OSCE Raika Jamali M D Gastroenterologist and hepatologist

OSCE Raika Jamali M. D. Gastroenterologist and hepatologist Sina hospital Tehran University of Medical Sciences

Case 23 l A middle age man with severe back pain, polydipsia and polyuria.

Lab findings § Hb= 9. 4 gr/dl, RBC=3. 1 x 10 6 , MCV=102, MCHC= normal , PLT=117000. § WBC= 7100 , poly=68% lymph=27% ESR=102 , PT=12, sec. Ca = 10. 1 mg/dl § § Albumin = 3. 4 & total protein = 6. 7 g/dl BUN, Creatinine = normal § 24 hr Urinary protein= normal §

l What is your diagnosis? Metastasis to lumbar spine l Idiopathic hypercalcemia l Primary polydipsia l Multiple myeloma l Chronic lymphocytic leukemia l

Case 24 l A middle age man presented with acute dyspnea (Figure A). After diuretic therapy and TNG infusion his symptoms relieved, (Figure B).

l What do you see in the radiographs ? Round Pneumonia l Pulmonary metastasis (cannon ball) l Pulmonary tumor l Pnemothorax l Pulmonary edema with pleural effusion l

Case 25 a young man presented with bloating and epigastric tenderness. You see the endoscopic view of antrum.

• What is your endoscopic diagnosis? – Lymphoid hyperplasia – Raised erosions – Ulcer – Fine nodularity • What is the most probable cause? – Drug reaction – Helicobacter pylori – Eosinophilic gastroenteritis

Case 26 • A middle age man presented with crampy abdominal pain and melena. There is history of kidney transplant and use of cyclosporine and azathioprine for 6 years. • You see the small bowel transit and the histology of resected segment.

• What do you see in the radiograph? • Bowel obstruction in jejunum • Bowel obstruction in duodenum • Gastric outlet obstruction • What is the most probable diagnosis? • Lymphoma • CMV infection • Tuberculosis

Case 27 • A lady that was diagnosed as a case of ulcerative colitis. She is taking 1 gram mesalazine three times a day and is in remission. • In her past history she mentions an operation for anal fistula. • During her routine check-up a moderate iron deficiency anemia and three plus occult blood was discovered.

A barium enema was performed:

• Colonoscopy and biopsies from the stenotic area revealed inflammation, depletion of goblet cells, granuloma and ulceration. • No dysplasia was observed.

• What is your diagnosis? – Crohn disease – Celiac disease – Lymphoma – Ulcerative colitis • What is your therapy of choice? – Surgical resection of the stenotic area – Infliximab – Metronidazole and ciprofloxacin

Case 28 • A lady referred with malaise and dark urine. She had cesarian section 3 weeks ago. Halothane was NOT used. • During operation she had developed severe bleeding and received 3 units of packed cells. She has had no previous operation. • • Wt: 68 kg AST: 580 IU/L, ALT: 730 IU/L, Alkaline phosphatase: 490 IU/L (normal: 306), Total bilirubin: 2. 1 mg/d. L, Direct bilirubin: 1. 3 mg/d. L, PT: 12. 3 sec (control 12) HBs. Ag –, HCV Ab: +, sonography: normal

• With impression of hepatitis C, peginterferon 180µgr weekly and ribavirin 1000 mg per day were started. • One week later the patient developed jaundice, nausea, mild fever, and right upper quadrant pain.

Laboratory findings: • AST: 2150 IU/L, ALT: 2010 IU/L, Alkaline phosphatase: 470 IU/L, • Total bilirubin: 8. 4 mg/d. L, Direct bilirubin: 6. 1 mg/d. L, PT: 17. 3 sec (control 12. 5) • Total protein 8. 3 gr/d. L, albumin: 3. 7 gr/d. L, • HCV Ab RIBA: + • HCV RNA PCR: • HBV DNA PCR: • K-F ring: • ANA: 1/320, • ASMA: 1/10, • ALKM 1: • Serum ceruloplasmin: 15 mg/d. L (normal: 20 to 35 mg/Dl)

• What is the next step in management? – Evaluation for possible liver transplant – Start prednisolone – Check for 24 h urinary copper – All of the above

Case 29 • • • A 78 years old man presents with longstanding history of heartburn. Physical examination is unremarkable. You see the upper GI endoscopy:

• What is the diagnosis ? – GERD induced esophagitis – Eosinophilic esophagitis – Corrosive esophagitis – Candidiasis esophagitis • What is the best management? – Proton pump inhibitor – Endoscopic dilation – Cromolyn inhaler

Case 30 • A young lady with acute dysphagia after recurrent vomiting. She is taking warfarin. • You see the endoscopic view.

• What is the diagnosis ? – GERD induced esophagitis – Esophageal hematoma – Candidiasis esophagitis • What is the best management? – Proton pump inhibitor – Endoscopic dilation – Check of PT, PTT, PLT

Case 31 • An old female underwent hepatic transplantation because of liver failure. • On 7 th day of admission she developed fever and increasing jaundice.

• What is your diagnosis? – Hepatic artery trombosis – Hepatic vein trombosis – Biliary leak • What is the best management? – Stent placement – Recurrent surgery for repair – anticoagulation

Case 32 • A young man presented with RUQ pain. • He had history of jaundice 6 months ago. • Span of liver is 16 cm. AST= 27 U/L ALT= 23 U/L ALP = 380 U/L Bilirubin T = 2 mg/dl

• What is your diagnosis? – Liver abcess – Liver cystadenocarcinoma – AD Polycystic kidney disease • What is the management? – Albendazole – Surgical removal – PAIR

Case 33 • You see the barium swallow and endoscopic picture of distal esophagus in a 35 lady with progressive dysphagia to liquids.

• What is your diagnosis? – Achalasia – Scleroderma – GERD • What is you treatment of choice? – Surgical myotomy – Balloon dilatation – TNG – Calcium channel blocker

Case 34 • A patient with fever, RUQ pain, and ichterus from 3 months ago. • Liver pathology is shown.

• What is the diagnosis? – Liver shistosomiasis – Hydatid cyst – Tuberculoma – Sarcoidosis • What is the treatment? – Metronidazole – Albendazole – Isoniazid – Steroid – Praziquantel