will be absorbed once in a while. It is not a textbook or reference book. We hope
you will learn that the approach to GI illnesses involves a synthesis of all the available data: historical, physical,
radiographic, laboratory, and endoscopic. Putting this information together to solve the patient’s puzzle is what’s so
fun about medicine in general, and gastroenterology in particular.
Abdullah A. Shaikh MD
Department of Medicine and Radiology
Baystate Medical Center/Tufts University
Springfield, Massachusetts, USA
Syed M. Hussain MD MRCS
Department of Medicine
University of Cincinnati
Cincinnati, Ohio, USA
David J. Desilets MD PhD
Department of Medicine
Baystate Medical Center/Tufts University
Springfield, Massachusetts, USA
Tara M. Catanzano MD
Department of Radiology
Baystate Medical Center/Tufts University
Springfield, Massachusetts, USA
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Abbreviations
ABD abdomen
ABG arterial blood gas
ALT alanine transaminase
AMA anti-mitochondrial antibody
ANA anti-nuclear antibody
ASA American Society of Anesthesiologists
AST aspartate transaminase
bHCG b-human chorionic gonadotrophin
BP blood pressure
BUN blood urea nitrogen
CA 19.9 carbohydrate antigen 19.9
CBC complete blood count
CHEM-6 chemistry 6
CHEM-7 chemistry 7
CK-MB creatine kinase-MB
Cl chloride
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CRP C-reactive protein
CT computed tomography
CVS cardiovascular
DEXA dual-energy X-ray absorptiometry
EGD esophagogastroduodenoscopy
EKG electrocardiogram
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
EXT extremities
GEN general
GGT g-glutamyl transferase
GI gastrointestinal
H+N head and neck
HAART highly active antiretroviral therapy
HbA1c glycated hemoglobin
HEENT head, eyes, ears, nose, throat
HIDA hepatobiliary iminodiacetic acid
HIV human immunodeficiency virus
HR heart rate
Ig immunoglobulin
INR international normalized ratio
IV intravenous
K potassium
LDH lactate dehydrogenase
LFT liver function test
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Abbreviations
MCV mean corpuscular volume
MRCP magnetic resonance cholangiopancreatography
MRI magnetic resonance imaging
MSK musculoskeletal
Na sodium
NSAID non-steroidal anti-inflammatory drug
p-ANCA perinuclear anti-neutrophil cytoplasmic antibodies
PET positron emission tomography
RA room air
RBC red blood cell
RESP respiratory
TSH thyroid-stimulating hormone
WBC white blood cell
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50 Gastrointestinal Cases and Associated Imaging
viii
cases 1-10_cases 1-10.qxd 11-05-2013 00:29 Page 1
Case 1
A 44-year-old woman presents to the emergency room with right upper quadrant pain. The pain began about 20
minutes after eating dinner. It is described as a "shooting pain" that is constant, radiates to her back, and is 6/10 in
intensity. The pain is worse on deep inspiration, and a tablet of oxycodone offers some relief. She denies nausea or
vomiting. Her bowel movements are regular. She has never had this pain before.
What is your differential diagnosis? What blood test(s) will you order?
The differential diagnosis includes cholelithiasis, 267 units/L
LFTs AST
acute cholecystitis, pancreatitis, gastritis, peptic ulcer 285 units/L
ALT
disease, gastric volvulus, and intussusception. 262 units/L
Alkaline phosphatase
3.6mg/dL
Total bilirubin
Physical examination
What is the pattern of the elevated LFTs?
Afebrile, HR 88 bpm, BP 130/78mmHg,
Vitals
oxygen saturation 99% on RA.
Elevated LFTs usually suggest either a
No distress.
GEN hepatocellular process or an obstructive (or
No scleral icterus.
HEENT cholestatic) process. A cholestatic process presents
Normal S1, S2. No murmurs, rubs, or
CVS with elevated alkaline phosphatase and elevated total
gallops.
bilirubin levels. With the passage of a gallstone
Clear to auscultation.
RESP
through the common bile duct, ALT may be the first
Soft and non-tender. No rigidity, guarding, or
ABD
measure to appear abnormal.
rebound tenderness. Bowel sounds are
normal. Rectal examination reveals an empty
vault.
No edema. What other blood tests will you order?
EXT
CBC, CHEM-7, and bHCG.
Does this narrow your differential diagnosis?
All are within normal limits.
Yes. Volvulus and intussusception can be removed
from the differential diagnosis, as bowel sounds are
altered in these clinical settings.
1