Gastroenterology Case Studies: Diagnosis & Therapeutic Strategies

1. OSCE Raika Jamali M.D. Gastroenterologist and hepatologist Sina hospital Tehran University of Medical Sciences

2. Case47 An old man presented with mild RUQ pain without jaundice.

3. What is your diagnosis? • Porcelin gall bladder • Gall bladder abcess • Acute cholecystitis • Hydatid cyst • What is the best initial therapeutic strategy? • Metronidazole and ciprofloxacin • Cholecystectomy • Albendazole

4. Case 48 • A young man presented with jaundice, fever and RUQ pain.

5. What is your diagnosis? • Porcelin gall bladder • Gall bladder abcess • Biliary leak • Primary sclerosing colangitis • What is the best initial therapeutic strategy? • Metronidazole and ciprofloxacin • Steroid and azathioprine • Ursodeoxycholic acid

6. Case 49 • A young man presented with generalized edema.

7. What is your diagnosis? • Celiac disease • MALTOMA • Intestinal lymphangiectasis • What is the best initial therapeutic strategy? • Metronidazole and ciprofloxacin • Steroid and azathioprine • MCT oil

8. Case 50 • A middle age woman with RUQ pain from 6 months ago and normal findings in physical examination. • Hx of OCP use for 7 years. • You see the hepatic angiography of the patient in next slide.

10. What is your diagnosis? • Focal nodular hyperplasia • Hemangioma • Adenoma • Hepatocellular carcinoma • What is the best initial therapeutic strategy? • Metronidazole and ciprofloxacin • Steroid and azathioprine • Discontinuation of OCP • Surgical removal

11. Case 51 • A middle age man presented with abdominal pain, weight loss and depression. • Tenderness in epigastrium was detected. • You see the CT scan of abdomen in next slide.

13. What is your diagnosis? • Focal nodular hyperplasia • Hemangioma • Adenoma • Metastatic carcinoma • What is the best initial therapeutic strategy? • CT guided biopsy of the lesion • Steroid and azathioprine • Chemoembolization • Surgical removal

14. Case 52 • A young man with fever, RUQ pain and ichterus. • History of diarrhea in 3 weeks ago.

15. T (oral) = 39.5°c Icteric sclera, She was pale , No peripheral LNP, Heart and lung are normal. Abdomen: RUQ & epigastric tenderness, No Morphy sign, Liver span=16 cm, No shifting dullness, Physical examination: Conscious, cooperative

16. Lab findings Hb = 9.4 gr/dl, RBC = 5.1x10 6 , MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 11100 , poly = 80% lymph = 20% ESR = 22 , PT = 32.5 sec. INR = 5.1, Albumin = 3.4 g/dl / total protein = 6.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

17. AST = 194 U/L ALT = 328 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Alpha feto protein = normal T= 12 Bilirubin mg/dl D=5.8

19. What is your diagnosis? • Liver metastasis • Liver abcess • Liver hemangioma • Liver cyst • Focal nodular hyperplasia • Liver adenoma • Hepatocellular carcinoma

20. What is the best treatment? • A) Prompt surgical consult for resection • B) Intraveous antibiotic plus appropriate hydration • C) Emergent percutaneous drainage • D) Angiographic chemoembolization • E) Follow up visits with oral antibiotics

21. Case 54 • A middle young woman with RUQ pain. • You see the Dynamic CT scan of the patient in next slides.

22. Vital signs are stable. No Icteric sclera, She was not pale , No peripheral LNP, Heart and lung are normal. Abdomen: RUQ tenderness, No Morphy sign, Liver span=15 cm, No shifting dullness, Physical examination: Conscious, cooperative

23. Lab findings Hb = 12.4 gr/dl, RBC = 5.1x10 6 , MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 7100 , poly = 68% lymph = 27% ESR = 22 , PT = 12.5 sec. INR = 1.1, Albumin = 4.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

24. AST = 19 U/L ALT = 32 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Alpha feto protein = normal T= 1.2 Bilirubin mg/dl D=0.8

27. What is your diagnosis? • Liver metastasis • Liver abcess • Liver hemangioma • Liver cyst • Focal nodular hyperplasia • Liver adenoma • Hepatocellular carcinoma

28. What is the best treatment? • A) Prompt surgical consult for resection • B) Intraveous antibiotic plus appropriate hydration • C) Emergent percutaneous drainage • D) Angiographic chemoembolization • E) Follow up visits

29. Case 55 • A middle young woman with RUQ pain and the history of OCP use. • You see the CT scan of patient in next slide.

30. Vital signs are stable. No Icteric sclera, She was not pale , No peripheral LNP, Heart and lung are normal. Abdomen: RUQ tenderness, No Morphy sign, Liver span=17 cm, No shifting dullness, Physical examination: Conscious, cooperative

31. Lab findings Hb = 13.4 gr/dl, RBC = 5.1x10 6 , MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 7100 , poly = 68% lymph = 27% ESR = 22 , PT = 12.5 sec. INR = 1.1, Albumin = 4.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

32. AST = 19 U/L ALT = 32 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Alpha feto protein = normal T= 1.2 Bilirubin mg/dl D=0.8

34. What is your diagnosis? • Polycystic kidney disease • Liver abcess • Liver hemangioma • Liver simple cyst (congenital) • Focal nodular hyperplasia • Liver adenoma • Hydatid cyst versus cystadenocarcinoma • Hepatocellular carcinoma

35. What is the best treatment? • A) Prompt surgical consult for resection • B) Intraveous antibiotic plus appropriate hydration • C) CT guided percutaneous aspiration • D) Angiographic chemoembolization • E) Follow up visits