Table Of ContentGastroenterology
CLINICAL CASES UNCOVERED
Gastroenterology
CLINICAL CASES UNCOVERED
Satish Keshav
MBBCh (Wits), DPhil (Oxon), FRCP (London)
Consultant Gastroenterologist and Honorary
Senior Lecturer
Translational Gastroenterology Unit
Nuffi eld Department of Medicine
John Radcliffe Hospital
Oxford
Emma Culver
MBChB, BSc (Hons), MRCP
Gastroenterology Registrar and Academic
Research Fellow
Gastroenterology Department
Nuffi eld Department of Medicine
John Radcliffe Hospital
Oxford
A John Wiley & Sons, Ltd., Publication
This edition fi rst published 2011 © 2011 by Satish Keshav and Emma Culver
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Library of Congress Cataloging-in-Publication Data
Keshav, Satish.
Gastroenterology / Satish Keshav, Emma Culver.
p. ; cm. – (Clinical cases uncovered)
Includes bibliographical references and indexes.
ISBN 978-1-4051-6975-2 (pbk. : alk. paper)
1. Gastroenterology–Case studies. 2. Digestive organs–Diseases–Case studies. I. Culver,
Emma. II. Title. III. Series: Clinical cases uncovered.
[DNLM: 1. Digestive System Diseases–diagnosis–Case Reports. 2. Digestive System Diseases–
diagnosis–Problems and Exercises. WI 18.2]
RC808.K47 2011
616.3΄3–dc22
2010039153
Set in 9/12 pt Minion by Toppan Best-set Premedia Limited
1 2011
Contents
Preface, vii
How to use this book, viii
List of abbreviations, ix
Part 1
Basics, 1
Basic science, 1
Approach to the patient, 14
Part 2
Cases, 29
Upper gastrointestinal
Case 1 A 61-year-old woman with progressive dysphagia, 29
Case 2 A 52-year-old man with atypical chest pain, 34
Case 3 A 57-year-old woman with upper abdominal discomfort, 40
Case 4 A 36-year-old man with upper abdominal discomfort
and heartburn, 45
Case 5 A 27-year-old woman with nausea and vomiting, 51
Case 6 A 73-year-old man with haematemesis and melaena, 56
Case 7 A 68-year-old woman with fatigue, weight loss and altered
bowel habit, 63
Lower gastrointestinal
Case 8 A 23-year-old woman with constipation, 69
Case 9 A 24-year-old woman with chronic diarrhoea, 74
Case 10 A 51-year-old woman with acute nausea, vomiting and diarrhoea, 80
Case 11 A 79-year-old woman with altered bowel habit and weight loss, 85
Case 12 A 54-year-old man with rectal bleeding, 90
Case 13 A 66-year-old woman with anaemia, 95
v
vi Contents
Liver disease
Case 14 A 64-year-old man with abnormal liver function tests, 100
Case 15 A 45-year-old man with acute jaundice, 109
Case 16 A 53-year-old woman with jaundice and abnormal liver tests, 115
Case 17 A 53-year-old man with abdominal swelling, 120
Case 18 A 36-year-old man who drinks alcohol, 125
Biliary and pancreatic disease
Case 19 A 79-year-old man with right upper quadrant colicky
abdominal discomfort, 131
Case 20 A 19-year-old man with acute abdominal pain, 136
Nutrition
Case 21 A 35-year-old woman with anorexia, 143
Case 22 A 48-year-old man with an increased body mass index, 148
Functional disorders
Case 23 A 21-year-old student with chronic abdominal pain, 153
Part 3
Self-assessment, 159
MCQs, 159
EMQs, 162
SAQs, 166
Answers, 167
Further reading, 173
Index of cases by diagnosis, 175
Index, 177
The colour plate section can be found facing p.54.
Preface
Clinical gastroenterology is both simple and complex.
The simplicity comes from the fi nite number of diag-
noses that are commonly encountered, and the relatively
limited number of symptoms that typically indicate
disease of the gastrointestinal system. However, there
are hidden depths to the practice of the speciality.
Gastroenterologists deal with disease affecting many
separate organs that all form part of the same system –
the liver, pancreas, stomach, etc. The clinical conse-
quences of some diseases can be dramatic and complex,
particularly, for instance, dysfunction of the liver.
Symptoms such as abdominal pain, altered bowel func-
tion and changes in weight can be combined in myriad
ways to pose true clinical puzzles. This book aims
to guide the reader through this complexity by offer-
ing real case studies and showing how, in practice,
clinicians can achieve some degree of clarity, and
offer to patients a reasonable diagnostic and thera-
peutic plan.
In the fi rst section, the book offers a basic and brief
overview of anatomical, physiological and pharmacologi-
cal facts that inform our thinking about gastroenterologi-
cal problems, and suggests how best to approach the
patient in the second chapter. Thereafter, in the second
section, each chapter deals with presenting symptoms
and signs and the subsequent chapters are arranged in six
sections to cover disease processes affecting the upper
gastrointestinal tract, lower gastrointestinal tract, liver,
pancreas and biliary tract, nutrition, and so - called func-
tional bowel disorders. These are important and often
overlooked because there is a profound lack of under-
standing about their pathogenesis. However, there are
many patients with irritable bowel syndrome and the
like, and a robust and reliable clinical approach to treat-
ing them is essential.
In each of the symptom - or sign - based chapters,
the emphasis is on clinical reasoning and strategy, and
the reader will have an opportunity to examine how the
many possible paths are in practice negotiated to reach a
diagnosis and formulate a plan for managing the situa-
tion. Exact doses and tests are de - emphasised, while strat-
egies, categories and context are highlighted, all within
the framework of dealing with the particular human
patient whose predicament is being examined.
Boxes and lists are strategically placed to aid memory
and recall, and to emphasise key facts. The last section,
which comprises a set of questions to test understanding,
is based on the contents of each chapter, and the empha-
sis in these is on core knowledge rather than the esoteric
or arcane.
Writing this book has proved to be an education as well
being hugely enjoyable, and our hope is that the reader
too will gain knowledge and understanding of the com-
plexity of gastroenterological medicine, whilst acquiring
some practical understanding of how to approach the
patient with gastrointestinal problems, and some sense of
satisfaction and fun. The typical reader might be a
medical or nursing student in their clinical years, or a
doctor in training, either in their foundation years or in
early speciality training. The book will be useful as pre-
paratory reading before joining the gastroenterology fi rm
in a clinical rotation, or as an aid to revision before
written and clinical examinations.
Satish Keshav
Emma Culver
vii
How to u se t his b ook
Clinical Cases Uncovered (CCU) books are carefully
designed to help supplement your clinical experience and
assist with refreshing your memory when revising. Each
book is divided into three sections: Part 1, Basics; Part 2,
Cases; and Part 3, Self - assessment.
Part 1 gives you a quick reminder of the basic science,
history and examination, and key diagnoses in the area.
Part 2 contains many of the clinical presentations you
would expect to see on the wards or to crop up in exams,
with questions and answers leading you through each
case. New information, such as test results, is revealed as
events unfold and each case concludes with a handy case
summary explaining the key points. Part 3 allows you to
test your learning with several question styles (MCQs,
EMQs and SAQs), each with a strong clinical focus.
Whether reading individually or working as part of a
group, we hope you will enjoy using your CCU book. If
you have any recommendations on how we could improve
the series, please do let us know by contacting us at:
