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In the name of GOD

In the name of GOD. Case 1 cc: diarrhea PI :67y/o woman with cheif complaint of diarrhea since 2 month ago H +: diarrhea was watery not bloody, frequencies 6-7 time per day. H _: symptom not associated with fever, feeding, abd

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In the name of GOD

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  1. In the name of GOD

  2. Case 1 cc:diarrhea PI:67y/o woman with cheif complaint of diarrhea since 2 month ago H+:diarrhea was watery not bloody, frequencies 6-7 time per day. H_: symptom not associated with fever, feeding, abd pain,tenesmus,nausea,vomitimg,wt loss , anorexia or GI bleeding .

  3. PMH: neg • DH: neg • F/H:neg • Allergy/H:neg • PH/E: NL

  4. CBC: WBC:7600 HB:10/9 MCV:83 MCH:28 PLT:230000 Ure:20 cr:1 Na:135 K:3/4 BS:115 AST,ALT ,ALKP,Bil:nl ESR:15 CRP:- S/E:WBC, RBC, OB ,op _ S/C:- U/A:-

  5. Trans Abd & pelvic sono: NL • Upper & Lower GI endoscopy: NL • Biopsies were taken from duodenal mucosa & colon

  6. Case 2 Cc:abd pain,lower extremities edema PI: 41y/o man was referred with cheif complaint of abd pain & lower extremities edema since 3 month ago H+: pain aggravated with feeding & associated nausea , vomiting &melena too. H_:not colicky , radiated to area, awake at night or Wt loss.

  7. PMH:neg • Drug/ H: H2blocker • F/H:: Neg history of GI disease ,hepatitis,orcancer in his family • Allergy- • PH/E: pale PR:120 Epigastric pain ,lower extremities pitting edema +2

  8. CBC: • WBC: 6000 EOS:600(10%)HG: 4 MCV: 65 PLT:480000 • BUN.Cr.Na,K.AST,ALT,BIL,ALKP,INR:NL • Alb:3.2 total pr:6 • Ferritin:7 fe:118 TIBC:286 Anti TTG:NL • S/E:WBC_ RBC 10-12 O/P:_ OB:+ • U/A:NL

  9. Upper GI ENDOSCOPY: There were 2 clean-based superficial ulcer without bleeding in ant, largest diameter was 6-8mm.multiple biopseis were taken • Trans abd Sonography: NL • Echocardiography: NL

  10. Case 3 Cc:epigastric pain PI:16y/o man with cheif complaint of epigastric pain since one month ago . H+: N/V & intermittent bloody diarrhea since 2 week ago. history 4kg wt loss & abd distention during last month. H_: pain not colicky or radiated to area,not exacerbated or improve with food Or awake him at night.

  11. PMH: Neg history of problem or surgical in past medical Allergy+ hepatitis neg

  12. Drug : Neg F/H: Neghistory of GI disease ,hepatitis,or cancer in his family

  13. R .O.S: • NO headache,vertigo or hearing loss • NO hair loss,skin change • NO dry mouth or eye • NO dysphagia or odynophagia • NO chest pain or dyspnea abdominal distention Sexual development nl NO swelling of joint or stiffness

  14. Physical Exam Pt not ill or toxic T:37.1 Ax at night BP: 110/80, PR: 89, RR :21 O2 sat: 95% no pale or ichteric no tenderness on PNs No lymphadenopathy noTemporal wasting No Hoarseness jvp Nl & no thyromegaly

  15. Chest examination • Revealed equal bilateral breath sounds, • with no wheezes & bilateral clear • She had a normal S1&S2 sound and no murmurs.

  16. Abdomen • Soft with nontenderness, no masses or hepatosplenomegaly. • shifting dulness+ • No hair loss or gynecomastia or spider angioma Ext • edema lower ext 1+ • no rash, telangiectasia, or other skin changes • no clubbing.no palmar erythema • joints revealed no warmth, swelling, erythematic, tender prox muscle

  17. WBC:10300 (PMN;47% lymph:22% Eos:30%) EOS:3100 • Hb:13.8 • MCV:84 • MCH:26 • MCHC:31 • PIT:420000

  18. Lab Data BS:105 AsT:33 AlT:11 Na:135 Bill(t):0.4 K:4.2 Bill(d):0.2 alkp:135 Alb:4 total pr:7.8 INR:1 Urea:44 ESR:2 Cr:1.1 LDH:440

  19. HbsAg- HbcAb- HcvAb - HIVAb – • Anti TTG Ab:nl

  20. S/E: WBC:MANY RBC:0 O/B:- O/P:- CYST:- • S/C:- • U/A:NL

  21. Trans abd Sonography: Liver nl in size & echo CBD diameter nl Portal vein nl Splenomegaly neg Lymphadenopathy neg Kidney nl in echo & size Moderate ascites

  22. Problem list: • A young man with epigastric pain since 1month ago.4kg wt loss,N/V,BLOODY diarrhea,ascites,eosinophilia in CBC(EOS>3100)

  23. Abd paracentesis • Appearance:yellow • WBC:990O PMN:95 LYM:5 • RBC:0 • LDH:321 • GLU:80 • Pr:5/8 • Alb:3/3 SAAG:0.7(low SAAG)

  24. Problem list: • A young man with • epigastric pain & N/V since 1month ago. • 4kg wt loss, • intermittent BLOODY diarrhea, • low SAAG ascites • eosinophiliaCBC(EOS>3100)

  25. Eosinophil-associated diseases and disorders ALLERGIC DISORDERSAtopic: dermatitis,Asthma,Rhinitis syndromes,Medication-related eosinophilia INFECTIOUS DISEASES Parasitic infections,Fungal infections,HIV and other retroviral infections HEMATOLOGIC AND NEOPLASTIC DISORDERS Hypereosinophilic syndromes ,Mastocytosis,Leukemia,Lymphoma,Other malignancies RHEUMATIC DISEASE Eosinophilia-myalgia syndrome and toxic oil syndrome ,Idiopathic eosinophilicsynovitis ,Vasculitis MISCELLANEOUS CAUSESA: adrenal insufficiency ,Atheroembolic disease,Immunodeficiency states Disease with specific organ envolment

  26. ADA:2.3 • Gram neg &Gram posbac were not seen IN smear & culture

  27. Laparoscopic peritoneal biopsy:بررسی کبد امنتوم وکل شکم ضایعه خاصی دیده نشد • Biopsywas taken from peritoneum

  28. Upper GI endoscopy: • Esophagus:upper,middle,lower third were NL • Stomach:fundus,body & antrum were NL • Duodenum:Bulb & 2nd part were NL

  29. Upper GI ENDOSCOPY

  30. lower GI endoscopy:Anus,desending ,transvers part,ascending & cecum were NL • The mucosa has angioectasia in rectum & sigmoid • Biopsies were taken from duodenal mucosa & colon

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