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11_Case Based Discussions
Pdf Summary
Case Presentations and Group Discussion<br /><br />Case 1:<br />A 58-year-old male presents with vomiting blood and black stool. He is tachycardic and hypotensive, suggesting volume depletion. Next steps in his management include placing 2 large bore IV's, beginning IV fluids, and starting IV proton pump inhibitors. The most common cause of upper GI bleeding in the US is peptic ulcer disease, often caused by NSAIDs and Helicobacter pylori infection. The best initial test for evaluating and treating patients with upper GI bleeding is esophagogastroduodenoscopy (EGD), which allows for precise diagnosis and treatment. Treatment options for a bleeding gastric ulcer include injecting epinephrine, placing a clip, and cauterizing the bleeding vessel. NSAIDs and aspirin are the most common causes of bleeding peptic ulcers.<br /><br />Case 2:<br />A 54-year-old woman presents with severe epigastric pain radiating to her back, accompanied by nausea and vomiting. Differential diagnoses at this point include choledocholithiasis, acute cholecystitis, acute pancreatitis, and peptic ulcer disease. The next best step in the evaluation is a right upper quadrant ultrasound to assess for stones in the common bile duct. Acute pancreatitis is confirmed with characteristic pain, elevated pancreatic enzymes, and typical CT scan findings. The most common causes of acute pancreatitis in the US are gallstones and alcohol. In this patient, triglyceride and calcium levels should be checked to assess for other possible causes. Treatment goals for acute pancreatitis include lowering triglyceride levels, hemoglobin levels, and BUN.<br /><br />Case 3:<br />A 67-year-old female with a large polyp in the cecum of the colon seeks a second opinion about the need for surgery vs. removal with colonoscopy. The recommended procedure for this lesion is endoscopic resection with dye-based solution to lift the lesion and provide enhanced visualization. Colonoscopic removal of large benign polyps is safe, with a low risk of bleeding and perforation. For a patient with a biliary obstruction caused by a pancreatic mass, the recommended procedure is endoscopic retrograde cholangiopancreatography (ERCP) to relieve the obstruction and place a biliary stent. Metal stents are preferred over plastic stents due to their longer patency.<br /><br />Case 4:<br />A 54-year-old man presents with worsening abdominal pain, weight loss, and an abdominal ultrasound showing a pancreatic mass causing biliary obstruction. The next step to obtain a tissue diagnosis of the pancreatic mass is endoscopic ultrasound (EUS) with fine needle aspiration. To relieve the biliary obstruction, an endoscopic retrograde cholangiopancreatography (ERCP) is performed to place a biliary stent. If the patient develops jaundice due to the pancreatic cancer, ERCP can be repeated to replace the biliary stent.<br /><br />Case 5:<br />A 29-year-old female with Crohn's ileitis is not responding to standard therapy and opts for treatment with adalimumab. Initial management of mild-moderate Crohn's ileitis does not typically include cyclosporine. Prior to starting biologic therapy in IBD, tests such as a chest X-ray, TB skin test, and hepatitis B serology check are typically done, but a 2-D cardiac echo is not necessary.
Keywords
upper GI bleeding
peptic ulcer disease
NSAIDs
Helicobacter pylori infection
esophagogastroduodenoscopy
choledocholithiasis
acute pancreatitis
gallstones
endoscopic retrograde cholangiopancreatography
adalimumab