CASE 1:

1

• CASE 1
• A 66-year-old Chinese male (S.H.) is referred to
  you by his family physician because of pain in
  the right upper quadrant. The pain has
  occasionally radiated to the back. He also noted
  darkening of his urine recently and was concerned
  that his skin was very itchy, day and night. He
  had lost no weight, his appetite was good, except
  when he was in pain, which occurred about six
  times in the past three months. He had no other
  symptoms.
• His past history revealed that he underwent a
  cholecystectomy 15 years ago for gallstones. He
  does not recall if jaundice was present. The
  operation was uncomplicated, but he remained in
  hospital for three weeks because he said he had a
  prolonged fever. He also had a kidney stone in
  the past which resolved with no intervention.
• S.H. was subject to chronic headaches and took
  codeine-containing analgesics at least three
  times a month. He was also taking
  antihypertensive medication for the past five
  years. His health was otherwise good

2

• Physical Examination
• The patient was not distressed. He was obviously
  jaundiced. His blood pressure was 145/95 mmHg. No
  abnormalities were noted otherwise, except for a
  well-healed scar in the right upper quadrant and
  some minor tenderness in the area. His liver and
  spleen were not palpable and no other masses were
  noted. Rectal examination revealed a slightly
  enlarged prostate and clay-coloured stool on the
  examining glove.
• The skin was jaundiced but no bruising or any
  other stigmata of chronic liver disease were
  present.
• Laboratory Results
• Results
• Normal Values
• Hemoglobin 165 g/L 125-160 g/L
• White blood cell count 9.8 x 109/L 4.0 - 10.0 x
  109/L
• AST 145 U/L 15 - 50 U/L
• Alkaline phosphatase 345 U/L 30 - 115 U/L
• GGT 560 U/L 25 - 50 U/L
• PT 12 sec 11.5 - 12.5 sec

3

• Diagnostic Imaging
• Abdominal ultrasound was performed by the
  referring physician which was reported as
  demonstrating a dilated common bile duct, a
  normal liver, a normal head of the pancreas and
  an obscured body and tail of the gland, due to
  intraintestinal gas. In addition, the kidneys and
  aorta were reported as normal. A chest X-ray was
  normal. A CAT scan was performed to better
  visualize the pancreas, which was normal.
  Dilatation of the common bile duct was confirmed.

4

• Course of Action
• After informed consent was obtained, an ERCP was
  performed and both the pancreatic duct and
  biliary duct were successfully opacified. There
  were stones in the common duct as noted on the
  X-ray. A papillotomy was performed and the stones
  were removed with a balloon. The patient was
  observed for four hours in the Day Care
  Department and was discharged. He was seen two
  weeks later and was well. His jaundice  had
  disappeared, his itch had subsided and he no
  longer  had any pain.

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• 1. ERCP and papillotomy is
• a) Only indicated in debilitated patientsb) Only
  indicated when surgery is too dangerousc) The
  procedure of choice in biliary tract obstruction,
  due to stonesd) Contraindicated if pancreatitis
  is present

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• The correct answer is (c)  -
• ERCP and papillotomy is the procedure of choice
  in this condition of retained common bile duct
  stones.

7

• 2. In the above patient, you are unable to enter
  the bile duct. One of the suggestions below is
  not recommended.
• a) Treat the patient with ursodeoxycholic acid by
  mouthb) Perform a precut papillotomy and try
  again next weekc) Attempt to enter the duct by
  cutting the intraduodenal portion of the duct
  above the papilla (infundibulotomy) d) Refer to
  radiology to attempt a transhepatic approach
  combined with another attempt at ERCP

8

• Question 2 - The correct answer is (a)
• Ursodeoxycholic acid is a bile salt used with
  some success to dissolve gallstones. It can also
  dissolve fragments of gallstones after
  lithotripsy, however, it has no value in the
  treatment of common bile duct stones

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• 3. Which of the following is the most common
  complication of ERCP and papillotomy
• a) Pancreatitisb) Cholangitisc) Perforationd)
  Hemorrhagee) Ileus

10

• CASE 2
• B.K. is a 56 year old male who has been a heavy
  drinker for most of his adult life. A year ago he
  consulted his family physician who suspected the
  presence of ascites on abdominal examination and
  referred him to the liver clinic.
• The patient had worked on the railways as a
  maintenance engineer most of his life. He used to
  consume three to six beers most evenings of the
  week, together with one to two glasses of rye. On
  Friday evening, and throughout the weekend he
  used to drink ten beers each day. Three years ago
  with his two children married and living in other
  cities, his wife died leaving him feeling very
  much alone. As a result, his alcohol intake had
  increased significantly.

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• Initial Physical Examination
• On examination he appeared to be about his stated
  age and was 173 cm tall and 74.5 kg in weight.
  Examination of his hands revealed bilateral mild
  Dupuytren's contractures and palmar erythema.
  Several spider nevae were noted to be present
  over the front and back of his upper trunk. There
  was bilateral gynecomastia and generalised muscle
  wasting. CVS examination demonstrated a blood
  pressure of 90/60 mmHg, a heart rate of 92
  beats/min and normal heart sounds with a
  midsystolic flow murmur. The abdomen was
  distended with marked fullness in both flanks.
  The liver was palpable with an enlarged left lobe
  which was hard and irregular. The spleen tip was
  ballotable. On percussion there was marked
  dullness in both flanks which shifted when the
  patient turned on his side and a fluid thrill was
  detected.

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• Laboratory Results
• Results
• Normal Values
• Hemoglobin 142 g/L 125-160 g/L
• White blood cell count 3.4 x 109/L 4.0-10.0 x
  109/L
• Platelet count 65 x 109/L 150-350 x 109/L
• Prothrombin time 15.5 sec. (control 11 sec.)
• INR 1.4
• Creatinine 110 µmol/L
• Blood urea nitrogen 2.6 mmol/L 3.6-7.1 mmol/L
• Sodium 140 mmol/L 136-145 mmol/L
• Potassium 3.5 mmol/L 3.5-4.5 mmol/L
• Bilirubin 35 umol/L 15-25 umol/L
• AST 120 U/L
• ALT 55 U/L
• ALP 120 U/L

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• Laboratory Results
• Albumin 28 g/L 35-50 g/L
• Globulin 45 g/L
• HBsAG negative
• Anti-HCV negative
• TSH 1.5 mU/L 1-5 mU/L

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• http//cppweb.bsd.uchicago.edu/liver.new/liverTOC.
  html

15

• History
• Chief Complaint
• This is the second hospital admission for a 47
  year old male postal clerk who presents with a
  chief complaint of chronic diarrhea.
• History of Present Illness
• He was admitted to another hospital for abdominal
  pain. X-ray studies revealed a gastric ulcer
  which had not healed despite medical therapy. A
  60 distal gastrectomy was performed and a
  gastrojejunostomy was created. Examination of
  resection specimen revealed a benign gastric
  ulcer. Shortly after discharge the patient noted
  a change in bowel habits to 8 to 12 malodorous,
  greasy, floating stools per day. He lost 28 Kg
  over a six month period despite a good appetite.
• Past Medical HistoryPrior Significant or
  Chronic Medical Illness
• None

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• Medications Allergies
• Medications
• None
• Vitamins Supplements MVI QD
• Allergies NKDA (No known drug allergies)
• Preventive Health
• Cholesterol screening Last lipid panel within
  NCEP (National cholesterol education project)
  guidelines
• Cancer Screening
• Last PSA (prostate specific antigen) Not
  applicable
• Last colonoscopy Not applicable
• Habits
• Exercise rarely
• Nutrition Appetite is poor.
• Safety
• Guns None
• Seat belts Always worn
• Bike helmets Not applicable

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• General Appearance
• The patient is emaciated, weighing 58 kg, and
  appears chronically ill.
• SKIN
• The skin is scaly.
• Vital Signs
• Blood pressure 120/80, pulse 76 and regular,
  temperature 37.0, respiratory rate 16
• HEENT
• EOMI (ExtraOcular Movements intact), PERRLA
  (pupils equal, round, reactive to light and
  accomodation), no hemorrhages or exudates TMs
  (tympanic membranes) WNL (within normal limits),
  pharynx benign, good dentition
• Lungs
• No scars or deformitiesNo dullness to
  percussionClear to auscultation bilaterally
  without crackles or wheezes
• Cardiovascular
• JVD not increasedPMI 5th ICS (intercostal
  space), MCL (mid clavicular line)Rate/Rhythm
  regular rate and rhythmHeart sounds Normal S1
  and S2, without S3, S4 or rubsMurmurs
  nonePeripheral pulses full

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• Abdominal Exam
• Appearance Flat, not distended, no scars or
  deformitiesBowel Sounds normalPalpation
  nontender. No rebound or guarding. No
  hepatosplenomegaly. Liver span normal 11
  cmRectal No mass, stool was FOBT negative.
• Genital Exam
• Circumcised phallus without external
  lesions.Testicles symmetric without masses or
  epididymal tenderness. No inguinal hernias
  palpated.
• Extremities
• 2 ankle edema
• Lymphatic Exam
• No pathologically enlarged lymph nodes in the
  cervical, supraclavicular, axillary or inguinal
  chains

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• Neurologic Exam
• Mental status The patient was alert and oriented
  X 3.
• Mini-mental state examination revealed a score of
  30/30
• Cranial Nerves II - XII were intact
• Motor exam 5/5 strength in the upper and lower
  extremities
• Sensory exam Intact to pinprick, light touch and
  proprioception
• Coordination exam Finger to nose, rapid
  alternating movements, heal to shin, Romberg and
  gait were all within normal limits
• Reflexes were 2 throughout, plantar toes were
  down going
• INITIAL LABORATORY DATA
• Hematocrit 35, MCV 95, MCHC 32, WBC 7,500 with a
  normal differential, but hypersegmented
  neutrophils and macrocytes and hypochromatic RBCs
  are present. Electrolytes are normal except for
  Ca 7.8 mg. Total protein 7g/dl, albumin 2.2g/dl.
  

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• Construct a problem list for this patient
  (remember a problem is any issue on history,
  physical exam, or any lab/test abnormality that
  requires evaluation or therapy.)

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• Chronic Diarrhea
• Weight loss
• Cachexia
• Hypoalbuminemia
• Ankle Edema
• Megaloblastic anemia
• Hypochromasia
• Greasy foul smelling stools
• S/P Gastric ulcer
• S/p Gastojejunostomy

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• For the main problem, what is your leading
  hypothesis? What other alternative hypotheses
  should be considered?
• Several possibilities come to mind. As a rule of
  thumb, Steatorrhea can be seen with mucosal or
  pancreatic insufficiency. In this case, one might
  consider whether the prior surgery for gastric
  ulcer has caused the diarrhea. This can occur for
  several reasons. First, if enough of the small
  bowel is bypassed, this can result in
  malabsorption. Additionally, if there is a lack
  of the pylorus due to surgery, this leads to
  "dumping" of nutrients into the intestine with
  resultant intestinal hurry and malabsorption.
  Finally surgery can inadvertently create blind
  loops, part of the intestine that is not within
  the main flow of nutrients. This can result in
  bacterial overgrowth and diarrhea. Other small
  bowel disease can cause malabsorption. (Celiac
  sprue, or Crohn's disease). As noted above,
  pancreatic insufficiency can also cause
  steatorrhea. A final possiblity would be diarrhea
  due to Zollinger-Ellison Syndrome (Z-E syndrome).
  This is rare disorder due to hypergastrinemia and
  subsequent hyperchlorhydria. This can cause
  refractory peptic ulcer disease. Additionally the
  high levels gastric acid output can neutrolize
  pancreatic enzymes and can cause malabsorption.

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• Tests
• Intestinal mucosal disease
• Celiac sprue
• IgA endomysial antibodies sensitivity 85 to 98
  percent specificity 97 to 100 percent
• IgA tissue transglutaminase antibodies
  sensitivity 90 to 98 percent specificity 95
  to 97 percent
• Small bowel biopsy
• Crohn's disease can be diagnosed by several
  modalities
• Small bowel study demonstrating fistula
• Small bowel biopsy
• Certain antibodies increase the likelihood of
  Crohn's disease. In short patients with Crohn' s
  are often pANCA negative and ASCA . While not
  highly sensitive (about 50) this pattern is
  highly specifice (97). (Which implies that if
  you do not see this pattern you can not r/o
  Crohn's. On the other hand if you do see this
  pattern you can usually rule in Crohn
• Bacterial overgrowth
• Often diagnosed by a response to an empirical
  trial of antibiotics
• Short gut Upper GI (barium study) to define the
  anatomy
• Pancreatic insufficiency
• 24 hour fecal fat
• One could also look for pancreatic calcifications
  on plain abdominal film or CT scan
• Zollinger-Ellison Syndrome (Z-E syndrome)
• Fasting serum gastric level

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• Bacterial overgrowth
• Often diagnosed by a response to an empirical
  trial of antibiotics
• Short gut Upper GI (barium study) to define the
  anatomy
• Pancreatic insufficiency
• 24 hour fecal fat
• One could also look for pancreatic
  calcifications on plain abdominal film or CT scan
  
• Zollinger-Ellison Syndrome (Z-E syndrome)
• Fasting serum gastric level

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• Considering several of the problems noted above
• Megaloblastic changes
• B12
• Folic acid
• Hypochromasia
• Ferritin
• Iron and TIBC
• Xylose absorption Xylose is a simple molecule
  which needs no digestion to be absorbed. Thus in
  pancreatic disease, xylose absorption is still
  normal. On the other hand mucosal disease can
  interfere with its absorption.
• What does this test? ....Integrity of the mucosa
• How to do the test? ..... 25 mg of oral d-xylose
  is given
• Normally 20-35 appears in the urine ie 4.5-7.5 g
  in a 5 hour collection

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• Stool smear - several large fat globules
• Fecal fat 32 gm/24 hours  (normal less than 6
  gm/24 hours)
• Serum iron 20 mg/dl (normal 50-100) TIBC 200
  m/dl (normal 250-410) ferritin 5mg/dl (normal
  30-300)
• Magnesium 1.0 mg/dl  (normal 1.6-2.5)
• Serum B12 200 ng/ml (normal gt300 )
• Folate 2.0 ng/ml (normal 3.6)
• Xylose absorption 1.3 g excreted in urine in 5
  hours after 25 g oral dose (normal 4-8 g)