A not-so-black-and-white case of gastrointestinal bleeding

What's causing the black tarry stool, episode of coffee-ground emesis and epigastric pain?

A 60-year-old woman presents at the Emergency Department complaining that she has been passing black, tarry stool since yesterday and had an episode of coffee-ground emesis some hours ago. It is the first time she has noticed these kinds of symptoms. Moreover, she reports episodes of epigastric pain on and off during the past week.

The patient has never undergone endoscopy. Her medical history includes diabetes mellitus, hypertension, hyperlipidaemia, gastro-oesophageal reflux disease (GORD), osteoarthritis and alcohol abuse. She admits that she occasionally uses nonsteroidal anti-inflammatory drugs (NSAIDs) to cope with episodes of pain caused by her osteoarthritis and that she took some in the past week. On physical examination she is tachycardic (92 beats per minute) and hypotensive (82/57 mm Hg), but afebrile and her oxygen saturation level is normal. Her abdomen is mildly distended, with some tenderness during deep palpation and increased bowel sounds. Her blood test results at presentation are shown in Table 1. A variceal bleed was suspected, and an emergency upper gastrointestinal endoscopy was performed (see video).   Case Question 1  WHAT IS YOUR CLINICAL DIAGNOSIS? A. Oesophageal melanoma
B. Oesophageal infection (e.g. CMV, HSV, Candidiasis)
C. Acanthosis nigricans
D. Acute oesophageal necrosis (AEN) Case Question 2    WHICH OF THE CONDITIONS FROM THE PATIENT’S MEDICAL HISTORY IS NOT ASSOCIATED WITH THEIR DIAGNOSIS?
A. Diabetes mellitus
B. NSAID use
C. Alcohol abuse 
D. Hypoalbuminemia
E. Hypertension
Case Question 3  WHICH OF THE FOLLOWING MEASURES IS NOT RECOMMENDED FOR THE MANAGEMENT OF THIS PATIENT?
A. Nil per os
B. Aggressive fluid resuscitation
C. Antibiotics 
D. IV acid suppression with PPIs
E. Glycaemic control

Pretty but probably poisonous    

What is the most likely histology of the lesion?

The beautiful polyp shown in the photograph (figure 1) was found in the rectum of a middle-aged man who was on a polyp surveillance programme.

WHAT IS THE MOST LIKELY HISTOLOGY OF THE LESION? a)    Hyperplastic polyp b)    Tubular adenoma c)     Tubulovillous adenoma d)    Villous adenoma e)    Traditional serrated adenoma

Possible pancreatitis or could it be cancer?

A retired man with an unusual cause of jaundice...

A 65-year-old man presents with obstructive jaundice. He admits to drinking up to half a bottle of wine every day. The photograph shows the findings of the abdominal CT that is organised (figure 1).  Subsequently, an endoscopic retrograde cholangiopancreatography (ERCP) is arranged to place a common bile duct (CBD) stent and obtain ampullary biopsy samples. Unfortunately the obstruction, just distal to the first part of the duodenum, prevents access to the papilla (figure 2).

WHAT IS THE LIKELY DIAGNOSIS? a)     Acute pancreatitis b)     Autoimmune pancreatitis c)     Chronic pancreatitis d)     Carcinoma of the head of the pancreas e)     Duodenal adenocarcinoma

Confusion over a rectal biopsy sample

How would you manage this nodule?    

The nodule shown in the photograph was found in the rectum of an elderly, asymptomatic patient undergoing a gastroscopy and colonoscopy because of mild iron-deficiency anaemia (figure 1). Biopsy samples were taken from the nodule and the H&E stain is shown (figure 2).

HOW WOULD YOU MANAGE THIS NODULE? a)     Ignore the polyp b)     Sample it again c)     Remove it by endoscopic mucosal resection d)     Remove it by endoscopic submucosal dissection e)     Remove it surgically

A coeliac conundrum

What would you do next for this middle-aged woman previously diagnosed with coeliac disease?

A middle-aged woman presented with loose stool and weight loss. Initially, she refused an endoscopy and a diagnosis of coeliac disease was made on the basis of a high tissue transglutaminase (tTG) antibody titre. She was started on a gluten-free diet (GFD) but her symptoms remained despite adherence to the GFD. After several months she agreed to undergo an endoscopy. The images show the endoscopic view of the duodenal mucosa (figure 1) and the corresponding histology slide (figure 2) stained with haemotoxylin and eosin (H&E).

WHAT WOULD YOU DO NEXT? a)     Refer the patient for a dietary review b)     Request a clonal analysis of the intraepithelial lymphocytes c)     Refer for HLA DQ2/DQ8 testing d)     Refer the patient for capsule endoscopy e)     Add prednisolone to the dietary restrictions

An interesting ileal finding

What are the treatment options for this lesion discovered during colonoscopy?

A 50-year-old woman is undergoing a colonoscopy because of loose stool. When the tip of the endoscope enters the terminal ileum, the lesion in the photograph is found. The patient asks you if any treatment will be necessary.

WHAT DO YOU TELL THE PATIENT? a)     The lesion is likely to be a lipoma and can probably be ignored b)     The lesion is likely to be adenomatous and should be removed by endoscopic mucosal resection (EMR) c)     The lesion is likely to be a neuroendocrine tumour (NET) and should be removed surgically d)     The lesion is likely to be a gastrointestinal stromal tumour (GIST), requiring annual surveillance e)     None of the above 

The hot PET

Hot spots in the descending colon. What would you do with the polyps found on subsequent colonoscopy?

A 72-year-old man previously presented with obstructive bowel symptoms. He was diagnosed with mantle cell lymphoma—a type of non-Hodgkin lymphoma—with involvement of the rectosigmoid junction and terminal ileum.

He underwent a left hemicolectomy and resection of the terminal ileum followed by chemotherapy (fludarabine, mitoxantrone, dexamethasone and rituximab). After treatment he went into prolonged remission and follow-up colonoscopies 5 years and 7 years later were both unremarkable. The findings of a gastroscopy and capsule endoscopy were also normal 7 years after treatment, at which time the patient was asymptomatic with normal blood results. His haematologist requested a surveillance FDG PET-CT scan, which demonstrated a hot spot in the descending colon (figure 1). A further colonoscopy was carried out and showed 2 polyps in the descending colon (figure 2; DC1 [15mm] and DC2 [50 mm]). The ileocolonic anastomosis and neoterminal ileum were both unremarkable. WHAT WOULD YOU DO WITH THESE POLYPS? a)     Ignore them, as they are inflammatory. b)     Take biopsy samples only. c)     Perform standard snare polypectomy. d)     Organise an endoscopic mucosal resection (EMR). e)     Organise an endoscopic submucosal dissection (ESD).

Quick or Quincke's thinking?

What next for a patient who's recently been feeling unwell & passing black stools?

A 40-year-old male patient went to his local A&E department with a short history of feeling unwell and passing black stools. He had a past history of chronic pancreatitis that was attributable to alcohol and a bleeding peptic ulcer some 15 years earlier. He was not taking any medication. On admission, the patient was pale with a heart rate of 75 BPM and his blood pressure was 125/80 mm Hg. The patient’s Hb level was 36 g/L, with a mean corpuscular volume of 8.93, iron 1.253 mmol/L and ferritin 0.27 pmol/L. On endoscopy, the oesophagus and stomach were unremarkable and the photographs show the appearance of the duodenal ampulla (figure 1a–c).

WHAT WOULD YOU DO NEXT? a)     Endoscopic retrograde cholangiopancreatography (ERCP) b)     Percutaenous transhepatic cholangiogram c)     Abdominal computed tomography (CT) d)     Angiogram e)     Abdominal ultrasound

A curious case of colitis

What type of colitis would you diagnose?

A 45-year-old Chinese woman presented with a 2-year history of intermittent loose stools, occasional PR bleeding and abdominal pain. The mucosal patches seen on the photograph were found in the left side of the colon. A full set of mucosal biopsy samples were taken and a representative histology slide, stained with H&E, is also shown.

WHAT IS THE MOST LIKELY DIAGNOSIS? a)    Schistosomal colitis b)    Crohn’s colitis c)    Ulcerative colitis d)    Ischaemic colitis e)    Amoebic colitis

An incidental gastric finding

What would you diagnose in this elderly, overweight man with diabetes and iron deficiency anaemia?

The lesion in the photographs was noted in the stomach of an overweight 70-year-old man with diabetes who was undergoing gastroscopy because of iron deficiency anaemia.

WHAT IS YOUR ENDOSCOPIC DIAGNOSIS? a)    Lymphangiectatic cyst b)    Small gastrointestinal stromal tumour (GIST) c)    Small leiomyoma d)    Xanthelasma e)    Small signet ring cell carcinoma

A scary looking polyp

What would you do if you found this polyp in the high rectum of an elderly patient?

These four photographs show a polyp that was found in the high rectum of an elderly patient.

WHAT WOULD YOU DO NEXT? a)     Take a full set of samples and wait for histology findings b)     Take samples and request an endoscopic ultrasound (EUS) c)     Take samples and request staging X-rays d)     Resect the polyp endoscopically e)     Refer the polyp for transanal resection

Damned if you do and damned if you don’t

How would you manage this polyp in the setting of ulcerative colitis?

The photograph shows a transverse colonic polyp that was found in a 55-year-old man who was under surveillance because of a 15-year history of ulcerative colitis. Analysis of biopsy samples has indicated that the polyp is a tubular adenoma harbouring low-grade dysplasia.

HOW WOULD YOU MANAGE THIS LESION?
a) This is probably a sporadic polyp that can be removed endoscopically.
b) Offer endoscopic resection only if analysis of a full set of random mucosa samples, taken throughout the colon, does not reveal any flat invisible dysplasia.
c) Endoscopically, this is a dysplasia-associated lesion or mass (DALM), but an endoscopic attempt at resection would nevertheless be appropriate.
d) The concept of a DALM is outdated and an attempt at endoscopic resection should be undertaken.
e) This patient should be offered a pan-proctocolectomy with ileo-anal pouch anastomosis.

Reassure, resect or retreat?

What's the diagnosis and management of this nodule likely to be?

This video clip shows a nodule that was found on the greater curve of the stomach in a 35-year-old man referred for a gastroscopy because of symptoms of reflux oesophagitis.

You take a full set of samples and after the examination the patient asks what the management of the lesion is likely to be.

What do you tell the patient? a) This is probably a hyperplastic polyp and eradication of any Helicobacter pylori may well induce spontaneous regression. You tell the patient that he will most likely be offered another examination in a year to reassess the stomach after treatment to eradicate Helicobacter pylori. b) This is probably a gastrointestinal stromal tumour (GIST). You tell the patient that he is likely to be offered an assessment by endoscopic ultrasonography (EUS) and, as the lesion is small, it is likely that surveillance will be offered. c) This is probably a neuroendocrine tumour (NET). You tell the patient that it is likely to require surgical resection. d) This is probably an early gastric cancer. You tell the patient that he is likely to be offered an attempt at endoscopic resection. e) This is probably an advanced gastric cancer. You tell the patient that he is likely to be offered a gastrectomy. 

KRAS or BRAF—that is the question

What's causing the altered bowel habits in this elderly patient?

The photograph shows a lesion that was found in the ascending colon of a 75-year-old man who was undergoing colonoscopy because of a change in bowel habit.

WHAT IS YOUR ENDOSCOPIC DIAGNOSIS?
a) Hyperplastic polyp
b) Sessile serrated polyp
c) Traditional serrated adenoma
d) Mixed hyperplastic polyp
e) Tubulovillous adenoma

Benign or malignant disease?

The photo shows the findings in a 65 year-old woman.

The photo shows the findings in a 65 year-old woman. The photograph shows the findings in a 65-year-old woman undergoing investigations for anaemia. Her only medications are ibuprofen for backache and tamoxifen, which was started 7 years previously. WHAT IS THE MOST LIKELY DIAGNOSIS?  a) NSAID-induced gastric ulceration b) CMV gastritis c) Gastric lymphoma d) Linitis plastica e) Gastric metastates

A 30-year-old diagnosis.

An elderly patient being investigated for iron deficiency anaemia.

The photograph shows what was found in an elderly patient who was being investigated for iron deficiency anaemia.

WHAT IS THE MOST LIKELY DIAGNOSIS? a) Gastritis associated with Helicobacter pylori infection b) Gastric cytomegalovirus infection c) Cameron ulceration d) NSAID-induced ulceration e) Ulceration from a diffusely infiltrating gastric cancer

An easy diagnosis but difficult aetiology

Try your diagnostic skills!

The photograph shows the mucosal appearance throughout the colon in a 49-year-old woman undergoing investigations for abdominal pain and diarrhoea.

WHAT IS THE CAUSE OF THE MUCOSAL APPEARANCE? a) Melanin b) Lipofuscin c) Haemosidderin d) Food colourings e) Cyanosis

A classic colonic lesion.

These photographs show a lesion that was resected from the sigmoid colon.

These photographs show a lesion that was resected from the sigmoid colon.

WHAT IS YOUR ENDOSCOPIC DIAGNOSIS? a) Hyperplastic polyp b) Tubular adenoma c) Tubulovillous adenoma d) Villous adenoma e) Serrated adenoma

A condition not associated with…?

The photograph shows what was found in a 55-year-old man who was undergoing upper digestive endoscopy because of iron deficiency anaemia.

WHICH OF THE FOLLOWING DOES NOT HAVE A RECOGNISED ASSOCIATION WITH THE CONDITION? a) Hypergastrinaemia b) Portal hypertension c) Liver disease without portal hypertension d) Systemic sclerosis e) Bile reflux

A suspicious sigmoid stricture?

Watch the video & decide!

This patient is undergoing an emergency flexible sigmoidoscopy after admission with sudden onset of vomiting and abdominal distension.

Watch the video WHAT IS THE DIAGNOSIS? a) Ischaemic stricture b) Crohn’s stricture c) Malignant stricture d) Diverticular stricture e) None of the above This is a most peculiar sigmoidoscopy! There is a narrowing of the lumen in the mid-sigmoid that the endoscopist is able to traverse. On the other side of the stricture you find yourself looking at… small bowel mucosa! The patient has suffered a colonic perforation that has given rise to a fistula into the ileum, so option e is the correct answer. Diverticular disease used to be a condition that was firmly in the surgical camp. However, uncomplicated diverticulitis is increasingly managed with conservative therapy and it appears that we don’t even need to give antibiotics in all cases.1 Only about a quarter of patients develop complications requiring surgery. Remarkably, patients who are well but have free air in the abdomen that is visible on X-ray, may be treated with antibiotics and bowel rest2  and abscesses are usually drained radiologically. In a case such as this, with a combined small bowel and colonic obstruction, surgery is indicated. The traditional operation is the Hartmann procedure with a proximal colostomy. The drawback is that a proportion of patients who undergo this procedure will never have their bowel continuity restored. In view of this, many colorectal surgeons have advocated that a primary anastomosis can be an equally safe but a better alternative in selected cases. There is no evidence from clinical trials to inform us which is the better option. However, the construction of a primary anastomosis is more demanding and requires the sound clinical judgment of an experienced colorectal surgeon to decide when this option is likely to fail. The Postgraduate Course of the UEG Week 2013 dedicated a complete session to the topic of diverticular disease (Diverticular disease: Important, poorly understood and badly managed) and is well worth a look. Just sign in to myUEG, put ‘Diverticular disease’ into the UEG Education Library search box and hit enter! References
  1. Chabok A, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99: 532–539. 
  2. Costi R, et al. Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment. Surg Endosc 2012; 26: 2061–2071. 
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