Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Gastroenterology (Review) Year 5 – Internal Medicine Presented by: Dr. Amgad El-Agroudy Prepared by: Ali JassimAlhashli

2. Questions • A 65 years old female presents for evaluation of symptoms of at least 2 years duration. She notes intermittent diarrhea lasting several days, alternating with several days of constipation, most days of most weeks. Her weight has been stable. She does have crampy abdominal pain primarily in the left lower quadrant, usually relieved by a bowel movement. Physical examination, CBC, ESR, stool cultures, stool for ova and parasites, stool for occult blood, stool for WBCs, stool for fecal fat and thyroid function studies are normal. Barium enema done for her and shown here: • What is the abnormality in this x-ray? • Diverticulosis. • What is the most appropriate course of action at this time might be to? • Start fiber and increase her fluid intake. • What are the risk factors for this disease? • Aging. • Lack of fiber in diet. • Mention one common complication for this disease. • Diveticulitis.

3. Questions • A 37 years old male presents with recurrent abdominal pain especially when he has an empty stomach. This pain is relieved by food and over-the-counter antacids. • What is your diagnosis? • Duodenal ulcer (because it is relieved by food). In general, risk factors for Peptic Ulcer Disease (PUD) are: NSAIDs, H,pylori infection, cancer of the stomach, Zollinger-Ellison syndrome, Crohn’s disease, burns and head trauma. • What is your next step for diagnosing this patient? • Upper endoscopy. • How are you going to manage this patient? • Proton-Pump Inhibitors (PPIs) such as omeprazole. • Lifestyle modifications (avoiding caffeine, avoiding fatty and spicy food, eating small meals… etc). If patient presents later to the hospital with no improvement in his condition (resistance) then you suspect H.pylori → do lab investigations → and treat accordingly with PPIs + amoxicillin and clarithromycin.

4. Questions • A 42 years old male who is overweight presents to A/E in SMC with right upper abdominal colicky pain after eating a meal of fried chicken. This pain is associated with nausea and vomiting. • What is you diagnosis? • Cholelethiasis. • A 45 years old man presents to A/E in SMC with hematemesis, ↓ blood pressure and tachycardia (120 beats/minute). • What is the best next step? • As this patient is having shock you have to start immediately with IV fluid resuscitation and send blood for blood group and matching (preparing for blood transfusion). Then, you have to give the patient a PPI while preparing him for endoscopy.

5. Questions • Which of the following patients should be immediately referred for endoscopy? • A 65-year old man with new onset of epigastric pain and weight loss (why?) → because endoscopy is indicating especially for those age < 45-55 or those with alarm symptoms (weight loss, anemia, heme-positive stools or dysphagia). You are suspecting malignancy in this patient. • A 32 years old patient whose symptoms are not relieved with antacids. • A 29 years old H.pylori positive patient with dyspeptic symptoms. • A 49 years old female with intermittent right upper quadrant pain following meals.

6. Questions • A 28 years old man comes to you complaining of a 5-day history of nausea, vomiting, diffuse abdominal pain, fever (38 C) and muscle aches. He has no significant medical history and he has not traveled outside Bahrain. He has 12 different lifetime sexual partners and he drinks alcohol occasionallym but not since this illness began. He is taking acetaminophen for 12 hours for fever. On examination, he is jaundiced. His liver is 12 cm, smooth and slightly tender. He has no abdominal distention. ALT 3440 IU/L, AST 2705 IU/L, total bilirubin 24.5 mmol/L, direct bilirubin 18.2 mmol/L, alkaline phosphatase 349 IU/L and PT is 14 seconds. • What is the most likely diagnosis? • Toxic hepatitis which occurs when your liver develops inflammation because of exposure to a toxic substance. Toxic hepatitis may also develop when you take too much of a prescription or over-the-counter medication (in this case it is acetaminohpen). • What is the most important immediate diagnostic test? • Check the level of acetaminohpen in the blood (not sure??) • What is the most appropriate treatment? • Supportive care and acetylcysteine which must be administered within 16 hours of acetaminohpen overdose to be effective.

7. Questions • A 25 years old medical student is stuck with a hollow needle during a procedure performed on a patient known to have hepatitis B and C viral infection. The student’s baseline laboratory studies include serology: • HBsAg: negative. • Anti-HBsAb: positive. • Anti-HBcIgG: negative. • What is true regarding this medical student’s hepatitis? • He has a prior vaccination with hepatitis B vaccine. • What post-exposure prophylaxis should the student receive? • Nothing but reassurance.

8. Questions • Chronic hepatitis B and C: • Transmitted by: blood products, needlestick injury and sexual contact. • Hepatitis C virus causes 60-70% of cases of chronic hepatitis. • Hepatitis C is the most common cause of chronic hepatitis in US. It is also the most common cause of cirrhosis and hepatocellular carcinoma. • Diagnosis: • To confirm chronic hepatitis B: persistence of hepatitis B surface antigen < 6 months. Remember that in chronic hepatitis B, the hepatitis B surface antibody is negative. • To confirm hepatitis C: PCR. • Treatment: • Chronic hepatitis B: interferon. • Chronic hepatitis C is now cured with the new combination antiviral drugs (Harvoni).

9. Questions • Mention 4 clinical signs found in the image. • Ascites. • Dilated veins (caput medusae). • Everted umbilicus. • Jaundice. • What is the indication of the procedure shown in the left lower iliac region? • (theraputic) paracentesis. Paracentesis is a procedure in which a needle or a catheter is inserted into the peritoneal cavity to obtain ascites fluid for diagnostic or theraputic purposes • What are the complications of this procedure? • Peritonitis (mostly S.aureus). • Hypotension. • Precipitating for hepatioencephalopathy. • What are the contraindications for this procedure? • Presence of an infection. • Presence of a bleeding tendency.

10. Questions • A 42 years old woman presents to the emergency complaining of 1-day of severe epigastric pain radiating to her back with several episodes of nausea and vomiting. On examination, she is afebrile, tachycardic, blood pressure = 115/74 mmHg and shallow respirations of 22 breaths/minute. Her abdomen is mildly ditended with marked right upper quadrant and epigastric tenderness to palpation but no organomegaly. Laboratory investigations: • Total bilirubin = 9.2 g/dL with a direct fraction of 4.8 g/dL. • ALP = 285 IU/L. • AST = 78 IU/L. • ALT = 92 IU/L. • Amylase = 1249 IU/L. • WBCs = 16,500/mm3 with 82% neutrophils. • What is the most likely diagnosis? • Acute pancreatitis which can be caused by the following: alcoholism and gallstones (most common causes), hypertriglycerdimeia, trauma, premature activation of trypsinogen into trypsin while still in the pancreas. Acute pancreatitis is diagnosed by the following triad: • Characteristic epigastric pain which radiates to the back. • Elevated level of lipase (which is more specific than amylase). • CT-scan. • How are you going to manage this patient? • Rest. • Pain killers (e.g. IV paracetamol or morphine). • Supportive management with IV fluids. • Avoiding fatty food.

11. Questions • A 28 years old man comes to you complaining of 2 days of abdominal pain and frequent diarrhea. The abdominal pain is crampy, diffuse and moderately severe and it is not relieved with defecation. In the past 6-8 months, he has experienced similar attacks. His oral mucosa is pink and without ulceration. His abdomen is soft and mildely distended, and minimal diffuse tenderness but no guarding or rebound tenderness. Hb = 10.3 g/dL. • What is the most likely diagnosis? • Inflammatory Bowel Disease (IBD). • What is your next step? • Endoscopy (why?) → to differentiate between Crohn’s disease and Ulcerative Colitis. • Notice that some questions in the exam might mention that the patient is presenting with erythemanodosum and abdominal pain (you have to suspect crohn’s disease).

12. Questions

13. Questions • A 35 years old female has chronic crampy abdominal pain and intermittent constipation and diarrhea but no weight loss or gastrointestinal bleeding. Her abdominal pain is usually releived with defecation. Colonoscopy and upper endoscopy with biopsies are normal, and stool cultures are negative. • What is the most likely diagnosis? • Irritable Bowel Syndrome (IBS). It is an indipathic disorder in which there is increased frequency of the normal peristaltic and segmentation contractions of the bowel. 20% of patients have constipation, a large number have diarrhea but everyone has pain. This condition is diagnosed with Rome criteria (which must occur for at least 3 months): • Pain relieved by a bowel movement. • Fewer symptoms at night. • Diarrhea alternating with constipation. All patient should be placed on high-fiber diet. Those with diarrhea can receive anti-diarrheal agents.

14. Questions • What is this lesion? • Palmarerythema. • What are the causes? • Portal HTN. • Chronic liver disease. • Pregnancy. • Polycythemia. • Thyrotoxicosis. • Rheumatoid arthritis. • Eczema and psoriasis. • SLE. • Secondary syphilis. • Causes mentioned above include: • Increased cardiac output/hyperdynamic circulation. • Capillary dilation in palms. • Localized inflammation. • High circulating estrogen levels.

15. Questions • A 40 years old male presents with hyperpigmentation, malabsorptive diarrhea, weight loss, recurrent arthritis and adenopathy. Which one of the following tests is likely to confirm the diagnosis? • MRI of head. • CT with thin cuts of adrenal glands. • Small bowel biopsy with periodic acid-Schiff staining. This is Whipple’s disease which is caused by infection with T. whippelii. Clinical manifestations: hyperpigmentation in sun-exposed areas, weight loss, diarrhea, arthralgia, lymphadenopathy and steatorrhea. Treatment with trimethoprim-sulfamethoxazole. • Dexamethasone suppression test. • Cosyntropin stimulation test.

16. Questions • A 30 years old male presents with personality changes, jaundice, joint pain and this eye finding. The disease is associated with these findings and is caused by defects in metabolism of which element? • Copper. This is Wilson’s disease which is autosomal recessive leading to accumulation of copper mainly in liver, brain and cornea. Diagnosis is through low ceruloplasmin level and has to be confirmed by liver biopsy. This condition is managed with penicillamine which is a copper chelator. Liver transplantation is curative.

17. Questions • Hemochromatosis: • It is an inherited genetic disease in which there is an overabsorption of iron in the duodenum. • Clinical presentation: • Cirrhosis is the most common finding. Hepatocellular carcinoma develops in 15-20% of patients. • Restrictive cardiomyopathy (15% of patient ) • Skin hyperpigmentation. • Diabetes. • Hypogonadism. • Diagnosis: ↑iron, ↑ferritin and diminished iron-binding capacity. Most accurate test is liver biopsy and abnormal C282Y gene. • Treatment: phlebotomy is used to remove large amounts of iron from the body. Deferoxamine is used only in those who cannot undergo phlebotomy.

18. Questions • A 70 years old male who is an alcoholic is admitted to the hospital with diffuse abdominal distention. • What is the most likely diagnosis of this patient? • Ascites due to liver cirrhosis. • What are the causes of mortality for his disease? • Spontaneous bacterial peritonitis. • Hepatic encephalopathy. • Mention two causes of breast changes in this image. • Drugs (spironolactone). • Estrogen.

19. Questions • A 26 years old male presented with abdominal pain, nausea and vomiting following a 4 day flu-like prodrome. He had no past medical history, took no medications and had undertaken no recent foreign travel. ALT 88 U/L, ALP 100 U/L, bilirubin 120 mmol/L. anti-hepatitis A IgM was raised. Anti-hepatitis B core IgM antibody and hepatitis B surface antigen were not detected. His albumin is 40 g/L and haptoglobins were normal. • What is the most likely diagnosis at the last follow up? • Gilbert’s syndrome. • Which of the following investigations is appropriate next? • Unconjugatedbilirubin levels.

20. Questions • A 67 years old male presents with a persistent history of heartburn. He keeps on returning to his GP and eventually she refers him to you. A trial of low-dose PPI and lifestyle measures has failed to alleviate his symptoms. Screening bloods are unremarkable. What is the most appropriate management? • Do an upper GI endoscopy. • A 22 years old female present to her GP after a holiday to India. Her family often ate out during their holiday. She presents with malaise, lack of appetite, jaundice and dark urine. She had a fever initially, but this subsided once jaundice appeared. On examination, she has hepatomegaly and is tender in the right upper quadrant. Her ALT and AST are 10 times the upper limit of the normal range, bilirubin is 6 times the upper limit of normal, ALP is only mildly elevated. What is the most likely diagnosis? • Hepatitis A.

21. Questions • A 66 years old male presents with worsening jaundice, intermittent abdominal pain and weight loss. He is jaundiced, cachectic and has a non-tender mass in the right upper quadrant. Which of the following investigations is most likely to establish the diagnosis? • CT-scan of the abdomen. • Liver biopsy. • Endoscopy. • Alpha-fetoprotein level. • Serum gastrin level. • A 26 years old female presents to her GP complaining of intermittent abdominal pain, distention and bloating and interspersed with bouts of loose motions. She works in a busy office and finds work stressful. She had previously taken a course of treatment for depression/anxiety. Examination, blood tests and sigmoidoscopy were all normal. What is the best-fit diagnosis? • Irritable Bowel Syndrome (IBS).

22. Good Luck!Wish You All The Best 