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Case Based Discussions

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This document presents five GI-focused case discussions with key diagnostic and management principles:

1. <strong>Upper GI bleeding:</strong> A 58-year-old man with hematemesis, melena, hypotension, and tachycardia should receive immediate resuscitation with <strong>2 large-bore IVs, IV fluids, and IV proton pump inhibitor therapy</strong>. The most common cause of upper GI bleeding in the U.S. is <strong>peptic ulcer disease</strong>, most often related to <strong>NSAIDs or H. pylori</strong>. <strong>EGD</strong> is the best initial diagnostic and therapeutic test. Bleeding ulcers can be treated endoscopically with <strong>epinephrine injection, clipping, or cautery</strong>.

2. <strong>Acute pancreatitis:</strong> A 54-year-old woman with severe epigastric pain radiating to the back was found to have <strong>acute pancreatitis</strong>, diagnosed by symptoms plus elevated lipase. The most common U.S. causes are <strong>gallstones and alcohol</strong>, but in this case <strong>hypertriglyceridemia</strong> was identified. Evaluation should include <strong>liver tests, pancreatic enzymes, CBC</strong>, and if needed triglycerides and calcium. Treatment includes aggressive hydration and lowering triglycerides, with <strong>fenofibrate</strong> being the most effective listed medication.

3. <strong>Colon polyp management:</strong> For a large sessile or flat cecal polyp, <strong>endoscopic mucosal resection (EMR)</strong> is appropriate. A <strong>dye-based injection</strong> is used to lift and better define the lesion before resection, reducing risk of deep thermal injury.

4. <strong>Pancreatic cancer and biliary obstruction:</strong> A pancreatic head mass with a double-duct sign should be evaluated with <strong>endoscopic ultrasound (EUS)</strong> for tissue diagnosis. If biliary obstruction develops, <strong>ERCP</strong> is used for drainage and stent placement. <strong>Metal stents</strong> are preferred for palliation because they last longer than plastic stents.

5. <strong>Crohn’s ileitis and biologic therapy:</strong> A patient with refractory ileal Crohn’s improved on <strong>adalimumab</strong> after failing standard therapy. <strong>Cyclosporine is not typically used</strong> for mild-moderate Crohn’s ileitis. Before biologic therapy, screening should include <strong>TB testing, chest X-ray, and hepatitis B serology</strong>.

Keywords

upper GI bleeding

peptic ulcer disease

acute pancreatitis

hypertriglyceridemia

endoscopic mucosal resection

pancreatic cancer

endoscopic ultrasound

ERCP

Crohn's ileitis

adalimumab