Clinical Topics Conference: Chapter
13, Gastrointestinal tract
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- Reflux esophagitis
- Celiac sprue
- Crohn disease
- Diverticular disease of the colon
Clinical vignette 1
A 60-year-old diabetic man sought medical attention because of retrosternal
pain, discomfort and heartburn which had become worse over the last three
months. He also had nocturnal regurgitation and on occasions nocturnal coughing.
He lead a sedentary life and had a 30 lb. weight gain. He smoked half a
pack of cigarettes a day, consumed moderate amounts of alcohol daily and
was a heavy coffee drinker.
He returned after 2 weeks of medical therapy. Upper gastrointestinal endoscopy
revealed linear erosions and a tongue-shaped patch of salmon-colored mucosa
in the distal esophagus above the squamo-columnar junction. Multiple mucosal
biopsies were obtained.
The patient was put on aggressive medical treatment and asked to come back
on yearly basis for check-up. Upon his return he had developed dysphagia
for solid foods. Endoscopy revealed a stricture in the distal esophagus.
The salmon-colored mucosa persisted. Multiple biopsies from the stricture
and the adjoining areas were obtained.
Discussion topics
- What are the clinical possibilities for the chest pain ?
- What is the significance of the endoscopy findings?
- What would the biopsies show from:
- the salmon-colored mucosa?
- the area adjoining the salmon-colored mucosa in the esophagus?
- Discuss the progression of the disease from the first to the third
visit.
- Describe the features that you would be concerned about in the biopsies.
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Clinical vignette 2
A 40-year-old male noticed
a gradual change in his bowel habits from one formed stool per day to five
or six loose, bulky, semiformed, sometimes watery, malodorous (rancid) yellowish
stools. He noted abdominal bloating, increased flatus and abdominal cramps
prior to bowel movement. Despite good appetite, he had lost 20 pounds over
the last six months. He had loss of energy and decreased capacity for physical
activity.
Red cell morphology in a peripheral smear showed microcytic cells and
some macro-ovalocytes. A few hypersegmented polymorphonuclear leukocytes
were also seen. Hemoglobin was 11 gm/dl, serum albumin was 2.7 g/dl,
Calcium 8.2 mg %, cholesterol 104 mg/dl, serum iron level of 32 g/dl, iron
binding capacity of 260 g/dl.
The patient continued to lose weight and the diarrhea persisted after
he was placed on restricted diet. A repeat mucosal biopsy of the small bowel
showed monotonous sheets of lymphocytes in the lamina propria with destruction
of the glands
Discussion topics
- Based on the history provided what are the clinical possibilities?
- Discuss the laboratory findings and the additional tests you would
like to do in the work-up of this case.
- Based on the mucosal biopsy of the small bowel, a diagnosis of Celiac
sprue was made. What are the histopathologic features of Celiac sprue? Are
the features specifically seen in celiac sprue?
- What is the pathogenesis of this disease ? How would you treat this
patient ?
- What is your diagnosis based on the second biopsy? How do you relate
the original diagnosis with the new findings?
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Clinical vignette 3
A 55-year-old male had sudden onset of severe right lower quadrant pain one year ago. A pre-operative
diagnosis of acute appendicitis was made and the appendix was removed through
a McBurney incision. Post-operative dull pain in the right lower quadrant
persisted for months. He developed fever and an abscess in the abdominal
wall close to the previous surgical scar was drained. Two months later he
developed colicky abdominal pain off and on. The pain was relieved by anti-spasmodics.
He began to develop diarrhea - two to three semi-formed stools per day.
He lost 15 lb. in the last one year. On physical examination an indistinct
mass 6 - 8 cm in diameter was felt in the right lower quadrant.
During the course of the work-up, the patient developed intestinal obstruction.
Ileo-colectomy was performed which included twenty inches of the distal
ileum. The ileum showed multiple strictures, linear mucosal ulcers and a thick,
rigid wall. A walled-off abscess was present at the ileocecal region on
the outer aspect of resected specimen. The abscess cavity communicated with
the lumen of the ileum through a narrow opening.
Discussion topics
- What are the clinical problems and what are the diagnostic possibilities?
- How would you work up this patient to establish your diagnosis?
- What is the microscopic hallmark of Crohn disease?
- How does Crohn disease differ from ulcerative colitis?
- What are the extra-intestinal complications of Crohn disease?
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Clinical vignette 4
A
62-year-old male presented to the emergency room with lower abdominal pain,
diarrhea and rectal bleeding for the past 3 days. He started by abdominal
cramps which became severe in intensity. He developed diarrhea and then
passed bright red blood in the stools. Physical examination revealed a temperature
of 101 oF, tenderness in the left lower quadrant with an ill-defined
firm mass in the same area. Rectal examination showed bright red blood on
the examining finger.
A plain x-ray of the abdomen revealed mild increase in the gas pattern of
the large bowel. Procto-sigmoidoscopy revealed a normal mucosa. Barium enema
revealed multiple diverticula in the rectosigmoid region. A fleck of barium
was seen adjacent and external to the diverticula. A small segment of the
colon was removed which showed numerous diverticula, one of which felt firm
to hard on palpation of the pericolonic fat. Microscopic examination showed
acute and chronic inflammation of the diverticulum associated with intense
fibrosis and granulation tissue of the adjoining fat.
Discussion topics
- What are the clinical problems and what are your diagnostic possibilities?
- What are some of the causes of lower gastrointestinal bleeding in this age group?
- What factors are important in the genesis of colonic diverticula?
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