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/l
K = 40
Cl = 40
Stool/plasma osmolality = 295
Stool osmotic gap = ????
Diagnostic possibilities?
Analysis of Fecal Electrolytes – normal values
Sodium
Potassium
Chloride
HCO3Anions (SO4-2,
PO4-3, fatty acids)
Magnesium
~20-40 mEq/l
~90
~15
~30
~85
Volume
0.2-0.4 liters/day
Plasma osmolality
Stool osmolality
Osmotic gap
~290-300 mEq/l
~290-300 mEq/l
~40-70
Fecal pH
> ~5.4
~10-20
Analysis of Fecal Electrolytes - I
Sodium
Potassium
Chloride
Magnesium
105
30
69
15
Electrolyte pattern?
Volume
3 liters/day
Plasma osmolality
Stool osmolality
295 mEq/l
301 mEq/l
Osmotic gap?
Fecal pH
> 5.4
Analysis of Fecal Electrolytes - II
Sodium
Potassium
Chloride
22
26
55
Electrolyte pattern?
Volume
1.3 liters/day
Plasma osmolality
Stool osmolality
295 mEq/l
299 mEq/l
Osmotic gap?
Fecal pH
> 5.4
Analysis of Fecal Electrolytes - III
Sodium
Potassium
Chloride
Magnesium
43
89
18
18
Electrolyte pattern?
Volume
0.28 liters/day
Plasma osmolality
Stool osmolality
295 mEq/l
302 mEq/l
Osmotic gap?
Analysis of Fecal Electrolytes - IV
Sodium
Potassium
Chloride
32
28
10
Electrolyte pattern?
Volume
1.5 liters/day
Plasma osmolality
295 mEq/l
Osmotic gap?
Analysis of Fecal Electrolytes - V
Sodium
Potassium
Chloride
Magnesium
20
45
10
10
Electrolyte pattern?
Volume
1.1 liters/day
Plasma osmolality
Stool osmolality
295 mEq/l
140 mEq/l
Osmotic gap?
Analysis of Fecal Electrolytes - VI
Sodium
Potassium
Chloride
Magnesium
103
42
18
11
Electrolyte pattern?
Volume
1.8 liters/day
Plasma osmolality
Stool osmolality
295 mEq/l
303 mEq/l
Osmotic gap?
Analysis of Fecal Electrolytes – secretory
diarrhea
Sodium
Potassium
Chloride
Magnesium
Electrolyte pattern?
Volume
Plasma osmolality
Stool osmolality
Osmotic gap?
Fecal pH
105
30
69
15
3 liters/day
295 mEq/l
301 mEq/l
> 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?
Case – H II
200 cm ileum
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?
Case K
• 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 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 leftsided 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- I
An 18 year old girl presents with an 8 week history of mild midabdominal 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
Hct
MCV
Platelets
10,000
32
95
250,000
(nl 4,000-8,000)
(nl 36-45)
(nl 80-99)
(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-1
A 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 - 2
On 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
Hct.
Platelets
PT
7.5
22
200,000
12 sec
What does this tell you?
What do you do next?
(nl ≤ 10)
(nl 36 - 45)
(nl 150,000 - 350,000)
(nl 9 - 12.5 sec)
Case U
A 35 year old man comes to see you for a general medical
examination.
When you take a history, you find out that his paternal
grandfather, father’s brother and his older brother all have
colon cancer.
What are your concerns about your patient?
What more information might you want to get from the
history?
What do you advise your patient to do and why?
Case V
• 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?
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 1
Laboratory 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)
Case 2
Laboratory Findings
Bilirubin
8.5
(0.2-1.2 mg/dl)
Alkaline Phos.
675
(23-100 IU/ml)
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)
Case 3
Laboratory Findings
Bilirubin
3.5
(0.2-1.2 mg/dl)
Alkaline Phos.
190
(23-100 IU/ml)
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)
Case 4
Laboratory Findings
Bilirubin
0.8
(0.2-1.2 mg/dl)
Alkaline Phos.
90
(23-100 IU/ml)
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)
Case 5
Laboratory Findings
Bilirubin
9.0
(0.2-1.2 mg/dl)
Alkaline Phos.
175
(23-100 IU/ml)
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)
Case 6
Laboratory Findings
Bilirubin
9.0
(0.2-1.2 mg/dl)
Alkaline Phos.
200
(23-100 IU/ml)
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)
Case 7
Laboratory Findings
Bilirubin
1.0
(0.2-1.2 mg/dl)
Alkaline Phos.
555
(23-100 IU/ml)
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)
Case 8
Laboratory Findings
Bilirubin
3.0
(0.2-1.2 mg/dl)
Alkaline Phos.
120
(23-100 IU/ml)
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:
AST/ALT
Alk Phos
Prothrombin time
sec)
5.6
1500/1900
330
11.5 sec
(nl <1.1 mg/dl)
(nl<70 IU)
(nl<110 IU)
(nl<12
• 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
negative
IgM antibody
IgG antibody
Hepatitis B
negative
positive
negative
negative
negative
negative
negative
sAg (surface antigen)
sAB (surface antibody)
IgM antibody to core
IgG antibody to core
eAg (e antigen)
eAB (e antibody)
DNA
Hepatitis C
negative
negative
antibody (IgG)
RNA by PCR
Hepatitis D
negative
negative
negative
RNA by PCR
IgM antibody
IgG antibody
Hepatitis E
negative
negative
IgM antibody
IgG antibody
Analysis of Hepatitis Tests
Hepatitis A
negative
negative
IgM antibody
IgG antibody
Hepatitis B
negative
positive
negative
positive
negative
negative
negative
sAg (surface antigen)
sAB (surface antibody)
IgM antibody to core
IgG antibody to core
eAg (e antigen)
eAB (e antibody)
DNA
Hepatitis C
negative
positive
antibody (IgG)
RNA by PCR
Hepatitis D
negative
negative
negative
RNA by PCR
IgM antibody
IgG antibody
Hepatitis E
negative
negative
IgM antibody
IgG antibody
Analysis of Hepatitis Tests
Hepatitis A
negative
positive
IgM antibody
IgG antibody
Hepatitis B
negative
negative
negative
negative
negative
negative
sAg (surface antigen)
IgM antibody to core
IgG antibody to core
eAg (e antigen)
eAB (e antibody)
DNA
Hepatitis C
negative
negative
antibody (IgG)
RNA by PCR
Hepatitis D
negative
negative
negative
RNA by PCR
IgM antibody
IgG antibody
Hepatitis E
positive
negative
IgM antibody
IgG antibody
Analysis of Hepatitis Tests
Hepatitis A
negative
positive
IgM antibody
IgG antibody
Hepatitis B
positive
negative
positive
negative
positive
negative
positive
sAg (surface antigen)
sAB (surface antibody)
IgM antibody to core
IgG antibody to core
eAg (e antigen)
eAB (e antibody)
DNA
Hepatitis C
negative
negative
antibody (IgG)
RNA by PCR
Hepatitis D
negative
negative
negative
RNA by PCR
IgM antibody
IgG antibody
Hepatitis E
negative
negative
IgM antibody
IgG antibody
Analysis of Hepatitis Tests
Hepatitis A
negative
positive
IgM antibody
IgG antibody
Hepatitis B
positive
negative
negative
positive
negative
positive
negative
sAg (surface antigen)
sAB (surface antibody)
IgM antibody to core
IgG antibody to core
eAg (e antigen)
eAB (e antibody)
DNA
Hepatitis C
negative
negative
antibody (IgG)
RNA by PCR
Hepatitis D
positive
positive
negative
RNA by PCR
IgM antibody
IgG antibody
Hepatitis E
negative
negative
IgM antibody
IgG antibody
Analysis of Hepatitis Tests
Hepatitis A
negative
negative
IgM antibody
IgG antibody
Hepatitis B
negative
negative
negative
negative
negative
negative
negative
sAg (surface antigen)
sAB (surface antibody)
IgM antibody to core
IgG antibody to core
eAg (e antigen)
eAB (e antibody)
DNA
Hepatitis C
positive
positive
antibody (IgG)
RNA by PCR
Hepatitis D
negative
negative
negative
RNA by PCR
IgM antibody
IgG antibody
Hepatitis E
positive
negative
IgM antibody
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 stain
Trichrome 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 of
new onset ascites.
You perform a paracentesis and send the fluid for a variety
of tests.
The tests come back and your resident asks you to interpret
the 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 Analysis
Test
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?
- Peritonitis
Non-cirrhotic portal hypertension
“Hydrodynamic/transudative”
“Exudative”
Ascites Fluid Analysis
Test
Ascites
Serum
Total protein
6.5
7.5
(8-9g/dl)
Albumin
3.5
4.3
(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?
What more could you do?
Ascites Fluid Analysis
Test
Ascites
Serum
Total protein
7.4
7.5
(8-9g/dl)
Albumin
3.4
4.1
(3.5-5.0g/dl)
Cell count (PMNs)
10
4000
(2000-6000)
Triglycerides
15
150
(<160mg/dl)
Amylase
950
40
(0-130 U/l)
How would you interpret these results?
Ascites Fluid Analysis
Test
Ascites
Serum
Total protein
6.5
7.5
(8-9g/dl)
Albumin
3.6
4.5
(3.5-5.0g/dl)
Cell count (PMNs)
10
4000
(2000-6000)
Triglycerides
820
150
(<160mg/dl)
Amylase
20
40
(0-130 U/l)
How would you interpret these results?
Ascites Fluid Analysis
Test
Ascites
Serum (normal)
Total protein
3.5
7.5
(8-9g/dl)
Albumin
2.5
4.5
(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?
Ascites Fluid Analysis
Test
Ascites
Serum (normal)
Total protein
2.6
7.6
(8-9g/dl)
Albumin
1.0
2.8
(3.5-5.0g/dl)
Cell count (PMNs)
774
8300
(2000-6000)
Triglycerides
15
150
(<160mg/dl)
Amylase
20
40
(0-130 U/l)
How would you interpret these results?
Ascites Fluid Analysis
Test
Ascites
Serum (normal)
Total protein
6.8
7.6
(8-9g/dl)
Albumin
3.9
4.3
(3.5-5.0g/dl)
Cell count (PMNs)
10,200
18,950 (2000-6000)
Triglycerides
15
150
(<160mg/dl)
Amylase
20
40
(0-130 U/l)
How would you interpret these results?
What other tests might be abnormal?
Ascites Fluid Analysis
Test
Ascites
Serum (normal)
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).
What is your differential diagnosis?
Case KK - 1: This patient has epigastric pain
and nausea/vomiting. What do you see?
Case LL
• 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?
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?
Case QQ
• 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 RR
Three patients are admitted to your service1. one has nausea, vomiting and dehydration
due to gastric outlet obstruction,
2. one is jaundiced, and
3. 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 - 1
A 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.
What is your differential diagnosis?
What do you do next?
Case TT - 2
WBC
14,000
(nl ≤ 10)
Hct
45
(nl 36 - 45)
Platelets
250,000
(nl 150,000 - 350,000)
Elecrolytes, Bun, Cr normal
AST
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 normal
Lipase
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?
Case UU
A patient comes to see you as he had an x-ray done
when 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?
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 the
wall 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).
What is your differential diagnosis?
What do you do next?
Case WW
• 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?