a variety of gastroenterology cases that covers important areas of clinical practice for residents and GI specialists.

1. Clinical Cases In Gastroenterology
and Hepatology
Ahmed Adel Abdelhakeem Amin
Internal Medicine Department
GI & Hepatology Unit
Assiut University Hospital
ahmed_adel_1984@yahoo.com

2. Case 1
53-year-old male complaining of difficult swallowing for the past 3
years, not so progressive, for both liquids and solids, no weight loss, with
nocturnal regurgitation.
How do you start work up?
 Endoscopy
 Barium swallow

3. Case 1
As a rule in dysphagia:
If suspected mechanical cause (to solids) : start with endoscopy.
If suspected motility disorder (to fluids) : start with barium swallow.
BUT
In all cases, endoscopy is a must !

4. Case 1
53-year-old male complaining of difficult swallowing for the past 3
years, not so progressive, for both liquids and solids, no weight loss, with
nocturnal regurgitation.
How do you start work up?
 Endoscopy
 Barium swallow

5. Barium swallow was made..

6. What is the most likely diagnosis?
 Achalasia
 Esophageal stricture
 Esophageal cancer
 Diffuse esophageal spasm

7. What is the most likely diagnosis?
 Achalasia
 Esophageal stricture
 Esophageal cancer
 Diffuse esophageal spasm

8. A case of dysphagia
• It is always about the History.
• Choking or coughing while swallowing: neurologic cause (oropharyngeal)
• Pain on swallowing (odynophagia): pill esophagitis or infection (mostly
opportunistic).
• Liquids more: motility disorder
• Progressive solid: stricture or malignancy
• Intermittent solid: lower esophageal ring.

9. A case of dysphagia
• Always needs a work up – never give PPI and wait!
• Always perform endoscopic evaluation, but if you have to choose
which one to start with:
 EGD: if dysphagia to solids (mechanical cause is suspected).
 Barium swallow: if more to fluids (motility disorder is more likely).

10. Motility disorders of esophagus
 Achalasia
 Diffuse esophageal spasm
 Scleroderma

11. Achalasia
 Degeneration of myenteric plexus of nerves
 Failure of relaxation of LES
 Dysphagia to both liquids and solids
 Regurgitation, aspiration
 Dry cough, chest pain
 No weight loss
 Nocturnal cough

12. Achalasia
 Always start with Barium swallow (dilated oesophagus – bird peak),
followed by EGD (rule out tumours), and motility studies (high
pressure LES and no organized peristalsis) for total confirmation.
 Pseudo-achalasia: AKA secondary achalasia, older age, progressive
weight loss, short duration of symptoms and due to malignancy.
Endoscopy is diagnostic.
 Treatment: pneumatic dilation – laparoscopic myotomy.

13. Diffuse oesophageal spasm
 usually young patient,
intermittent dysphagia to
cold liquids – atypical chest
pain – barium swallow –
sometimes no abnormalities
in diagnostic tests.

14. Mechanical causes of dysphagia
 Lower oesophageal ring
 Cancer oesophagus
 Oesophageal stricture
 Oesophagitis

15. Lower oesophageal ring
 Intermittent solid dysphagia
 Often relieved by regurgitation
 Diagnosed by endoscopy and
barium swallow
 Treated by dilation followed by
PPI therapy

16. Case 2
 24-year-old male, presents with symptoms of oesophageal food
impaction, for 2 hours after eating chicken. He is salivating and spitting
frothy secretions. This is his 4th episode. he denies any heartburn. His
physical examination is normal, and he only gives history of bronchial
asthma.
 What is the next step?
• Consult endoscopist to perform EGD
• Consult surgery
• CT chest
• Barium swallow

17. Case 2
 24-year-old male, presents with symptoms of oesophageal food
impaction, for 2 hours after eating chicken. He is salivating and spitting
frothy secretions. This is his 4th episode. His physical examination is
normal, and he only gives history of bronchial asthma.
 What is the next step?
• Consult endoscopist to perform EGD
• Consult surgery
• CT chest
• Barium swallow

18. Case 2
 24-year-old male, presents with symptoms of oesophageal food
impaction, for 2 hours after eating chicken. He is salivating and spitting
frothy secretions. This is his 4th episode. His physical examination is
normal, and he only gives history of bronchial asthma.
 What is the most likely cause?

19. Eosinophilic oesophagitis
 Young males
 Recurrent food impaction – solid
 History of bronchial asthma or allergy
 Diagnosed by endoscopy: ringed oesophagus
 Treatment: PPI – ingested fluticasone

20. Case 3
18-year-old male presented to the ED with sudden onset of
pain with any attempt to swallow either solids or liquids. He
points to mid-chest as the area that hurts. It just started in the
morning, and he denies any reflux symptoms or prior
dysphagia. His past history is negative. He is taking some
medications for acne but he cannot remember the name.
What is the most likely diagnosis?

21. Case 3
18-year-old male presented to the ED with sudden onset of
pain with any attempt to swallow either solids or liquids. He
points to mid-chest as the area that hurts. It just started in the
morning, and he denies any reflux symptoms or prior
dysphagia. His past history is negative. He is taking some
medications for acne but he cannot remember the name.
What is the most likely diagnosis?
Pill-induced oesophagitis

22. Odynophagia
 Pill-induced: NSAIDS, doxycycline, KCl, FeSO4, aspirin.
 Infection: mostly opportunistic (Herpes, candida, CMV).
 Rarely: with other common causes of dysphagia as Schatzki
ring.
 History is crucial – EGD confirms diagnosis.

23. Case 4
 45-year-old male, presenting to the outpatient clinic with dry cough for 4
months now, not responding to OTC drugs. He reports that he saw a chest
physician last week and told him that he has to see a gastroenterologist to check
for the possibility of acid reflux. What is the best diagnostic test to rule out GERD
in this case?
• Upper endoscopy
• Barium swallow
• 24-hour PH monitoring
• Motility studies

24. Case 4
 45-year-old male, presenting to the outpatient clinic with dry cough for 4
months now, not responding to OTC drugs. He reports that he saw a chest
physician last week and told him that he has to see a gastroenterologist to check
for the possibility of acid reflux. What is the best diagnostic test to rule out GERD
in this case?
• Upper endoscopy
• Barium swallow
• 24-hour PH monitoring
• Motility studies

25. GERD
Typical symptoms: heartburn – dyspepsia – regurgitation.
Atypical symptoms: chronic cough especially nocturnal – recurrent upper
respiratory infections – recurrent asthma – atypical chest pain.
Alarming symptoms: dysphagia – weight loss – bleeding
Complications: Barrett's oesophagus > adenocarcinoma – peptic stricture
– upper GI bleeding.

26. GERD
Typical symptoms + no alarming symptoms + duration of symptoms less
than 10 years: no need for endoscopy unless there are refractory
symptoms.
Atypical symptoms: 24-hour PH monitoring is the main diagnostic option
if endoscopy is normal. Treatment in these patients should be aggressive
and prolonged.
Alarming symptoms: endoscopy is a must.

27. Case 5
 35-year-old female, presenting to the ED with history of hematemesis of fresh
blood twice in the past 3 hours. She feels light-headedness, and her blood
pressure is 80/50, her pulse is 110 b/m. she gives history of taking ibuprofen for
2 weeks now for back pain. What is the initial management?
• Urgent endoscopy
• IV fluids and blood crossmatch
• Start IV PPI infusion
• Surgical consultation

28. Case 5
 35-year-old female, presenting to the ED with history of hematemesis of fresh
blood twice in the past 3 hours. She feels light-headedness, and her blood
pressure is 80/50, her pulse is 110 b/m. she gives history of taking ibuprofen for
2 weeks now for back pain. What is the initial management?
• Urgent endoscopy
• IV fluids and blood crossmatch
• Start IV PPI infusion
• Surgical consultation

29. Upper GI bleeding
 Common causes:
• Bleeding peptic ulcer
• Bleeding varices
• Simple severe gastritis
• Mallory Weiss syndrome
• Malignancy
 Other less common:
• Angiodysplasia
• Aorto-enteric fistula
• Osler-Weber-Rendu , Peutz-Jegher syndrome.

30. Upper GI bleeding
► Management:
• Always start with ABC, resuscitation is the most important first line of
management. Blood is the best volume expander to be used.
• NGT and aspiration is indicated especially in peptic ulcer disease.
• If NGT does not show blood, this can’t exclude upper GI source of bleeding.
• Drugs: according, PPI if ulcer is suspected, Vasopressin analogues if varices.
• Upper endoscopy after stabilization of patients.

31. Upper GI bleeding
► Pharmacologic therapy:
• IV PPI infusion for bleeding peptic ulcers, followed by continuous infusion for 72
hours after endoscopic treatment if high risk ulcer (visible vessel or blood clot). If
the ulcer has clean base in endoscopy, the patient can be given oral PPI and
discharged safely.
• IV infusion of octreotide or Glypressin for cases of bleeding varices. This should
be continued for 3-5 days after endoscopic treatment. Long term prevention is
done by regular EVL and beta blockers.

32. Upper GI bleeding
► Endoscopic therapy:
• Peptic ulcer: adrenaline injection – endo-clips. Risk assessment is crucial about
deciding the route of treatment and decision about discharge.
• Oesophageal varices: Band ligation.
• Gastric varices: histoacryl injection.
• Angiodysplasia: argon photocoagulation (APC).

33. Case 6
► A 40-year-old woman, has suffered from chronic heartburn and diarrhea for the
past 2 years. She takes Omeprazole, which gives some relief of heartburn, but
not the diarrhea which is 5-6 loose stools per day. She has some epigastric
discomfort. Upper endoscopy showed grade III lower oesophagitis, shallow
ulcers in the duodenal bulb and minute duodenal ulcers in the second part.
► What do you recommend?

34. Case 6
► Continue Omeprazole but add sucralfate.
► Continue omeprazole but add metoclopramide.
► Order H Pylori ELISA
► Order serum fasting gastrin

35. Case 6
► Continue Omeprazole but add sucralfate.
► Continue omeprazole but add metoclopramide.
► Order H Pylori ELISA
► Order serum fasting gastrin

36. Zollinger Ellison Syndrome
► Don’t forget: consider ZE syndrome whenever you have a patient with chronic
diarrhea and chronic heartburn with pan inflammatory process in upper
endoscopy.
► Always remember: it may be part of MEN I syndrome (20%).
► Diagnosis:
• serum fasting gastrin level – you should stop any PPI for at least 7 days before
the test. Why?
• EUS is ideal for localizing gastrinomas.
• Surgical exploration might be needed as diagnostic and therapeutic option.

37. Case 7
► 25-year-old female presented with 3 years history of chronic diarrhea and
abdominal cramps. She was told that she had IBS and maintained on high fibre
diet. Now she has the same symptoms which awakes her at night. Her PMH and
family history are negative. She reports that she lost 4 Kg in the past four
months. Examination is normal except slight tenderness in right iliac fossa. What
do you recommend?
• Reassure. It is IBS and only add a spasmolytic.
• Order stool analysis and give empirical antibiotics for a week.
• Do colonoscopy
• Give her mesalamine

38. Case 7
► 25-year-old female presented with 3 years history of chronic diarrhea and
abdominal cramps. She was told that she had IBS and maintained on high fibre
diet. Now she has the same symptoms which awakes her at night. Her PMH and
family history are negative. She reports that she lost 4 Kg in the past four
months. Examination is normal except slight tenderness in right iliac fossa. What
do you recommend?
• Reassure. It is IBS and only add a spasmolytic.
• Order stool analysis and give empirical antibiotics for a week.
• Do colonoscopy
• Give her mesalamine

39. Case 7
► Colonoscopy was done to the patient and showed multiple shallow ulcers in the
ascending colon. Biopsies were taken and showed non specific chronic
inflammation.
► What is the best treatment to start with?
• Metronidazole
• Oral steroids
• Oral azathioprine
• Oral mesalamine
• Infliximab

40. Case 7
► Colonoscopy was done to the patient and showed multiple shallow ulcers in the
ascending colon. Biopsies were taken and showed non specific chronic
inflammation.
► What is the best treatment to start with?
• Oral steroids
• Oral azathioprine
• Oral mesalamine
• Infliximab

41. IBD
► Always suspect IBD rather than IBS if there is any of: bleeding – high
inflammatory markers – anaemia – low vitamin B12 – nocturnal diarrhea. So
ALWAYS do CBC and ESR in every suspected case of IBS. If abnormal proceed for
colonoscopy.
► Biopsy is diagnostic but not always conclusive. Differentiation is mainly made by
clinical scenario and endoscopic findings.

42. IBD
Crohn’s diseases Ulcerative colitis
Clinical features  Chronic non bloody diarrhea
 Rt iliac fossa mass
 Rectal sparing
 Bleeding per rectum and
bloody diarrhea
 Lt iliac fossa pain
 Tenesmus
Extraintestinal  Gall stones
 Oxalate renal stones
 PSC
Complications  Obstruction
 Fistulae and perforation
 Intestinal obstruction
 Colorectal cancer
 Massive bleeding

43. IBD
Crohn’s diseases Ulcerative colitis
Endoscopy  Deep ulcers
 Skip lesions
 Cobble stone mucosa
 Shallow ulcers
 Continuous widespread
lesions
 Pseudo polyps
Radiology (Barium)  Fistulae and strictures
 Rose thorn ulcers
 Proximal bowel dilatation
 Loss of haustrations
 Drain-pipe colon

44. IBD
Crohn’s diseases Ulcerative colitis
Pathology  From mouth to anus
 Skip lesions
 Starts from rectum and
upwards but never affects
beyond ileocecal valve
 Continuous lesions
Histology  Affects all layers from
mucosa to serosa
 Granulomas
 Excess goblet cells
 Affects only mucosa and
submucosa
 Granulomas are infrequent
 Depletion of goblet cells
 Crypt abscesses

45. IBD
► Treatment is mainly aiming at: induction of remission followed by maintenance
therapy.
► For inducing remission: In UC mesalamine (5-ASA) is effective in mild to
moderate cases. While in CD steroids is essential (Ivor oral according to severity),
as 5-ASA are not so effective (usually as an add-on therapy if there is evidence of
colonic disease).
► Systemic IV steroids is a must in both diseases in severe cases.
► Infliximab only in fistulising or perianal disease (CD), or in severe resistant cases
(both). You should exclude TB first.

46. Cancer risk in UC
 2 % after 10 years
 15 % after 20 years
 Pancolitis has greater risk than localized disease
 Factors that predicts cancer development:
 Age of onset < 15 years
 Pancolitis
 Disease duration > 10 years
 Unremitting disease
 Poor compliance to treatment
 Cancer screening:
 Duration > 10 years : every 2 year
 Duration > 20 years : every 1 year.

47. IBD
 Loss of haustrations and
pipe-like colon in a case of
ulcerative colitis.

48. Case 8
► 25-year-old male, recently diagnosed with ulcerative colitis, with about 2 months
history of bleeding per rectum, 3 times per day, and urgency. His colonoscopy
showed typical picture of UC involving both rectum and sigmoid colon. All the
way around beyond that is normal, and the ileocecal junction is normal as well.
What is the best initial treatment?
• Oral mesalamine
• Mesalamine enema
• Oral steroids
• Infliximab

49. Case 8
► 25-year-old male, recently diagnosed with ulcerative colitis, with about 2 months
history of bleeding per rectum, 3 times per day, and urgency. His colonoscopy
showed typical picture of UC involving both rectum and sigmoid colon. All the
way around beyond that is normal, and the ileocecal junction is normal as well.
What is the best initial treatment?
• Oral mesalamine
• Mesalamine enema
• Oral azathioprine
• Infliximab

50. UC – Treatment by extent
► Proctitis: suppositories
► Proctosigmoiditis: enema
► More extensive: oral therapy

51. Case 8
► 30-year-old female with long history of loose bowel movements for about 3-4
years presented to you with slight fatigue. She denies any history of bleeding per
rectum, and her menstruation is normal. O/E she is slightly pale. Her Hb level is 8
g/dl and MCV is 64. she has an itchy rash on extremities.
► What do you plan for this patient?
• IBS, give her antispasmodics and antidiarrheal agents.
• Reassure and increase fibre in diet
• Order tissue transglutaminase
• Order stool analysis

52. Case 8
► 30-year-old female with long history of loose bowel movements for about 3-4
years presented to you with slight fatigue. She denies any history of bleeding per
rectum, and her menstruation is normal. O/E she is slightly pale. Her Hb level is 8
g/dl and MCV is 64. she has an itchy rash on extremities.
► What do you plan for this patient?
• IBS, give her antispasmodics and antidiarrheal agents.
• Reassure and increase fibre in diet
• Order tissue transglutaminase
• Order stool analysis

53. Coeliac disease
► Always falsely diagnosed as IBS (sounds like IBS but anaemic).
► Again, any case of IBS that has anaemia, dermatitis or manifestations of
malabsorption (iron deficiency or macrocytic anaemia, hypocalcaemia,
osteoporosis) should be investigated for coeliac disease.
► Diagnosis: TTG Abs + Upper endoscopy and biopsy from duodenum that shows
villous atrophy.
► Associated conditions: Osteoporosis, dermatitis herpitiformis, unexplained raised
LFTs.
► Treatment: Gluten-free diet (Wheat, barley and rye) ‫الشعير‬ ‫و‬ ‫القمح‬

54. Dermatitis herpitiformis

55. Coeliac disease
►Villous atrophy
in coeliac
disease

56. Case 9
► 2/ A 25-year-old man who is known to have diabetes mellitus and suffers from
recurrent chest infections is referred to the gastroenterology team with chronic
diarrhoea. The letter from his GP states the patient has had persistently
abnormal liver function tests over the last three months and an abdominal
ultrasound scan showed a fatty liver and gallstones.
► What is the most likely diagnosis?

57. Cystic fibrosis
► Cystic fibrosis (CF) is an autosomal recessive disorder that affects secretory
epithelia, where patients have dry protein-rich secretions which lead to
complications of the pulmonary and gastrointestinal systems. It also affects
pancreatic exocrine and endocrine functions (malabsorption and diabetes
mellitus).
► Twenty per cent have a fatty liver, and gallstones are seen in 15% of young
adults with the disease. Patients may also develop secondary biliary cirrhosis
with mucus plugging of bile ducts and portal hypertension.

58. Case 10
► A 41-year-old woman comes to the gastroenterology clinic for review. She underwent
extensive resection of her distal small bowel for Crohn's disease around three months earlier.
She is still suffering from diarrhoea and is worried that her Crohn's disease is still active. On
examination her BP is 105/70 mmHg with a pulse of 80. Her abdomen is soft and non-tender.
Investigations show:
► Hb: 10, Wbc: 4.5, Plt: 195, Na: 138, K: 3.8, CRP: 9 (<10).
► What is the most likely diagnosis?
• Short bowel syndrome
• Bile acid diarrhea
• Bacterial overgrowth
• Active crohn’s disease
• Ischemic colitis

59. Case 10
► A 41-year-old woman comes to the gastroenterology clinic for review. She underwent
extensive resection of her distal small bowel for Crohn's disease around three months earlier.
She is still suffering from diarrhoea and is worried that her Crohn's disease is still active. On
examination her BP is 105/70 mmHg with a pulse of 80. Her abdomen is soft and non-tender.
Investigations show:
► Hb: 10, Wbc: 4.5, Plt: 195, Na: 138, K: 3.8, CRP: 9 (<10).
► What is the most likely diagnosis?
• Short bowel syndrome
• Bile acid induced diarrhea
• Bacterial overgrowth
• Active crohn’s disease
• Ischemic colitis

60. Case 10
► In patients with extensive small bowel resection for CD there are different
causes for diarrhea:
• Active crohn’s: tenderness, raised WBCs, raised CRP, systemic manifestations
• Short bowel syndrome: mostly voluminous amounts of fluid, > 5 litres per day,
through ileostomy opening.
• Bile acid diarrhea: due to lack of reabsorption of bile acids from ileum.
• Bacterial overgrowth: mostly associated with scleroderma more than CD, and
associated with excessive bloating.

61. Case 11
► A 50-year-old woman is seen in the clinic because of deranged liver function
tests (LFTs). She drinks at most 4 units of alcohol weekly. On examination she is
obese with a BMI of 45kg/m2 and her LFTs show: ALT 140, AST 150, bilirubin 14
umol.
► What is the most likely cause?
• Diabetes mellitus
• Drug induced
• Chronic alcoholic hepatitis
• Hypothyroidism

62. Case 11
► A 50-year-old woman is seen in the clinic because of deranged liver function
tests (LFTs). She drinks at most 4 units of alcohol weekly. On examination she is
obese with a BMI of 45kg/m2 and her LFTs show: ALT 140, AST 150, bilirubin 14
umol.
► What is the most likely cause?
• Diabetes mellitus
• Drug induced
• Chronic alcoholism
• Hypothyroidism

63. NASH
► For a patient to be considered at risk of chronic alcoholic hepatitis he should
consume at least 40 units per week. Which is not present in this case.
► The presence of morbid obesity suggests that this is a case of NASH, and the
most common cause in these patients is diabetes mellitus.
► NASH is a disease that is diagnosed by exclusion, and sometimes a liver biopsy
is indicated to confirm the diagnosis. Good glycaemic control and weight loss
is the corner stone in management of patients with NASH.

64. NASH

66. THANK OU