Gastroenterology:
Clinical Case Discussion
Nav Saloojee MD FRCPC
Case 1 ODYNOPHAGIA
• 35 y.o homosexual male presents with
odynophagia.
• HIV for about 5 years. CD4 100. VL 5000.
• Hep C from IV drug use
• No AIDS defining illnesses and has been
noncompliant with antiretroviral therapies.
•Physical exam is unremarkable except for
the presence of oral thrush.
Filling defects on barium study.
Esophageal plaques on EGD
Odynophagia
Infection
Candida
CMV
HIV ulcers
HSV
Pill esophagitis
Tetracycline/doxycycline
NSAIDS
Slow K
Iron
Others
Inflammatory
• ( Severe GERD, Crohn’s, Behcet’s, Pemphigoid,
Chemo / radiation )
Toxic ingestion
Lye
Esophageal Disease In HIV
• Esophageal candidiasis
• ~80% will develop esophageal symptoms but some
asymptomatic
• CD4 generally 100 cm
•Bile salt malabsorption
•bile salt loss exceeds hepatic synthetic capacity
•depletion of the bile salt pool.
•resultant fat malabsorption, fat soluble vitamin
malabsorption and Ca Oxalate stones
•Cholestyramine enhances diarrhea due to worsened fat
malabsorption. Rx Low fat diet or MCT.
Case 7
• 57-year-old man
• Recently diagnosed as having ulcerative colitis
• Presents with persistent bloody diarrhea
• Abdominal pain
• He had a fever of 38.8 degrees. HR 120. BP 110 / 70
• Decreased bowel sounds, and a tense, mildly
distended abdomen.
• WBC 15
Case 7
Diagnosis?
Treatment ?
Toxic Megacolon
Differentiate from ileus where there is no colonic
inflammation
Inflammation leads to colonic paralysis
Can result from IBD / Ischemia / Infectious colitis
X-ray evidence of colonic distension. > 6 cm in
transverse colon
Fever, tachycardia, high WBC
High mortality with perforation
Remember, perforation can occur in ulcerative colitis
(or other forms of colitis ) without toxic megacolon
Toxic Megacolon : Treatment
NPO, F&E, NG
IV Solumedrol 20 mg q8h for 24 hours
Immediate surgical consult
Colectomy if fails to resolve in 24-48 hours or if
peritoneal signs
Case 8
• What is the likely diagnosis?
• What is the likely presentation?
Case 9
Colon Cancer at cecum.
What was the likely presentation?
Colon Cancer
•Proximal Colon Cancers tend to grow larger before causing
symptoms
•Iron deficiency is a common presentation for Right colonic tumours
•The left colon has a narrower lumen and is more prone to
obstruction
•Left Colonic tumours are more likely to present with altered bowel
habit or hematochezia
Case 10 . Lower GI Bleed.
•74 year old woman
•Presents to the Emergency with 4 episodes of passing blood per
rectum that day
•No abdominal pain, or other GI symptoms
•Past history of mild chronic renal failure due to hypertension
•On an ACE inhibitor. No other medications
•BP 150/90. HR 90. No postural changes
•Physical exam normal except red blood on rectal exam
•Hb 120. MCV normal. Urea 17. Creatinine 210. Other labs normal.
•Receives appropriate supportive care
Lower GI Bleed
•DDX
• Diverticular Bleed
• Angiodysplasia
• Colon Cancer
• Ischemic Colitis
• Consider a brisk upper GI bleed
• Other causes less common
•Investigation
• If Hemodynamic changes, consider EGD
• If bleeding stops or only mild / moderate, then colonoscopy
• If severe bleeding persists, angiogram to localize source and
possibly embolize
• Surgery if continued bleeding
Endoscopic Management of
Acute Lower GI Bleeding
Approach to Lower GI Bleed
Acute Lower GI Bleed
Resuscitate
EGD if UGIB suspected
Bleeding Stops Bleeding Persists
Colonoscopy after Angiogram to localize bleed
bowel preparation
Refer to surgery
Case 10
• Angiodysplasia at cecum on colonoscopy. Cauterized.
• No rebleeding
• Angiodysplasia seem to be a more common source of LGIB
in patients with CRF
•Small bowel angiodysplasia detected on enteroscopy
•Patient had required transfusions approximately every 3 weeks
for 2 years. Over 50 units prbcs transfused.
•Previous EGD x2, Colonoscopy x2, SBFT, CT abdo and
angiogram
•Lesion cauterized