Gastroenterology CLINICAL CASES UNCOVERED Gastroenterology CLINICAL CASES UNCOVERED Satish Keshav MBBCh (Wits), DPhil (Oxon), FRCP (London) Consultant Gastroenterologist and Honorary Senior Lecturer Translational Gastroenterology Unit Nuffi eld Department of Medicine John Radcliffe Hospital Oxford Emma Culver MBChB, BSc (Hons), MRCP Gastroenterology Registrar and Academic Research Fellow Gastroenterology Department Nuffi eld Department of Medicine John Radcliffe Hospital Oxford A John Wiley & Sons, Ltd., Publication This edition fi rst published 2011 © 2011 by Satish Keshav and Emma Culver Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientifi c, Technical and Medical business to form Wiley-Blackwell. Registered offi ce: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identifi ed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientifi c research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specifi c method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifi cally disclaim all warranties, including without limitation any implied warranties of fi tness for a particular purpose. In view of ongoing research, equipment modifi cations, changes in governmental regulations, and the constant fl ow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Keshav, Satish. Gastroenterology / Satish Keshav, Emma Culver. p. ; cm. – (Clinical cases uncovered) Includes bibliographical references and indexes. ISBN 978-1-4051-6975-2 (pbk. : alk. paper) 1. Gastroenterology–Case studies. 2. Digestive organs–Diseases–Case studies. I. Culver, Emma. II. Title. III. Series: Clinical cases uncovered. [DNLM: 1. Digestive System Diseases–diagnosis–Case Reports. 2. Digestive System Diseases– diagnosis–Problems and Exercises. WI 18.2] RC808.K47 2011 616.3΄3–dc22 2010039153 Set in 9/12 pt Minion by Toppan Best-set Premedia Limited 1 2011 Contents Preface, vii How to use this book, viii List of abbreviations, ix Part 1 Basics, 1 Basic science, 1 Approach to the patient, 14 Part 2 Cases, 29 Upper gastrointestinal Case 1 A 61-year-old woman with progressive dysphagia, 29 Case 2 A 52-year-old man with atypical chest pain, 34 Case 3 A 57-year-old woman with upper abdominal discomfort, 40 Case 4 A 36-year-old man with upper abdominal discomfort and heartburn, 45 Case 5 A 27-year-old woman with nausea and vomiting, 51 Case 6 A 73-year-old man with haematemesis and melaena, 56 Case 7 A 68-year-old woman with fatigue, weight loss and altered bowel habit, 63 Lower gastrointestinal Case 8 A 23-year-old woman with constipation, 69 Case 9 A 24-year-old woman with chronic diarrhoea, 74 Case 10 A 51-year-old woman with acute nausea, vomiting and diarrhoea, 80 Case 11 A 79-year-old woman with altered bowel habit and weight loss, 85 Case 12 A 54-year-old man with rectal bleeding, 90 Case 13 A 66-year-old woman with anaemia, 95 v vi Contents Liver disease Case 14 A 64-year-old man with abnormal liver function tests, 100 Case 15 A 45-year-old man with acute jaundice, 109 Case 16 A 53-year-old woman with jaundice and abnormal liver tests, 115 Case 17 A 53-year-old man with abdominal swelling, 120 Case 18 A 36-year-old man who drinks alcohol, 125 Biliary and pancreatic disease Case 19 A 79-year-old man with right upper quadrant colicky abdominal discomfort, 131 Case 20 A 19-year-old man with acute abdominal pain, 136 Nutrition Case 21 A 35-year-old woman with anorexia, 143 Case 22 A 48-year-old man with an increased body mass index, 148 Functional disorders Case 23 A 21-year-old student with chronic abdominal pain, 153 Part 3 Self-assessment, 159 MCQs, 159 EMQs, 162 SAQs, 166 Answers, 167 Further reading, 173 Index of cases by diagnosis, 175 Index, 177 The colour plate section can be found facing p.54. Preface Clinical gastroenterology is both simple and complex. The simplicity comes from the fi nite number of diag- noses that are commonly encountered, and the relatively limited number of symptoms that typically indicate disease of the gastrointestinal system. However, there are hidden depths to the practice of the speciality. Gastroenterologists deal with disease affecting many separate organs that all form part of the same system – the liver, pancreas, stomach, etc. The clinical conse- quences of some diseases can be dramatic and complex, particularly, for instance, dysfunction of the liver. Symptoms such as abdominal pain, altered bowel func- tion and changes in weight can be combined in myriad ways to pose true clinical puzzles. This book aims to guide the reader through this complexity by offer- ing real case studies and showing how, in practice, clinicians can achieve some degree of clarity, and offer to patients a reasonable diagnostic and thera- peutic plan. In the fi rst section, the book offers a basic and brief overview of anatomical, physiological and pharmacologi- cal facts that inform our thinking about gastroenterologi- cal problems, and suggests how best to approach the patient in the second chapter. Thereafter, in the second section, each chapter deals with presenting symptoms and signs and the subsequent chapters are arranged in six sections to cover disease processes affecting the upper gastrointestinal tract, lower gastrointestinal tract, liver, pancreas and biliary tract, nutrition, and so - called func- tional bowel disorders. These are important and often overlooked because there is a profound lack of under- standing about their pathogenesis. However, there are many patients with irritable bowel syndrome and the like, and a robust and reliable clinical approach to treat- ing them is essential. In each of the symptom - or sign - based chapters, the emphasis is on clinical reasoning and strategy, and the reader will have an opportunity to examine how the many possible paths are in practice negotiated to reach a diagnosis and formulate a plan for managing the situa- tion. Exact doses and tests are de - emphasised, while strat- egies, categories and context are highlighted, all within the framework of dealing with the particular human patient whose predicament is being examined. Boxes and lists are strategically placed to aid memory and recall, and to emphasise key facts. The last section, which comprises a set of questions to test understanding, is based on the contents of each chapter, and the empha- sis in these is on core knowledge rather than the esoteric or arcane. Writing this book has proved to be an education as well being hugely enjoyable, and our hope is that the reader too will gain knowledge and understanding of the com- plexity of gastroenterological medicine, whilst acquiring some practical understanding of how to approach the patient with gastrointestinal problems, and some sense of satisfaction and fun. The typical reader might be a medical or nursing student in their clinical years, or a doctor in training, either in their foundation years or in early speciality training. The book will be useful as pre- paratory reading before joining the gastroenterology fi rm in a clinical rotation, or as an aid to revision before written and clinical examinations. Satish Keshav Emma Culver vii How to u se t his b ook Clinical Cases Uncovered (CCU) books are carefully designed to help supplement your clinical experience and assist with refreshing your memory when revising. Each book is divided into three sections: Part 1, Basics; Part 2, Cases; and Part 3, Self - assessment. Part 1 gives you a quick reminder of the basic science, history and examination, and key diagnoses in the area. Part 2 contains many of the clinical presentations you would expect to see on the wards or to crop up in exams, with questions and answers leading you through each case. New information, such as test results, is revealed as events unfold and each case concludes with a handy case summary explaining the key points. Part 3 allows you to test your learning with several question styles (MCQs, EMQs and SAQs), each with a strong clinical focus. Whether reading individually or working as part of a group, we hope you will enjoy using your CCU book. If you have any recommendations on how we could improve the series, please do let us know by contacting us at: