Problem Solving Sessions

Author(s): Rebecca W. Van Dyke, M.D., 2012

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Problem Solving Cases

Learning Objectives

• After attending one or more these eleven 30 minute sessions the student should be able to:• • 1. Demonstrate increased competence in using knowledge obtained from lectures and

textbooks to answer patient questions about their diseases.• • 2. Demonstrate increased competence at correctly interpreting laboratory tests for liver

disease, viral hepatitis, analysis of stools samples and analysis of ascites samples. • • 3. Demonstrate increased competence in identifying abnormalities on radiographic studies and

suggesting a diagnosis (or diagnoses).• • 4. Demonstrate increased competence in selecting drug treatments for GERD, diarrhea.• • 5. Demonstrate increased competence in identifying what complications might occur when

patients undergo certain GI surgical procedures and how these may be managed.• • 6. Demonstrate increased problem-solving skills for patients with GI diseases.

Industry Relationship Disclosures

Industry Supported Research and Outside Relationships

• None

January 26, 2012

Your patient has an endoscopy and these pictures were obtained. What problems might this patient have or

develop in the future? Why did this occur?

Case A

• A 24 year old medical student has developed epigastric pain.

• She thinks she has an ulcer.

• How would you determine whether she has an ulcer?

• Is there a “best” approach?

Case – B

A 75 year old patient comes to see you as a new patient in geriatrics clinic. In taking a history you discover he had surgery for recurrent stomach ulcers in 1963. He thinks part of his stomach was removed at the time.

What kind of operation did he likely have?

What is his current anatomy likely to be?

What problems can occur with these types of surgery?

Case C

• 75 year old woman is concerned she may have gastric cancer.

• This disease arises in the gastric epithelium.

• How would you try to find out if she has gastric cancer?

• What can you do?

• Is there a “best”way to answer her question?

Case - D• The family is gathered for a Super Bowl party,

complete with all the usual munchies.

• Your uncle pulls you aside and tells you he gets bad heartburn from the salsa, which he loves.

• Now that you are a medical student, he want advice on how to prevent the heartburn.

• What do you suggest?

Case – D1• Three hours later your cousin, who gorged on

pizza, complains of terrible heartburn and wants you to do something RIGHT NOW to relieve her symptoms.

• What do you suggest?

Case – D2• Your grandmother overhears these conversations

and loudly complains that her doctor has told her she is susceptible to stomach ulcers and therefore she cannot take her “arthritis” pills.

• She has severe pain in her hands, hip and knees and wants to know why the doctor took away her medications and what you can do to solve her problem.

• What pills were removed and why?

• What options are available?

Case E• A 60 year old woman went to the Mayo Clinic

and was told she had Zollinger-Ellison syndrome.

• She returns to Ann Arbor and comes to you for care.

• You recall the Z-E syndrome is due to a small gastrin-secreting tumor.

• What problems might you expect her to develop?

• What signs and symptoms might she develop?

• What could you do to help treat or prevent these problems?

Case F• A patient comes to see you having been told he

has a duodenal ulcer.

• He wants to know how/why he got the ulcer.

• What do you tell him (patient education)?

• What can he do to heal this ulcer as fast as possible (treatment)?

• What can he do to prevent future ulcers (secondary prevention)?

January 27, 2012

• A 29 year old man come to see you because of recurrent gas and diarrhea.

• He wants to know:

• Does he have lactose intolerance?

• Does milk cause his symptoms?

• Does he have lactase deficiency?

• How would you answer each question for him?

Case – G

A 55 year old man comes to your office for evaluation of diarrhea. Diarrhea began in the past year although he cannot pinpoint an exact time. He notes 3-5 loose stools during the day and none at night.

He has no abdominal pain and has not lost weight. His only other medical problem is frequent heartburn for which he takes antacids. The physical examination is normal except the digital rectal examination which yields loose/watery light brown stool that is negative for occult blood.

What is your differential diagnosis?What do you do next?

Case – G-2

Diarrhea continues after he stops the antacid intake

Stool electrolytes: Na = 90 mEq/lK = 40Cl = 40

Stool/plasma osmolality = 295

Stool osmotic gap = ????

Diagnostic possibilities?

Analysis of Fecal Electrolytes – normal values

Sodium ~20-40 mEq/lPotassium ~90Chloride ~15HCO3

- ~30Anions (SO4

-2, ~85 PO4

-3, fatty acids)Magnesium ~10-20

Volume 0.2-0.4 liters/day

Plasma osmolality ~290-300 mEq/lStool osmolality ~290-300 mEq/lOsmotic gap ~40-70

Fecal pH > ~5.4

Analysis of Fecal Electrolytes - I

Sodium 105Potassium 30Chloride 69Magnesium 15

Electrolyte pattern?

Volume 3 liters/day

Plasma osmolality 295 mEq/lStool osmolality 301 mEq/l

Osmotic gap?

Fecal pH > 5.4

Analysis of Fecal Electrolytes - II

Sodium 22Potassium 26Chloride 55

Volume 1.3 liters/day

Osmotic gap?

Fecal pH > 5.4

Analysis of Fecal Electrolytes - III

Osmotic gap?

Analysis of Fecal Electrolytes - IV

Sodium 32Potassium 28Chloride 10

Plasma osmolality 295 mEq/l

Osmotic gap?

Analysis of Fecal Electrolytes - V

Osmotic gap?

Analysis of Fecal Electrolytes - VI

Osmotic gap?

Analysis of Fecal Electrolytes – secretory diarrhea

Electrolyte pattern?Volume 3 liters/dayPlasma osmolality 295 mEq/lStool osmolality 301 mEq/lOsmotic gap?Fecal pH > 5.4

High sodium, no osmotic gap, normal pH, high volume = secretory diarrhea

January 30, 2012

Case – H I

An 85 year old woman with untreated atrial fibrillation throws an embolus that lodges in the superior mesenteric artery proximal to the origin of the ileocolic artery causing ischemic necrosis of what part of the bowel?

200 cm ileum

Case – H II

Case – H III

She undergoes emergency surgery with resection of 200cm of this part of the bowel and anastamosis of the proximal ileum to the transverse colon.

She recovers uneventfully,however what problems might she develop due to loss of this bowel?

Case – I- I• A patient has systemic sclerosis

(scleroderma).

• You read in your textbook that this disease destroys GI smooth muscle, first in the esophagus, later small bowel and colon.

• The patient wants to know what problems she is likely to develop in the future.

• What do you tell her?

Case J• A patient travels to South America and is bitten by

the reduviid bug, transmitting Trypanosoma cruzi.

• He develops Chagas disease.

• You recall your parasitology and that this trypanosome specifically involves the wall of the esophagus and LES destroying NO-secreting neurons.

• What signs and symptoms will the patient develop and why?

• A patient comes to you requesting an injection of botulinus toxin in the lower esophageal sphincter.

• What will this toxin do in this location?

• What type of symptoms might be expected to be relieved?

• What complications might occur?

Case K

Case L

A 75 year old man comes to see you because of diarrhea.

He has 5-7 loose watery stools a day and urgency.He says the volume of the stools are moderate.

You evaluate him and find on biopsy that he has microscopic colitis. You remember that this is a chronic disorder that cannot be cured.

What treatment options are available?

What would you advise him to do?

Case M

A 28 year old woman comes to see you because of urgency, diarrhea and bright red blood mixed with some of her stools. This has been going on for about 2 months.

You evaluate her and make a diagnosis of left-sided ulcerative colitis.

What problems need management?

What types of treatment might you give her?

Case N

A 35 year old woman comes to you for evaluation of diarrhea and weight loss. Last year she had surgery for active Crohn’s disease at which time over a meter (>100 cm) of distal ileum was resected.

She recovered well from the surgery but then developed frequent soft stools and has lost about 20 pounds of weight.

What pathophysiologic explanation can you develop for her diarrhea and how would you test your hypothesis?

What other problem(s) would you look for in this patient?

Case – O- I

• A patient comes to see you saying a doctor told him he had “colitis”.

• He has daily soft or liquid stools and thinks he was told he had ulcerative colitis, but is not sure.

• He occasionally sees streaks of blood.• Symptoms have been present for 6 months.• What diagnoses are possible?• How could you determine the type of

“colitis”?

Case – O- II• The same patient returns with medical records

including a colonoscopy report.

• The colonoscopy showed inflammation and ulcers located only in the sigmoid colon and in the cecum.

• What do you think the correct diagnosis is?• How would you prove this?• He continues to have symptoms - how would you

treat him?

January 31, 2012

Case P

• A 30 year old business woman has worsening diarrhea, now 3-6 times a day, especially after meals. None at night

• She had these symptoms for several years but they have worsened lately as business is worse.

• Every few weeks she gets constipation for 3-4 days, then diarrhea.

• She gets crampy abdominal pains on many days.• What problems could cause her symptoms?• How would you evaluate and treat her?

Case – Q- IAn 18 year old girl presents with an 8 week history of mild mid- abdominal pain, diarrhea, and weight loss. The pain is described as “achy” but not very specific. She notices it more at night when she is trying to sleep.

She now has 3-5 soft semi-formed bowel movements per day and occasionally she has to get up at night to pass stool. She notes anorexia and “loss of energy” and has lost 5 pounds in weight. She has not seen blood in her stools. She has not traveled in the last year and knows no one with diarrhea. She takes no medications.

What is your differential diagnosis?What do you do next?Any lab tests you want?

Case – Q- II

WBC 10,000 (nl 4,000-8,000)Hct 32 (nl 36-45)MCV 95 (nl 80-99)Platelets 250,000 (nl 150,000-350,000)

Electrolytes, BUN, Cr normal

What have you learned?

What can you think of to do next?

What do these images show?

What signs or symptoms might this patient have had?

Case R

• A patient is brought into the ER having vomited bright red blood 6 times this morning, each time “cups and cups” of blood.

• What do you do first?

• What are the diagnostic possibilities?

Case S

You have a patient in whom food does not pass out of the stomach normally.

What symptoms do you expect?

What underlying diseases might the patient have?

February 1, 2012

Case T-1A 43 year old woman is brought to the emergency room

because of vomiting blood. Yesterday she felt somewhat weak, nauseated and not her usual self. This morning she began vomiting, brought up large amounts of bright red blood and clots and felt dizzy.

She has been taking ibuprofen for the past three weeks because of shoulder bursitis. She has a long history of taking antacids for burning epigastric and substernal pain that occurs 3-5 times per week between meals or at night.

Four years ago when she tried to donate blood, she was told she could not do so because she had abnormal liver tests. She does not smoke and no longer drinks alcohol although she drank regularly until she was 35.What is her main problem when you see her in the ER?What do you want to do next?

Case T - 2On physical examination she looks reasonably well.

Lying: BP 110/60, P85 Sitting: BP 90/45, P110

Examination is normal. She has active bowel sounds, but epigastric tenderness upon palpation without any masses. Stool obtained by digital rectal examination is burgundy/black, soft and markedly positive by hemoccult testing.

How much has this woman bled?What else do you want to know?

Case T - 3

WBC 7.5 (nl ≤ 10)Hct. 22 (nl 36 - 45)Platelets 200,000 (nl 150,000 - 350,000)PT 12 sec (nl 9 - 12.5 sec)

What does this tell you?

What do you do next?

A 35 year old man comes to see you for a general medical examination.

When you take a history, you find out that his paternalgrandfather, father’s brother and his older brother all havecolon cancer.

What are your concerns about your patient?

What more information might you want to get from thehistory?

What do you advise your patient to do and why?

Case U

• A patient comes to the ER with severe and frequent nausea and vomiting of food and gastric contents after virtually every meal for the past 6 weeks.

• She has lost 15 pounds• On exam she is thin with orthostatic changes in BP

and pulse.• What electrolyte/blood test abnormalities might you

expect?• What types of problems could cause these

symptoms?• How do you prove what is causing her problem?

Case V

How do you educate and treat each of these patients? Cases W 1-3

• Your 11 year old future Olympic ice skater gets nauseated and often vomits after her fast spins.

• Your pregnant sister starts vomiting every morning.

• A patient with lung cancer tells you he cannot continue chemotherapy as his vomiting is too severe.

February 2, 2012

Case X

• A 45 year old woman comes to see you as she has started passing gas and stool through her vagina.

• Needless to say she is very distressed and wants this solved immediately.

• What had to have happened?

• How can you prove it?

• Later this week, think about what kind of diseases could have caused this problem.

What is abnormal on this x-ray and what is it?

What do you see on this x-ray?

What does this x-ray show?What would you find on exam?

What do you see in this image – the abdominal x-ray?

CT enterography of normal abdomen for your interest

Case Y

• A patient has a “lupus anticoagulant” or anti-phospholipid antibody and develops a portal vein thrombosis with complete obstruction of portal venous blood flow.

• What complications would you expect to occur?

Analysis of Liver Tests

Case 1Laboratory Findings

Bilirubin 8.5 (0.2-1.2 mg/dl)

Alkaline Phos. 250 (23-100 IU/ml)

AST 1500 (20-35 IU/ml)

ALT 1750 (18-30 IU/ml)

Albumin 4.0 (3.5-4.5 g/dl)

PT 11.0 (10.5-12.0 sec)

AST 92 (20-35 IU/ml)

ALT 99 (18-30 IU/ml)

Albumin 4.0 (3.5-4.5 g/dl)

PT 11.5 (10.5-12.0 sec)

AST 300 (20-35 IU/ml)

ALT 400 (18-30 IU/ml)

Albumin 4.0 (3.5-4.5 g/dl)

PT 12.0 (10.5-12.0 sec)

AST 2500 (20-35 IU/ml)

ALT 28 (18-30 IU/ml)

Albumin 4.0 (3.5-4.5 g/dl)

PT 11.0 (10.5-12.0 sec)

AST 210 (20-35 IU/ml)

ALT 100 (18-30 IU/ml)

Albumin 3.2 (3.5-4.5 g/dl)

PT 14.5 (10.5-12.0 sec)

AST 2500 (20-35 IU/ml)

ALT 3200 (18-30 IU/ml)

Albumin 4.0 (3.5-4.5 g/dl)

PT 14.5 (10.5-12.0 sec)

AST 20 (20-35 IU/ml)

ALT 22 (18-30 IU/ml)

Albumin 4.0 (3.5-4.5 g/dl)

PT 11.5 (10.5-12.0 sec)

AST 65 (20-35 IU/ml)

ALT 68 (18-30 IU/ml)

Albumin 2.0 (3.5-4.5 g/dl)

PT 15.5 (10.5-12.0 sec)

February 3, 2012

Analysis of Serologic Tests for Viral Hepatitis – Case Z

• A 23 year old medical student comes to the emergency room with the following symptoms:– 1 week of nausea, vomiting, severe fatigue and 1 day of

jaundice

• Lab tests are:– bilirubin: 5.6 (nl <1.1

mg/dl)– AST/ALT 1500/1900 (nl<70 IU)– Alk Phos 330 (nl<110 IU)– Prothrombin time 11.5 sec

(nl<12 sec)

• You send every serologic test you can think of – the results come back and you have to interpret them.

Analysis of Hepatitis Tests

Hepatitis A positive IgM antibodynegative IgG antibody

Hepatitis B negative sAg (surface antigen)positive sAB (surface antibody)negative IgM antibody to corenegative IgG antibody to corenegative eAg (e antigen)negative eAB (e antibody)negative DNA

Hepatitis C negative antibody (IgG)negative RNA by PCR

Hepatitis D negative RNA by PCRnegative IgM antibodynegative IgG antibody

Hepatitis E negative IgM antibodynegative IgG antibody

Hepatitis A negative IgM antibodynegative IgG antibody

Hepatitis B negative sAg (surface antigen)positive sAB (surface antibody)negative IgM antibody to corepositive IgG antibody to corenegative eAg (e antigen)negative eAB (e antibody)negative DNA

Hepatitis C negative antibody (IgG)positive RNA by PCR

Hepatitis A negative IgM antibodypositive IgG antibody

Hepatitis B negative sAg (surface antigen)negative IgM antibody to corenegative IgG antibody to corenegative eAg (e antigen)negative eAB (e antibody)negative DNA

Hepatitis E positive IgM antibodynegative IgG antibody

Hepatitis B positive sAg (surface antigen)negative sAB (surface antibody)positive IgM antibody to corenegative IgG antibody to corepositive eAg (e antigen)negative eAB (e antibody)positive DNA

Hepatitis B positive sAg (surface antigen)negative sAB (surface antibody)negative IgM antibody to corepositive IgG antibody to corenegative eAg (e antigen)positive eAB (e antibody)negative DNA

Hepatitis D positive RNA by PCRpositive IgM antibodynegative IgG antibody

Hepatitis A negative IgM antibodynegative IgG antibody

Hepatitis B negative sAg (surface antigen)negative sAB (surface antibody)negative IgM antibody to corenegative IgG antibody to corenegative eAg (e antigen)negative eAB (e antibody)negative DNA

Hepatitis C positive antibody (IgG)positive RNA by PCR

Hepatitis E positive IgM antibodynegative IgG antibody

Case AA• A 32 year old man had developed a greatly

enlarged abdomen over the past several months.

• He asks you what this is due to.

• What are the possible causes of his enlarged abdomen?

• What can you do to investigate the cause of this enlargement?

A patient brings you a liver biopsy. Here is one image from it.

What does the patient have and what problems might the patient develop?

Case BB - A patient comes to see you with liver biopsy slides. This is what you see. What is the problem and

what symptoms might the patient develop?

H&E stainTrichrome stain

February 6, 2012

Case CC

• A patient with cirrhosis wants to know if she has the following. How would you try to find out?– Hepatocellular carcinoma– Ascites– Esophageal varices– Hepatic hydrothorax

• pleural effusion due to ascites

Case DD

• A 35 year old woman had a CT scan of the abdomen that showed a thrombus occluding her splenic vein.

• She wants to know what problems she will develop because of this.

• Why did she develop this thrombus?

What are these skin findings?

Case EE

• A patient with cirrhosis and portal hypertension is concerned about his health and reads advertisements for Gator-aid - that if makes you stronger and better able to exercise. He buys a large case and drinks 3-4 bottles per day.

• What problem(s) is he likely to develop?

Case FF

• A patient with cirrhosis and portal hypertension is concerned that his arms and legs are getting thinner.

• He starts to work out at a gym and consults the nutritionist there who advises a high protein diet with meat and protein powder supplements.

• What problem might he develop?

What do you see here?What diagnoses are you thinking of?

Case GG

A patient is admitted to your service for evaluation ofnew onset ascites.

You perform a paracentesis and send the fluid for a varietyof tests.

The tests come back and your resident asks you to interpretthe results.

• Remember Dr. Moseley’s lecture on complications of cirrhosis and ascites

• When a patient presents with new onset ascites, diagnostic studies need to be done and analyzed to determine the cause of ascites and whether there is a complication (infection)

Ascites Fluid AnalysisTest Ascites Serum (normal)

Total protein 2.2 7.5 (8-9g/dl)

Albumin 1.0 2.9 (3.5-5.0g/dl)

Cell count (PMNs) 10 4000 (2000-6000)

Triglycerides 15 150 (<160mg/dl)

Amylase 20 40 (0-130 U/l)

How would you interpret these results?

Non-cirrhotic portal hypertension

“Hydrodynamic/transudative” “Exudative”

- Peritonitis

Ascites Fluid AnalysisTest Ascites Serum

Albumin 3.5 4.3 (3.5-5.0g/dl)

Cell count (PMNs) 10 4000 (2000-6000)

Amylase 20 40 (0-130 U/l)

How would you interpret these results? What more could you do?

Albumin 3.4 4.1 (3.5-5.0g/dl)

Cell count (PMNs) 10 4000 (2000-6000)

Amylase 950 40 (0-130 U/l)

Albumin 3.6 4.5 (3.5-5.0g/dl)

Cell count (PMNs) 10 4000 (2000-6000)

Amylase 20 40 (0-130 U/l)

Albumin 2.5 4.5 (3.5-5.0g/dl)

Cell count (PMNs) 10 4000 (2000-6000)

Amylase 20 40 (0-130 U/l)

Albumin 1.0 2.8 (3.5-5.0g/dl)

Cell count (PMNs) 774 8300 (2000-6000)

Amylase 20 40 (0-130 U/l)

Albumin 3.9 4.3 (3.5-5.0g/dl)

Cell count (PMNs) 10,200 18,950 (2000-6000)

Amylase 20 40 (0-130 U/l)

How would you interpret these results?What other tests might be abnormal?

Total protein 6.8 7.6 (8-9 g/dl)

Albumin 3.9 4.3 (3.5-5.0 g/dl)

Cell count (PMNs) 10,200 18,950 (2000-6000)

Triglycerides 15 142 (<150 mg/dl)

Amylase 20 40 (0-130 U/l)

LDH 495 150 (120-240 IU/l)

Glucose 15 112 (73-110 mg/dl)

February 7, 2012

Acute hepatitis B case from small group yesterday

• What is this patient’s prognosis (what may happen to him)?

• He has an infectious disease – what do you need to do when wearing your public health hat?

Case HH• A patient of yours takes a drug (A) that is

metabolized in the liver primarily by CYP3A4

• She develops a new problem and you give her another drug (B). However it is also metabolized in the liver by CYP3A4

• What problems could occur?

Case II• You are treating a patient for tuberculosis

with isoniazid. You read that this is primarily metabolized by CYP2E1.

• Your patient tells you he drinks alcohol regularily - up to 6 beers per day plus some liquor on the weekends.

• Does this concern you?

Case JJ A 35 year old man presents with 18 hours of pain that began in the periumbilical region as an “aching” pain. Subsequently, the pain became more severe and was felt also in the right lower quadrant. He has vomited stomach contents several times and feels nauseated. Examination shows a pale sweaty man curled on his side in pain. Pulse is 110 and he is febrile (T 100.8˚F). Bowel sounds are absent. He is very tender in the right lower quadrant and “guards” in this area. When the examiner pushes down on the left lower quadrant and releases quickly, severe pain is felt in the right lower quadrant.

Laboratory studies are essentially normal except for a leukocytosis (WBC 13,000).

Case KK - 1: This patient has epigastric pain and nausea/vomiting. What do you see?

• A patient develops localized carcinoma of the ampulla of Vater.

• This is treated by surgical resection of the duodenum and part of the pancreas. The stomach and biliary/pancreatic ducts are each anastamosed to loops of jejunum.

• What problems might develop?

Case LL

Patient Case MM

• 65 year old comes in with left lower quadrant abdominal aching pain for the last 2 days with fever

• He is concerned he may have acute diverticulitis as he has had similar symptoms in the past.

• How would you determine whether he had diverticulitis?

February 8, 2012

Case NN• A patient has an abdominal x-ray performed

for an unrelated reason.

• The radiologist reports the presence of calcifications throughout the pancreas

• The patient wants to know what this means?

• What do you tell her?

• What might you want to do with her?

Case OO• You are caring for a patient with acute

pancreatitis

• The patient asks you what complications he might develop – what do you tell him?

• He wants to know how he got this disease – what do you tell him?

Case PP-1• You are taking care of a patient with acute

pancreatitis and the resident asks you how sick the patient is.

• What factors can you assess to tell if this patient is severely ill with pancreatitis or not?

• A 20 year old girl was involved in a severe MVA. She was driving and had a crush injury to her pancreas from the steering wheel.

• She develops severe acute pancreatitis and requires surgery to resect the necrotic tissue and she loses about 80% of her pancreas.

• She survives but is likely to develop what complications?

Case QQ

Case RR

Three patients are admitted to your service- 1. one has nausea, vomiting and dehydration due to gastric outlet obstruction, 2. one is jaundiced, and3. one has severe epigastric pain and weight loss. What single disease could they all have?

Case SS

• A patient comes to see you with 6 months of chronic abdominal pain thought to be due to chronic pancreatitis (from alcohol).

• Upon evaluation you determine the patient has lost about 35 pounds of weight over this period and has malabsorption due to pancreatic insufficiency.

• Why did the patient develop pancreatic insufficiency?

• How can you treat the pain?• How can you treat the pancreatic insufficiency?

Case TT - 1A 35 year old man is brought to the emergency room with a one day history of abdominal pain. The patient felt well until 18 hours ago when he developed constant epigastric pain that he describes as “boring through” to the back associated with nausea and vomiting of gastric contents. He feels somewhat better if he sits up bent forward.

On examination he is pale, sweaty and in pain. Vital signs are normal except a pulse of 100. Abdominal exam shows hypoactive infrequent bowel sounds and severe epigastric pain on even mild palpation. There is no “rebound” tenderness.

Case TT - 2

WBC 14,000 (nl ≤ 10)Hct 45 (nl 36 - 45)Platelets 250,000 (nl 150,000 - 350,000)Elecrolytes, Bun, Cr normalAST 145 I.U. (nl < 45)ALT 160 I.U. (nl < 50)Alk phos 290 I.U. (nl < 110)Bili 2.0 mg/dl (nl < 1.0)Albumin 4.5 gm/dl (nl 3.5-4.5)PT 10.5 sec (nl 10-12.5)Amylase 10 X normalLipase 20 X normal

Abdominal x-ray shows no free air

Case UU

• A patient with pancreatic cancer develops jaundice.

• Why did the jaundice develop?• What complications will occur?• What can be done about the jaundice?

February 9, 2012

What do you see in this x-ray?

What do you see here?What diseases could cause this?

What accompanying problems might you expect?

A patient comes to see you as he had an x-ray donewhen he went to the Emergency Room for abdominal pain and it showed gallstones.

He wants to know if he should have his gallbladder taken out.

Who should have their gallbladder removed?

What signs and symptoms might he have had that would convince you he should have a cholecystectomy?

Case UU

VV - Each of the following patients has gallstones – what type?

• 45 year old woman who is obese and has had 4 children.

• A 21 year old man with sickle cell disease.

• A 25 year old woman with Crohn’s disease who has had >100 cm of her terminal ileum resected.

• A 50 year old who lost most of his small bowel due to a gunshot wound and receives nutrition through a central vein (total parenteral nutrition).

What do you see here?

75 year old man with diabetes and history of acute right upper quadrant pain, fever, elevated white blood count. This

is emphysematous cholecystitis. Cultures of the gallbladder grew Clostridium perfringens

Air in GB,air/fluid level

Air in thewall of the GB

Case VV

A 35 year old man presents with 12 hours of pain that began as a constant “aching”, “sharp” mid abdominal pain that slowly moved to the right upper quadrant.

The patient is tachycardic (P=98) with a low grade fever (100˚F) and on abdominal examination has moderate pain on palpation in the periumbilical/epigastric region and severe pain in the right upper quadrant.

Laboratory studies are normal except for a mild leukocytosis (WBC 11,000).

• A patient has pain in the epigastric region that began 2 days ago. What organs could be reponsible for this pain?

• What do each of the following pain patterns suggest as etiologies?

– Sharp/severe penetrating pain radiating through to the back.

– Dull aching pain that increased over several hours and then moved to the RUQ?

– Burning epigastric pain that did not radiate?

Case WW

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