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Picture tests in

Dr. S.P. Hewawasam
Honorary Consultant Gastroenterologist/
Senior Lecturer in Physiology
Faculty of Mecicine-University of Ruhuna

UGIE of a patient with dysphagia.

1) What in the Endoscopic Diagnosis?

1)Schatzki ring

Oesophageal mucosal ring in the lower

oesophagus/GOJ. Produces non-progressive dysphagia
for solids. Mostly congenital. Endoscopy itself (with a
large diameter scope) /Dilatation is therapeutic

Ba swallow of Schatzki ring

This primigravida of 8/52 P.O.A. presented with haematemesis.

2) What is the diagnosis?

2) Mallory Weiss tear from the cardiac

aspect(retroflexed view)
Usually involves the gastric mucosa near the squamo-columnar
mucosal junction. Sometimes healed by the time when
endoscopy happens. Bleeding stops spontaneously in most
cases but it may be profuse.
When it causes complete rupture of the distal end of the
oesophagus (usually on the left side), the condition is referred
to as Boerhaave's syndrome.
Continued bleeding may respond to Endoscopic clips,
vasopressin therapy or angiographic embolization. Surgery is
rarely needed.

This patient presented with Nausea and Vomiting associated with an

epigastric mass.
3.1)What is the diagnosis?
3.2) What is the name given for this dermatological condition?
3.3) To which kind of psychiatric disorders does it fall into?

3.1) Trichobezoar
3.2) Trichotillomania-pulling of hair
3.3) Obsessive-Compulsive disorder(OCD)
Associated with the psychiatric conditiontrichophagia
Most trichobezoars are difficult to remove
endoscopically and surgical removal is
Other bezoars- Pharmacobezoars,
Most patients have psychiatric
disturbances/ mental retardation
Rapunzel syndrome- A trichobezoar
extending into terminal ileum
Endoscopic appearance of a

This patient was referred for UGIE because his mother died of a
breast cancer.
4) What is the diagnosis?

4)Peutz-Jeghers Syndrome

Hamartomatous polyps.
Most common in small bowel 60-90%
esp jejunum. Stomach 15-30%, Colon
50% asymptomatic at diagnosis.
Can present with bleeding , obstruction,
intussusception(in upto 70%).

This biopsy specimen belonged to a patient with T1DM and loose

motions for last 10 years.
5.1)What is the diagnosis?
5.2) Name another endocrine association
5.3) Name a neoplastic association of this condition


Coeliac disease(gluten enteropathy)


5.3)Coeliac disease leads to an increased risk of both adenocarcinoma and

lymphoma of the small bowel (enteropathy-associated T-cell
lymphoma (EATL) or other non-Hodgkin's lymphomas)

Biopsy of small bowel showing coeliac disease

manifested by blunting of villi, crypt hyperplasia,
and lymphocyte infiltration of crypts

This patient suffered a brainstem stroke 1 year ago, underwent

an endoscopic procedure 2 weeks after the stroke.
6.1) What is the current endoscopic finding you see here?
6.2) Name 2 other indications for the endoscopic procedure above

6.1) Buried bumper syndrome of a Percutaneous Endoscopic

Gastrostomy(PEG) tube

This patient underwent an endoscopic procedure to investigate

malena prior to this intervention.
7.1) What is this intervention?
7.2) Name the Endoscopic procedure patient underwent.
7.3) Identify A and B

7.1) Laparoscopy
7.2) Double balloon enteroscopy and endoscopic tattooing
7.3) A-Meckel diverticulum
B-Endoscopic tattoo

This blood culture of this patient grew an organism.

8.1) What is the endoscopic diagnosis?
8.2) What is the most likely organism in the blood culture?
8.3) What complication may account for this clinical presentation?

8.1) Colonic carcinoma

8.2) Streptococcus bovis
8.3) Infective endocarditis

Colonoscopy finding of a patient with iron deficiency anaemia

9.1) What is the diagnosis
9.2) Name the cardiac pathology which is associated with this lesion
9.3) Explain the mechanism of bleeding in from these lesions in
condition mentioned in 9.2

9.1) Angiodysplasia of the colon

9.2) Aortic stenosis
9.3) Acquired von Willebrand disease seen in aortic
The combination of a narrow opening and a higher flow rate in aortic
stenosis results in an increased shear stress on the blood.
This higher stress causes von Willebrand factor to unravel in the same way
it would on encountering an injury site.
As part of the normal homeostasis of the blood, when von Willebrand factor
changes conformation into its active state, it is degraded by its natural
catabolic enzyme ADAMTS13, rendering it incapable of binding the collagen
at an injury site.
As the quantity of von Willebrand factor in the blood decreases, the rate of
bleeding dramatically increases.

This patient presented with low grade fever and right upper quadrant
pain for 5 days. Serum total Billirubin and Alkaline phosphatase were
normal and U.S.S abdomen was negative on 2 occasions on day 1
and day 5. Subsequently he underwent this investigation.
10.1) What is this investigation?
10.2) What is the diagnosis?

10.1) Cholescintigraphy (HIDA scan)

10.2) Acute cholecystitis
This nuclear medicine examination uses a technetium labelled hepatic
iminodiacetic acid (HIDA), which is injected intravenously and is then
taken up selectively by hepatocytes and excreted into bile. If the cystic duct
is patent, this agent will enter the gallbladder, leading to its visualization
without the need for concentration. The HIDA scan is also useful for
demonstrating patency of the common bile duct and ampulla. Visualization
of contrast within the common bile duct, gallbladder, and small bowel occurs
within 30 to 60 minutes. The test is positive if the gallbladder does not
visualize, which is invariably due to cystic duct obstruction, usually from
edema associated with acute cholecystitis or an obstructing stone
Cholescintigraphy has a sensitivity and specificity of approximately 97 and
90 percent, respectively.
The sensitivity and specificity of ultrasonography for detection of gallstones
are in the range of 84 and 99 percent, respectively

A critically ill patient in ICU with a diarrhoea and colonoscopic

findings in figure A was treated with material shown in figure B,
obtained from a healthy relative.
11.1) What endoscopic diagnosis?
11.2) What was the procedure that the patient underwent.

11.1) Pseudomembranous colitis with yellow, adherent

pseudomembranes due to Clostridium difficile infection
11.2) Faecal transplantation

This patient underwent emergency UGIE prior to this intervention. One

day following the intervention, the patient became comatose.
12.1) Why did the patient underwent UGIE?
12.2) What was the intervention?
12.3) What complication has developed?

12.1) For endoscopic therapy of variceal(portal

hypertensive) upper GI bleeding
12.2) Transjugular Intrahepatic Porto-systemic Shunt
12.3) Hepatic Encephalopathy

This patient had a chronic elevation of hepatic transaminases.

13.1) What is the name given to this hepatocyte appearance?
13.2) What causes this hepatocyte staining characteristics?

13.1) Ground glass hepatocytes in H&E stain

13.2) The appearance is classically associated with

abundant hepatitis B antigen in the endoplasmic
reticulum, but may also be drug-induced

Immunostaining of hepatitis B surface antigen (HBsAg) in

cytoplasm of ground-glass hepatocytes in an asymptomatic
HBV carrier

This 53 year old female was found to be having a cystic lesion in

the head of the pancreas by a trans-abdominal ultrasound
underwent this investigation
14) What is this investigation?

14) Endoscopic Ultrasound (EUS) guided fine needle

aspiration of a cystic pancreatic tumour

These food items are known to trigger severe abdominal cramps,

excessive bloating and diarrhoea in certain individuals.
15.1) How are these food items collectively called?
15.2) What could be the working diagnosis for these individuals?

15.1) High FODMAP food

15.2) Irritable bowel syndrome(IBS)