GI endoscopy quizAna Ignjatovic

Brian P Saunders

Questions

Case 1

A 70-year-old asthmatic patient presents with pain on

eating. An OGD is performed (Figure 1).

1. What is the most likely diagnosis in the oesophagus?

Case 2

A 72-year-old woman presents with iron deficiency anaemia.

Colonoscopy is normal. An OGD is performed at the same time

(Figure 2).

1. What abnormality is demonstrated in the stomach?

2. How is this condition best treated endoscopically?

Case 3

A 67-year-old man presents with haematemesis and melaena. An

OGD reveals a normal oesophagus and stomach but a lesion in

the duodenal bulb is seen (Figure 3).

1. What is the lesion?

2. Which pathogen is associated with these lesions?

Case 4

A 65-year-old man presents with rectal bleeding. He has previ-

ously had radiotherapy for prostate cancer. At colonoscopy this

appearance is seen in the rectum (Figure 4).

1. What is the likely diagnosis?

2. What are the treatment options?

Figure 1 Figure 3

QUIZZESShe is training as a Specialist Registrar in Gastroenterology and General

Medicine in the Oxford region, UK. Competing interests: none declared.

Brian P Saunders FRCP is a Consultant Gastroenterologist and Specialist

Endoscopist and the Director of the Wolfson Unit for Endoscopy at St

Marks Hospital, Harrow, UK. Competing interests: none declared.Ana Ignjatovic MRCP is a Research Fellowat StMarksHospital, Harrow, UK.Figure 2MEDICINE 39:3 195Figure 4 2010 Published by Elsevier Ltd.

Case 5

A 20-year-old man presents with diarrhoea and rectal bleeding.

Flexible sigmoidoscopy is performed. Figure 5 shows macro-

scopic appearance of the rectum.

1. What is the most likely diagnosis?

2. Which of the following would you expect to find on

histopathology

Crypt abscesses Granulomas Preserved crypt architecture

Case 6

A 70-year-old man with history of atrial fibrillation and diabetes

presents with bloody diarrhoea, hypotension and raised lactate.

The image shows the colonoscopic appearance of the sigmoid

colon (Figure 6).

1. What is the diagnosis?

Case 7

Figure 7 is the colonoscopic image of a rectum in a 50-year-old

woman with a long history of constipation who presented with

mucous discharge and tenesmus.

1. What is the diagnosis?

2. Does it need endoscopic resection?

An 80-year-old woman was treated with intravenous benzylpe-

nicillin and flucloxacillin for a left leg cellulitis. After 5 days of

treatment she developed profuse diarrhoea, abdominal pain and

raised white cell count.

1. What does the sigmoidoscopy show? (Figure 8).

2. Should intravenous vancomycin be used as a treatment?

Figure 5

QUIZZESFigure 6MEDICINE 39:3 196Figure 8Case 8Figure 7 2010 Published by Elsevier Ltd.

Case 9

This polypoid lesion was seen in the caecal pole of a 65-year-old

patient attending for colonoscopy as part of the national BCSP

(FOBT). This is an image of the caecum at colonoscopy(Figure 9).

1. Should this be endoscopically resected?

nged

(Figure 10).

1. What is the abnormality seen on capsule and MRI (arrowed)?

2. What other features are typical of PJS?

3. Which gene is commonly associated with PJS?

1. Gastric antral vascular ectasia (GAVE).

Helicobacter pylori and NSAIDs are the two most common causes

alfate

enemas, hyperbaric oxygen.

1. Ulcerative colitis.

spital

QUIZZESFigure 10endoscopy, followed by MR enterography was arraCase 10

An 18-year-old patient, known to have PeutzeJeghers syndrome

(PJS), presented with iron deficiency anaemia and intermittent

abdominal pain. OGD and colonoscopy were normal. The

anaemia persisted despite iron supplements and a capsule

Figure 9MEDICINE 39:3 197management with intravenous corticosteroids as first line.to moderate ulcerative colitis include oral and topical mesal

(rectal enemas). Acute severe colitis requires in-ho2. Crypt abscesses.

Ulcerative colitis is a chronic, relapsing and remitting inflamma-

tory condition that is often present in young adults. Inflammation

is circumferential and continuous and extends from rectum

proximally. Typical histological appearances include disruption of

normal crypt architecture, crypt abscesses and inflammatory cell

infiltrate. Granulomas are diagnostic of Crohns disease and are

generally not seen in ulcerative colitis. Treatment options for mild

azineCase 5Radiation proctitis is seen in patients who have undergone pelvic

radiotherapy, most commonly for prostate cancer. Patients

typically present with rectal bleeding, diarrhoea and tenesmus.

Isolated telangiectasia can be treated with argon plasma coagu-

lation to attempt to stop the bleeding. Topical application of

formalin and sucralfate enemas may be used with patients who

have more diffuse disease.2. Argon plasma coagulation, topical formalin, sucrof duodenal ulcers. Eradication of H. pylori and protein pump

inhibitors (PPIs) are the treatments of choice for non-bleeding

ulcers. Dual endoscopic therapy, using adrenaline (epinephrine)

injection, thermal therapy or clips, is the first-line treatment for

ulcers that have evidence of recent haemorrhage.

Case 4

1. Radiation proctitis.2. Helicobacter pylori.2. Argon plasma coagulation (APC).

GAVEhas characteristic appearance of ectatic vessels radiating out

from the pylorus giving it a watermelon appearance. Most cases

occur in patients aged >70. Association with cirrhosis and

systemic sclerosis has been documented. Argon plasma coagula-

tion to destroy the ectatic blood vessels is used to try to control the

bleeding. Multiple sessions of APC therapy may be necessary.

Case 3

1. Duodenal ulcer.Case 2Answers

Case 1

1. Oesophageal candidiasis.

Immunocompromised states, such as HIV, chemotherapy, dia-

betes mellitus, older age, inhaled corticosteroid therapy (in this

case), alcoholism and acid-suppression predispose patients to

Candida oesophagitis. Typical endoscopic appearance is of

multiple, discrete white plaques coating the oesophagus, which

cannot be washed off. Biopsies or brushings should be taken and

patients treated with antifungal medication. 2010 Published by Elsevier Ltd.

Case 6

1. Ischaemic colitis.

Ischaemic colitis develops as a result of inadequate blood flow to

the colon and is usually preceded by hypotension, myocardial

infarction or cardiac insufficiency. It often presents with rectal

bleeding, abdominal pain and leucocytosis and raised plasma

lactate. Endoscopic appearances range from granular, haemor-

rhagic mucosa to ulceration and necrosis. Initially, patients are

managed with intravenous antibiotics, but severe cases may

require surgical intervention.

Case 7

1. Solitary rectal ulcer syndrome.

2. No.

Solitary rectal ulcer syndrome is a rare disorder with incom-

pletely understood pathophysiology. Erythematous mucosa,

polypoid lesions and shallow ulcers are typically seen at endos-

copy. Differential diagnosis includes malignancy, infection and

inflammatory bowel disease (especially Crohns disease). Diag-

nosis is made on the basis of histopathological examination.

Treatment is difficult and includes bulk laxatives, behavioural

modification (biofeedback) and surgery for patients with massive

bleeding or obstructive symptoms.

Case 8

1. Pseudomembranous colitis.

2. No.

clindamycin and amoxicillin predispose to C. difficile infection,

which can range in severity from asymptomatic carriage to acute

severe colitis. Pseudomembranous colitis represents the severe

end of the spectrum and should be treated by oral metronidazole

or vancomycin. Intravenous vancomycin does not reach bacte-

ricidal concentrations in the colon and is an ineffective treat-

ment. Metronidazole can be used orally or intravenously. Severe

cases of pseudomembranous colitis may require colectomy.

Case 9

1. No e this is an inverted appendix.

An inverted appendix or buried appendix stump post-appendi-

cectomy could be mistaken for a polyp. Resecting it endoscopi-

cally would result in perforation.

Case 10

1. A hamartomatous PJS polyp.

2. Muco-cutaneous pigmentation and hamartomatous polyps of

the small intestine, colon and rectum.

3. STK11 (LKB1).

PJS is an autosomal dominant condition, associated with a muta-

tion in STK11 (LKB1) gene in up to two-thirds of cases. Presence of

muco-cutaneous pigmentation and hamartomatous polyps of the

small intestine, colon and rectum characterize PJS. Cancers most

frequently associated with PJS include gastrointestinal (gastro-

oesophageal, small bowel, pancreatic and colorectal) and breast

QUIZZESPseudomembranous colitis is almost always caused by infection

with Clostridium difficile, a Gram-positive, spore and toxin-

producing anaerobe. Toxins A and B are produced and cause

mucosal injury and typical pseudomembranes which can be

seen at endoscopy. Antibiotics, especially cephalosporins,MEDICINE 39:3 198cancer. Large polyps (Figure 10 - MRI and capsule views of a small

bowel polyp) frequently bleed or cause intussusception. Patients

may require multiple laparotomies over their lifetime and there-

fore endoscopic management (including single or double balloon

enteroscopy) is preferable where possible (Figure 10). 2010 Published by Elsevier Ltd.

GI endoscopy quizQuestionsCase 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9Case 10

AnswersCase 1Case 2Case 3Case 4Case 5Case 6Case 7Case 8Case 9Case 10