this ppt are educational

2. MORTILITY / MORBIDITY MEETING
FOR THE MONTH OF MARCH 2019
Dr HAFEEZ YAQOOB
R 4 LNH KARACHI

3. C/C
29 Years old F house wife , Married 2 years back
unable to conceive since marriage , R/O Karachi
k/C of Asthma since 2013 .
▪ Presented through OPD on 15/3/19 with C/O
▪ Documented Weight loss of 17 kg ….. For Last 1 yr
▪ Recurrent Abdominal pain for last 4 months
on/off
⮚Loose motions …….. On /off for Last 3 months
⮚Persistent vomiting …… for last Last 15 days .

4. HOPI
Pt presented through OPD with above
mentioned date/ complaints for last 1 year
and was on treatment for asthma and
abdominal pain and loose motions but A/C
to her , her symptoms for asthma severity
improved with medications , but her c/o for
abd pain , loose motions , weight loss did not
improve even though she has visited multiple
physicians during last 3 to 4 months . She
explained her abd pain , loose motion ,
persistent vomiting as follows .

5. HOPI
Abdominal Pain ; 4 months
- Sudden in onset / occurs in whole
abdomen / Moderate to severe in
intensity / Cramping in character / No
radiation to back /relieved some times
with Pain killer medications i.e (inj
Tramadol ) Aggravates during mid of
night for which she has to visit ER
/episodic ( every 10 to 15 days ) .

6. HOPI
❑LOOSE MOTIONS ; 3-4 months
⮚Watery in consistency / freq - 3 to
4 episodes some times may
increase 5 to 6 times per day with
½ to 1 cup in Quantity / yellowish in
color with no blood or mucus .

7. Hopi
❑Persistent vomiting
last 15 days
▪ 3 – 4 episodes /day .
▪ Contains food particles
▪ Associated e severe abd pain /
occurs 1 to 2 hours after meal /
non projectile / no blood , fecal
content
▪ She has documented loss of 17
KG of body weight for last 1 year
.

8. What will be your Management plan ?
• Admit the patient in Ward .
• Pass I/V line , start I/V fluids , Antibiotics ,
Prokinetic .
• Send base line labs ( CBC , UCE , Ca , Mg , Po4, BSR
, URINE D/R , ESR , CXR , U/S upper abdomen ,

9. Hospital course ( Day 1 )
• As pt admitted through opd with abd pain / loose
motions / persistent vomiting , she was assessed
clinically , detail history taken and physical
examination was done on the bases of which her
work up were sent as mentioned .
• Mean while she was started symptomatic
treatment with PPI/ PROKINETIC / ANTIBIOTICS /
I/V FLUIDS / inj Hydrocortisone .
• Observed FOR VOMITING , TEMP , I/O CHARTING

10. Past Medical HX
▪ As Her past Hx was evaluated , she has a
remarkable past medical Hx with
▪ Asthma / Uterine Fibroid / typhoid Fever /
Multiple Medications HX .
▪ As she is K/C of Asthma Since 2013 she is on
regular treatment for Asthma .

11. Past Medical HX
• She visited - multiple
gynecologists , since Feb
of 2018 for
• infertility
• Dysmenorrhea
• Uterine Fibroid
- Was prescribed multiple
medications .
- Including some hormonal
injections .

12. Past Medical HX
• She Visited a homeopathic
Doctor multiple times for
relieve of asthma attacks ,
abd pain , loose motions .
• Prescribed medications
• ( R 24 / R- 5 / GHR -17 /SYP R
-8 ) .
• When her abd pain get worst
by these Homeopathic med .
• She consulted a Physician .

13. Past Medical HX
• The physician treated her for typhoid fever for 7
days .
⮚ Prescription included .
• ( Omeprazole ) / xanax ( Alprazolam)
• panadol (sos ) / atrovent ( ipratropium ) , clinil (
Beclometasone dipropionate ) / ciprofloxacin for 7
days .

14. Past Medical HX
She Visited to a pulmonologist 5 to 6 times for
treatment of asthma for last 2 years on/off .
( advised tab deltacortil / tab theopylline ( Quibran )
Aerokast (Montelukast sodium ) , NISE(Nimesulide) ,
PPI ( Novipraz ) , Fexet 60 mg (Fexofenadine ),
combivoir ( Formoterol) and tiovair ( Tiotropium
Bromide ).
A/C to pt while she was on these above medications
her symptoms were better , as she stopped the
medications she developed abd pain ass with loose
motions . Then she has to visit ER mostly mid of the

15. ❑ She had to visit multiple times to
ER of different private hospitals
for abdominal pain and shortness
of breath , palpitation on
different occasions and was
managed in ER with
❑PPI/Prokinetic / nebs / O2
inhalation .
❑Advised to Consult a
pulmonologist /
Gastroenterologist .

16. Past Medical HX
❑ she has Recently visited a
(Gastroenterologist) in a
private hospital for
• persistent vomiting
• loose motions ,
• abd pain
• She was advised to GET EGD
Done .

17. Family Hx
• 3 brothers & 3 sisters all are healthy and alive
no hx of TB or Contact with TB patient in
recent past or any Malignancy .
• Mother is alive , Father had died while she was
child .

18. Socioeconomic Hx
• Has her own house , well ventilated , with 3
rooms , total of 4 persons in house .
• Used filtered water , then started using mineral
water as her loose motion was not improving .
• She worked as a school teacher in Saudi Arabia
for few months but now has no job .
• Husband works in a furniture manufacturing work
shop .

19. • HX OF VACCINATION ; Vaccinated for influenza 1
year ago .
• HX OF BLOOD TRANSFUSION ; Nil
• HX OF ALLERGY ; allergic to Dust , perfumes ,
allergy to oral and I/V contrast and some foods .
• HX OF TRAVEL ; No Recent Hx of Travel .
• PAST SURGICAL HX ; N/S
• PERSONAL HX : low mood , dec interest in work ,
dec appetite , bowel habits distrubed , no addiction
to any drug . ( she used to keep pets as a hobby in
her recent past )

20. Systemic Enquiry
• RESP : dyspnea , Wheeze , tachypnea , cough
• GI : Abd pain , dec Appetite , loose motions ,
• CVS ; Palpitation .
• CNS : headache , vertigo , black out .
• Musculoskeletal : Gen body weakness and aches .
• Skin : dark brown to black color hyper pigmentation
on the body , face and limbs . Hx of generlized
itching
• GUT : Dysmenorrheal , Irregular menstrual cycle .
• Rest of the systemic enquiry was unremarkable

21. SUMMARY OF HX
• 29 F married for last 2 years unable to conceive yet
, k/c Asthma admitted with c/o chronic abdominal
pain ass with watery loose motions 3-4 episodes
with persistent vomiting , documented weight loss
, h/o drug , food allergy and hyper pigmentation on
skin , h/o depression , multiple visits to ER mid of
night for c/o abd pain . Having no hx of TB contact
or pulmonary TB in recent past , no FHx of
malignancy , no bleeding P/R , oral or genital ulcer .

22. Where do you fit this Hx ?

23. On the Bases of Hx What will be Your DDx
• ABDOMINAL TB .
• LYMPHOMA .
• PEPTIC ULCER DISEASE .
• Celiac Disease
• Ulcerative colitis / Crohns ‘S Disease .
• Drug Induced
• Mastocytosis

24. Young female lying on bed , conscious , awake , oriented
to TPP with normal height and built , under weight and
wasted , dehydrated , having multiple dark brown to
black color hyper pigmented marks with variable sizes
and shapes on face , limbs and body , with thin and
brittle hair texture , following vitals signs .
• Bp 110/70 mmHg , pulse 100 / min regular , temp A/F
• R/R 18 /min ,
• No paler , cervical or axillary Lymphadenopathy ,
alopecia , j - , c - , k - , L - , A - .

25. SYSTEMIC EXAM
❑ Abdomen ;
• normal shape , no scar marks or dilated veins seen
, soft , Non tender , no sign of free fluid, gut sounds
audible , No organomegaly .
❑ RESP ; B/L polyphonic wheeze was present .
❑ Rest of the systemic exam Was unremarkable .

26. DAY 1 LABS ( 15/3/19 )
CBC HB 13.9 TLC
14.3
PLTS 743 Pt 11
LFT 0.23 0.1 0.13 ALT
20
ALP
114
GGT
21
AST 27
UCES U 8 Cr 0.4 CL 99 Na
132
K 3.3 Bic
21
Po4
3.9
Mg 1.7 Ca
8.4
Lipase
12
Amylase
183
Stool
D/R
Red cells
few
Pus
cells
few
Bacterial
flora ++
Cysts
- V
Ova
-v
Urine
D/R
Rbc
Nil
Pus
cells
4-6
Epith cell
10-15
Casts
Nil
Crystal
s
Nil

27. CXR
• ECG ; Normal

28. What will you do Next ?
• UPPER GI Already DONE from a private clinic (
shows pan gastritis / duodenal ulcer / fissured D2
• BX REPORT
- Moderate active H. PYLORI
• D1 / D2 BX
- FOCAL VILLOUS BLUNTING , MILD INCREASE IN
INTRAEPITHIAL LYMPHOCYTES , MODERATE
CHRONIC NON SPECIFIC INFLAMMATION.

29. What will you do Next ?
• CT Whole ABOMEN / Colonoscopy ?

30. Hospital course 2 day
• She symptomatically improved with
medications as above mentioned , her
episodes of vomiting dec , abdominal pain
was milder in severity as compared to the day
she was admitted .
• Plan was to ct same Rx till CT Scan not Done .

31. Labs 2nd day
CBC HB 11.7 TLC 14.3 PLTS 732

32. What are the findings on this CT Film ?

33. CT SCAN FINDINGS ?
• ILEOCECAL JUNCTION AND TERMINAL ILEUM
APPEARS MILDLY THICKENED , CONTRAST IS
PASSING INTO THE RIGHT COLON , MULTIPLE
ENLARGED LYMPH NODES ARE SEEN IN
MENENTERY , ONE OF THEM MEASURES 1.3 X
1.1 CM , DISTAL SMALL BOWEL LOOPS ARE
MILDY DILATED

34. What is your next step of management ?

35. Colonoscopy

36. 3rd day
TLC 21
ESR 14
Na 141 Cr 0.4 K 3.1

38. COLONOSCOPY REPORT
• TERMINAL ILEUM ULCERS / TRANSVERSE COLON
ULCER, Multiple Bx taken .
• small internal Hemorrhoids
• Pt was observed for few hours and was discharged
to home medications
• Discharge medications ( ciproxcin / flagyl / colofac/
motilium )
• Advised follow up after Bx report .

39. Old Records
• IGE level > 2500 IU/ml ( < 100) . 15/8/17
• IGE level ( 5000 )
• Cbc ( 12.5 / 698/ 9.9 ( 15/8/17 .
▪ U/S whole abd ; 11/2/19.
- Benign looking mesenteric lymph nodes
measuring 1.3X0.8 cm , 1.4 x 0.7 CM reactive
lymph nodes with normal looking bowel
loops , single intramural fibroid on left side of
fundal region .

40. What is your final Dx on the BASES OF
• HX / PHYSICAL EXAM / LABS
• CT SCAN FINDINGS
• EGD / COLONOSCOPY

41. Colonic Bx Report
❑ chronic active colonic inflammation .
▪ Mastocytosis .

42. What is next step ?
• Skin Biopsy .
• Bone marrow .
• Sr histamine level
• ANTI TTG IgA/Ig G .

43. Allergic Mastocytic Gastroenteritis
and Colitis: An Unexplained Etiology
in Chronic Abdominal Pain and
Gastrointestinal Dysmotility
Gastroenterology Research and
Practice
Volume 2012, Article ID 950582, 6
pages

44. Discussion

45. Discussion
• In the current literature, there are two loosely defined
entities associated with increased numbers on mast
cells on gastrointestinal biopsies. The first of these is
mastocytic enterocolitis.
• Mastocytic enterocolitis is defined as more than 20
mast cells per high-power field by tryptase stain in
individuals with chronic diarrhea of unknown etiology .
• Mast cell activation syndrome occurs in individuals who
have symptoms associated with mast cell instability
including dermatographism, flushing, mental fog, or
poor concentration, abdominal pain, diarrhea,
anaphylaxis, and asthma who have a dramatic
improvement in their symptoms in response to
antihistamines and H2 blockers.

46. Discussion
• Because of the nocturnal awakening observed in
such patients,
• It is also suggested that adding an antileukotriene
such as montelukast or a 5-liopoxygenase inhibitor
such as zileuton extended-release tablets (Zyflo CR).
- In patients with more severe symptoms that
significantly disrupt their activities of daily living
and/or sleep, we suggest the addition of budesonide
(Entocort) or a short course of prednisone.

48. Take HOME MASSAGE
❑ PT with Chronic abdominal pain hx of asthma and
skin pigmentation should be investigated for
mastocytosis .
❑ when you encounter with a pt of chronic abd pain ,
diarrhea then you should plan for both UPPER /
LOWER GI Endoscopy to rule out TB or any other
malignant conditions related with the disease .
❑ Earlier investigations like imaging By CT SCAN can
shortens the disease burden and speeds up the
decision of treatment .