Short cases

Gastroenterology part 2 exam prep

Case 1 : A 24 years old Male with
Hepatomegaly with Jaundice. No stigmata of
Portal HTN present. What's DD??
• Acute Hepatitis cause may be viral, Wilson, AIH,
alcoholic, or drug induced
• Liver Abscess
• Subacute Budd Chiari syndrome
• Infectious cause most likely Leptospirosis or Enteric
Fever
Investigations:
• LFTs, CBC
• PT. INR
• HAV IGM, HEV IgM, HBsAg, HBc IgM, Blood C/S,
• USG abdomen
• S ceruloplasmin, 24 hr urinary cu, KF ring exam, ANA,
ASMA, AST/ALT ratio, GGT,
• Liver biopsy if no cause found
Case 2 : A 24 years old Male with Hepatosplenomegaly with
Jaundice. No stigmata of cirrhosis present. What's DD??
• Acute Hepatitis cause may be viral, Wilson, AIH, alcoholic or drug
induced
• Liver cirrhosis with portal hypertension
• Subacute budd chiari syndrome
• Hemolytic anemia
• Infections like liver abscess, typhoid fever, infectious mononucleosis
CASE 3: A 35 YEARS OLD MALE WITH JAUNDICE,
HEPATOMEGALY AND PRURITUS ( without palpable GB)

• D/D: Cholestatic Jaundice , may be intrahepatic or extrahepatic

• Intrahepatic causes:
• Cholestatic phase of acute hepatitis-viral, Dili, alcoholic, AIH, wilson
• PSC/ PBC
• Intrahepatic cholangio ca and HCC
• Extrahepatic causes:
• Choledocholithiasis (including mirizzi syndrome), benign stricture in
ch. Pancreatitis, PSC, IgG4 cholangiopathy, HIV cholangiopathy
• Without palpable GB: Hilar cholangio CA, ( rarely ampullary CA, CA
head of pancreas, distal cholangio CA)
Q. What are the intrahepatic causes of cholestatic (obstructive)
jaundice?

A. As follows:
Primary biliary cirrhosis
Primary sclerosing cholangitis
Viral hepatitis (especially HEV)
Drugs and alcohol
Autoimmune hepatitis
Cystic fibrosis
Postoperative
Benign recurrent intrahepatic cholestasis
Pregnancy.
Investigations
• LFTS, CBC,
• PT INR
• Urea, creatinine for CT with contrast
• Blood culture, viral serology, AMA, ASMA,ANA, Ca 19-9, CEA level, HIV
serology, Ig G4 level,
• USG abdomen to differentiate intrahepatic vs extrahepatic cholestasis
• Multiphase CT abdomen
• MRI/ MRCP to serve as road map for ERCP
• EUS ( with FNA/ FNB)
• SPY scope cholangioscopy with biopsy
• ERCP with brush cytology/ biopsy of lesion,
• Liver biopsy if no extrahepatic cause of cholestasis
CASE 4: A 45 YEARS OLD WOMAN WITH JAUNDICE,
HEPATOMEGALY AND PRURITUS with palpable GB

• Malignant causes: ( Courvoisier's sign )

• CA head of pancreas,
• Distal cholangio CA,
• Ampullary CA,
• CA gall bladder,
• visceral malignancy/ lymphoma with nodal mass compressing CBD
• Benign causes: ( exceptions to Courvoisier's law)
• chronic pancreatitis, rarely in choledocholithiasis ( with impacted stone)
• parasitic biliary obstruction, ( Ascariasis, Clonorchis sinensis)
• congenital choledochal cyst,
• common hepatic duct obstruction proximal to the takeoff of the cystic duct
Investigations: ( same as in previous case)
• LFTS, CBC,
• PT INR
• Urea, creatinine for CT with contrast
• Blood culture, viral serology, AMA, ASMA,ANA, Ca 19-9, CEA level, HIV serology, Ig G4 level,
• USG abdomen to differentiate intrahepatic vs extrahepatic cholestasis
• Multiphase CT abdomen
• MRI/ MRCP to serve as road map for ERCP
• EUS ( with FNA/ FNB)
• SPY scope cholangioscopy with biopsy
• ERCP with brush cytology/ biopsy of lesion,
• Liver biopsy if no extrahepatic cause of cholestasis
CASE 5: A 15 YEARS OLD GIRL/ BOY WITH MILD TO
MODERATE SPLENOMEGALY AND PALLOR (WITHOUT
JAUNDICE)
• Non cirrhotic portal hypertension d/t PVT
• Splenic vein thrombosis sec to hypercoagulable state/ pancreatitis
• Cirrhosis with portal hypertension
• Infectious causes, like disseminated TB/ typhoid/ malaria/ infectious
mononucleosis
• CT disorder: like SLE
• Lymphoreticular disorder like lymphoma ( as patient can still have in
accessible lymph nodes)
• Myeloproliferative disorder like acute myeloid leukemia
INVESTIGATIONS:
• CBC, peripheral smear
• LFTs , AST/ ALT ratio, albumin, globulin , A/G ratio, PT INR, APRI, FIB-4 score
• HBsAg, Anti HCV by Elisa
• Doppler USG abdomen
• Multiphase Ct abdomen
• Fibro scan/ SWE
• EGD for varices
• ANA, blood culture, screening for thrombophilia like protein c, s, anti
thrombin III,
• Screening for myeloproliferative disorder with JAK-2 mutation,
• Bone marrow biopsy
Case 6: A 15 YEARS OLD BOY WITH
SPLENOMEGALY, MILD JAUNDICE AND
PALLOR
• Hemolytic anemia due to: Autoimmune, hereditary spherocytosis,
Wilson's disease, G6PD deficiency,
• Portal vein thrombosis/ non cirrhotic portal hypertension
• Cirrhosis with portal hypertension ( d/t HBV/ Wilson)
• Chronic / subacute Budd Chiari syndrome
• Infectious causes, like typhoid/ malaria/ infectious mononucleosis
• Lymphoma
Investigations:
• Cbc, peripheral smear ,MCV ↑, retic count, LDH,
• LFTS with increased indirect bilirubin,
• Haptoglobin :↓
• Coombs test direct and indirect, ANA,
• Osmotic fragility test/ flow cytometry, copper studies, G6PD levels.
• Doppler USG abdomen
• Multiphase Ct abdomen
• Fibro scan/ SWE, APRI, FIB-4
• EGD for varices
• ANA, blood culture, screening for thrombophilia like protein c, s, anti thrombin III,
• Screening for myeloproliferative disorder with JAK-2 mutation,
• Bone marrow biopsy
CASE 7: A MIDDLE AGED MAN WITH
MASSIVELY ENLARGED SPLEEN WITH
ASCITES
• Cirrhosis with portal hypertension
• Acute budd Chiari syndrome ( underlying cause may be
myeloproliferative disease like polycythemia rubra vera, CML)
• Portal vein thrombosis ( may be associated with mild transient
ascites-underlying cause may be myeloproliferative disease like
polycythemia rubra vera, CML)
• Lymphoma / leukemia
CASE 8: A MIDDLE AGED MAN WITH MASSIVELY
ENLARGED SPLEEN WITHOUT ASCITES
• Non cirrhotic portal hypertension/ extrahepatic PVT.
• Cirrhosis with portal hypertension
• Chronic budd chiari syndrome
• Myeloproliferative disorder like CML ( seen in youngs as well),
myelofibrosis ( if age >50 years),
• Tropical splenomegaly/ hyperreactive malarial splenomegaly
• Kala azar ( visceral leishmaniasis)
• Gauchers disease ( lysosomal storage disease)
Investigations:
• CBC, peripheral smear
• LFTs , AST/ ALT ratio, albumin, globulin , A/G ratio, PT INR, APRI, FIB-4 score
• HBsAg, Anti HCV by Elisa
• Doppler USG abdomen
• Multiphase Ct abdomen
• Fibro scan/ SWE
• EGD for varices
• Thick/ thin films for MP, LD bodies on peripheral smear/ bone marrow for visceral leishmaniasis,  
• Gaucher’s disease: bone marrow biopsy with PAS positive macrophages, reduced
glucocerebrosidase activity in peripheral leukocytes. Diagnosis can also be
confirmed by mutation analysis
• ANA, blood culture, screening for thrombophilia like protein C, S, anti thrombin III,
• Screening for myeloproliferative disorder with JAK-2 mutation,
• Bone marrow biopsy
CASE 9: A MIDDLE AGED MAN WITH JAUNDICE, FIRM
NODULAR ENLARGED LIVER, SPLENOMEGALY AND
PRURITUS (WITH PETECHIAE)

Cirrhosis with cholestasis: due to

• 1. HCC
• 2. Metastatic liver disease
• 3. Cirrhosis with choledocholithiasis/ chronic pancreatitis
• 4. PBC leading to cirrhosis
Investigations:
• CBC, PT INR,
• LFTS, AST/ALT ratio, A/G ratio
• AFP level
• USG ABDOMEN
• Multiphase CT abdomen
• Workup for cause of cirrhosis: Hbsag, anti hcv, AMA, ANA , ASMA,
copper studies, iron studies, HFE gene mutation analysis
• Workup for complications: fibroscan, EGD
• MRI abdomen with contrast / MRCP
CASE 10: A MIDDLE AGED MAN WITH
JAUNDICE,ASCITES, ENLARGED SPLEEN
(WITH OR WITHOUT STIGMATA OF CIRRHOSIS)
• Decompensated liver cirrhosis with portal hypertension ( underlying
cause may be Hepatitis B, C, NASH, alcoholic liver disease, Wilsons
disease)
• Decompensated liver cirrhosis with HCC
• Decompensated liver cirrhosis with ACLF/ acute decompensation due
to sepsis, acute viral hepatitis, DILI
• Budd Chiari syndrome / SOS.
Investigations:
• CBC, PT INR,
• LFTS, AST/ALT ratio, A/G ratio
• AFP level
• USG ABDOMEN doppler
• Multiphase CT abdomen
• Workup for cause of cirrhosis: Hbsag, anti hcv, AMA, ANA , ASMA,
copper studies, iron studies, HFE gene mutation analysis
• Workup for complications: fibroscan, EGD, ascitic tap, Anti HAV IgM ,
Anti HEV IgM, Hbsag, Anti HBc IgM
CASE 11: A MIDDLE AGED MAN WITH ASCITES, SPLENOMEGALY WITH
STIGMATA OF CIRRHOSIS LIKE PALMAR ERYTHEMA, CLUBBING, Muehrcke
nails, SPIDER NAEVI, GYNAECOMASTIA, LOSS OF MALE PUBIC HAIR
PATTERN ( WITHOUT JAUNDICE)

• Decompensated liver cirrhosis with portal hypertension ( underlying

cause may be Hepatitis B, C, NASH, alcoholic liver disease, Wilsons
disease, hemochromatosis, PBC, PSC, Alpha 1 anti trypsin deficiency,
congestive hepatopathy (constrictive pericarditis, mitral stenosis, tricuspid
regurgitation, cor pulmonale, cardiomyopathy) , Secondary biliary cirrhosis, Drug
induced like methotrexate, amiodarone, idiopathic)
Investigations:
• CBC, PT INR,
• LFTS, AST/ALT ratio, A/G ratio, APRI, FIB-4,
• USG ABDOMEN
• Workup for cause of cirrhosis: HbsAg, anti Hcv, AMA, ANA , ASMA,
copper studies, iron studies, HFE gene mutation analysis
• Workup for complications: fibroscan, EGD, ascitic tap, AFP, Multiphase
CT abdomen
Case 12: A 15 YEARS OLD BOY WITH ASCITES ,
SPLENOMEGALY AND STIGMATA OF CIRRHOSIS
(cirrhosis in young)
• Decompensated liver cirrhosis with portal hypertension UNDERLYING CAUSES
INCLUDE:
• Chronic hepatitis B
• Wilson disease
• Alpha 1 antitrypsin deficiency
• Inherited metabolic disease like Gauchers disease ( type 1; glycogen storage
disease, diagnosed on bone marrow biopsy with PAS positive macrophages,
reduced glucocerebrosidase activity in peripheral leukocytes and
mutation analysis)
• Cryptogenic cirrhosis/ PFIC type 3/ tyrosinemia type 1/ caroli’s disease
associated with CHF (caroli’s syndrome)
Investigations:
• CBC, PT INR,
• LFTS, AST/ALT ratio, A/G ratio, APRI, FIB-4,
• USG ABDOMEN
• Workup for cause of cirrhosis: Hbsag, anti Hcv, HB c IgG, ANA , ASMA,
copper studies ( serum ceruloplasmin, 24 hour urinary cu > 100, KF ring),
alpa 1 antitrypsin levels ↓ and protease inhibitor (PI) phenotyping ,
 increased urinary excretion of succinylacetone and markedly
elevated blood tyrosine concentration for tyrosinemia,
• Workup for complications: fibroscan, EGD, ascitic tap, AFP, Multiphase
CT abdomen
CASE 13: A MIDDLE AGED WOMAN WITH ASCITES AND
PALLOR, WITHOUT PALPABLE LIVER OR SPLEEN

• Decompensated cirrhosis with portal hypertension

• Tb peritonitis
• Peritoneal carcinomatosis
• Pancreatic ascites
• Nephrotic syndrome
• SLE
Investigations
• CBC, PT INR,
• LFTS, AST/ALT ratio, A/G ratio, APRI, FIB-4,
• USG ABDOMEN
• Workup for cause of cirrhosis: HbsAg, anti HCV, HB c IgG, ANA , ASMA, copper studies,
• Workup for complications: fibroscan, EGD,
• Ascitic tap with SAAG ratio, ADA level, ascitic fluid amylase, ascitic fluid for malignant
cells,
• CT abdomen with iv and oral contrast,
• Urine complete, Spot urinary protein to creatinine ratio/ 24 hour urinary proteins
• ANA, Anti Ds DNA
• Laparoscopic peritoneal biopsy
CASE 14: A YOUNG LADY WITH HEPATOSPLENOMEGALY
AND BILATERAL CERVICAL LYMPHADENOPATHY

• Lymphoma
• Leukemia
• Disseminated TB
• Disseminated malignancy
• Infectious mononucleosis
investigations
• Cbc, P/F, ESR, CRP, ANA, LFTS, RFTS,
• Chest x ray pA view
• Sputum for AFB smear, Gene expert, MTB C/S,
• CT NECK, chest and abdomen
• Excisional lymph node biopsy
CASE 15:A MIDDLE AGED MAN WITH
HEPATOSPLENOMEGALY AND ASCITES WITH RAISED JVP

• Constrictive pericarditis
• Chronic TR
• Cardiac cirrhosis/ congestive hepatopathy
• Rheumatic heart disease with infective endocarditis
• CCF ( usu. No splenomegaly)
investigations
• Cbc, rfts, lfts, pt inr, a/G ratio, Ast/alt ratio
• Cxr PA view
• Echocardiography, USG. abdomen
• Ct Chest and abdomen
• Cardiac catheterization
CASE 16:A MIDDLE AGED WOMAN WITH ILEOCAECAL
MASS PALPABLE IN RIGHT ILIAC REGION

• Ileocaecal TB
• Caecal CA
• Crohns disease
• Adnexal/ ovarian mass
• Appendicular mass
• Amoeboma
investigations
• CBC, ESR, LFTS, RFTS,
• CXR PA view
• USG abdomen for ileocaecal mass, gut wall thickening,
ascites, ,mesenteric lymph nodes,
• CT ABDOMEN with oral and iv contrast
• Ileocolonoscopy with terminal ileal biopsy in 1. saline for MTB C/S, AFB
smear, PCR for MTB 2. Formalin for H/P showing caseating granuloma
• Ba follow through/ Ct enterography for crohn’s
• Diagnostic laparoscopy/ full thickness intestinal biopsy
CASE 17: A MIDDLE AGED MAN WITH PALPABLE
TENDER MASS IN LEFT ILIAC REGION
• Colorectal CA
• Diverticular abscess
• Impacted Faeces/ fecal mass
investigations
• Cbc, mcv , p/F, lft . Rft, CEA level
• Stool for occult blood
• Usg. abdomen
• CT abdomen with oral and iv contrast
• Colonoscopy with biopsy
CASE 18: A MIDDLE AGED LADY WITH
MASS PALPABLE IN EPIGASTRIC
REGION
• Solid mass: • Cystic mass:
• Enlarged left lobe of liver in • Pancreatic pseudocyst
cirrhosis • Hydatid cyst
• HCC • Left lobe abscess
• Left lobe abscess • Pancreatic cystic neoplasm
• Gastric Carcinoma (fundal mass)
• Nodal masss
• Pancreatic CA
investigations
• Cbc, lft, RFT, a/G ratio
• Usg abdomen
• Mutiphase ct abdomen
• EGD and biopsy
• EUS and FNA /FNB
Case 19: an old emaciated lady with firm nodular mass
in epigastric and umbilical region with splenomegaly

• Pancreatic CA with splenic vein thrombosis

• Lymphoma
• Gastric CA
• Small bowel mass ( carcinoma / lymphoma)
• Nodal metastasis
• Retroperitoneal mass
investigations
• CBC with P/F, LFTS, RFTS, PT. INR,
• LDH, CA 19-9,
• USG abdomen, chest X ray PA view
• Ct abdomen, pelvis and chest with oral and iv contrast
• MRI/ MRCP if cholestatic LFTS
• Biopsy: USG guided, CT guided, EUS guided FNB,
• Laparoscopy for staging and biopsy
CASE 20: A MIDDLE AGED LADY WITH LAPAROSCOPIC
CHOLECYSTECTOMY SCARS WITH SPLENOMEGALY

• Post op case of biliary pancreatitis with splenic vein thrombosis

• Portal vein thrombosis
• Splenic abscess
• Hemolytic anemia/ Wilson disease
CASE 21: A YOUNG BOY WITH TENDER HEPATOMEGALY
AND MILD TO MODERATE SPLENOMEGALY

• Acute Hepatitis cause may be viral, drug induced, Wilson, AIH or

alcoholic
• Liver Abscess
• Subacute Budd Chiari syndrome/ Acute budd chiari syndrome on
diuretics
CASE 22:A YOUNG BOY WITH NON TENDER
HEPATOMEGALY AND MODERATE SPLENOMEGALY
• Non cirrhotic portal hypertension/ PVT
• Early Cirrhosis with portal hypertension
• Chronic/ subacute budd chiari syndrome
• Infections: like Malaria , typhoid fever, infectious mononucleosis,
• Myeloproliferative disorder like PRV, AML, CML
• Lymphoma
• Disseminated TB
Case 23: a middle aged man with enlarged
left lobe of liver with stigmata of cirrhosis
• Cirrhosis of liver
• Cirrhosis with HCC
• Liver mets
Case 24: a middle aged man with enlarged
left lobe of liver without stigmata of cirrhosis
• Cirrhosis of liver
• Left lobe HCC/ metastatic liver disease
• Left lobe abscess
• Cholangiocarcinoma with right portal vein thrombosis ( atrophy-
hypertrophy complex)
• Chronic / subacute Budd chiari syndrome
Case 25: a case of massive hepatomegaly
( edge > 10 cm below costal margin)
• HCC
• Metastatic liver disease
• Polycystic liver disease
• liver abscess
• CCF
• Infiltrative disease like amyloidosis (in middle aged)
Case 26: A Middle Age lady with Deep jaundice and palmar erythema
plus, succussion splash positive with Tender hepatomegaly, Regular
border and firm in consistency and No ascites.

• Ca head of pancreas with duodenal infiltration (compressing CBD)

• Ampullary ca with duodenal infiltration
• Gastric CA with liver mets ( but liver will be nodular, may have
irregular borders)
CASE 27 : A 55 YEARS OLD MALE HAVING MERCEDEZ
BENZ SCAR WITH MILD SPLENOMEGALY AND JAUNDICE

POSTLIVER TRANSPLANT PATIENT WITH JAUNDICE DUE TO

• Biliary stricture : which may be anastomotic/ Non anastomotic
(ischemic)
• Acute hepatitis: viral, DILI, alcoholic, CMV, EBV
• Sub acute/ Chronic rejection
• Reactivation of underlying liver disease ,usu after 1 year post LT
( including FCH in first 3 months)
• Biliary cast syndrome ( e.g following donation after cardiac death)
investigations
• Cbc, LFTS, PT INR, RFTs
• Usg abdomen with doppler (for hepatic vessels)/ Hepatic angiography
if doppler is abnormal.
• MRCP
• ERCP after MRCP, PTC guided, EUS guided drainage for treatment
CASE 28 : A 50 YEARS OLD LADY WITH
MASS PALPABLE IN RIGHT ILIAC
FOSSA (RIF)
• Ileocecal TB
• Crohn’s disease
• Colorectal Carcinoma/ Caecal CA
• Appendicular mass
• Amoeboma
• Lymphoma
• Ovarian mass/ adnexal mass
• Ectopic pregnancy (IF YOUNG AGE)