Tough patient cases from 2017

 

AGA’s member-only online networking platform, the AGA Community, was the hub for clinical case scenarios in 2017. About 100 deidentified patient cases were submitted to the forum, generating over 475 private and public responses from your peers.

Here is a summary of the three cases that sparked the most discussion among AGA members. You can view all discussions in the forum at community.gastro.org/discussions.
 

#3 “Esophageal hyperkeratosis” (February 2017)

Patient scenario: Patient was having dysphagia. EGD showed circumferential thickening of esophageal lining in the lower half of the esophagus causing partial obstruction; lumen diameter was 7 mm (scope was able to pass with mild resistance). Human papillomavirus (HPV) stain was negative. Multiple biopsies were negative for malignancy, so the practice did not recommend esophagectomy and believed the symptoms were consistent with hyperkeratosis of esophagus. Endoscopic cryotherapy was being considered.

Question: Has anyone come across a case like this?
 

#2 Thickened stomach (May 2017)

Patient scenario: A 74-year-old male presented early satiety, anemia, and dyspepsia. EGD showed diffuse moderate erythema of the stomach sparing the antrum, and two small superficial duodenal ulcers. Biopsies showed mild chronic inflammation, duodenitis, and negative for H. pylori. The patient was started on a proton pump inhibitor (PPI).

One month later, patient reported early satiety, a 40-pound weight loss over last few months, nausea and vomiting, with minimal improvement while using the PPI. A CT scan of the abdomen and pelvis showed diffuse thickening of the stomach, but was otherwise unremarkable.

One month after that, a repeated EGD showed moderate erythema with enlarged gastric folds, cobblestone of mucosa, again all sparing the antrum. The colonoscopy results were unremarkable. Gastric biopsies showed mild chronic inflammation. Endoscopic ultrasound showed a thickened gastric wall to 14 mm (normal 5 mm) and fine needle aspiration showed normal gastric foveolar epithelium. The patient received a PEG-J tube to maintain nutrition, and then had a laparoscopic assisted full thickness gastric biopsy, which showed benign hypertrophic gastric smooth muscle tissue.

Serum protein electrophoresis and urine protein electrophoresis test results were normal, with total IgG and IgA normal, total IgM low at 31 (normal 60-265), albumin low, other proteins normal, and immunofixation negative. Prealbumin was low at 5 (normal 15-45). Albumin initially normal and over a couple of days low at 2.6 (normal 3.4-5.0). Total protein initially normal and over a couple of days was low at 6.3 (normal 6.8-8.8). Gastrin level was insignificant on the PPI, in the 400s. Zollinger Ellison gastrin not impressive, and the patient is HIV negative.

Question: With a negative biopsy and other test results, Menetrier’s, malignancy, sarcoidosis, eosinophilic gastroenteritis, and amyloidosis can be ruled out. What could the diagnosis be?
 

#1 IBD and prior hep B (July 2017)

Patient scenario: A 53-year-old male diagnosed with ulcerative colitis (UC) at outside hospital after presenting with abdominal pain, perforation of sigmoid colon. He underwent total colectomy with ileostomy, which showed he has remnant rectum, and the path of colon showed UC with sigmoid stricture. There is no malignancy or dysplasia, and the terminal ileum included in the resection was normal. He had complicated post-op course with enterocutaneous fistula.

He underwent takedown of ileostomy, small bowel resection and ileostomy revision. Path showed segmental small bowel showing viable mucosa with acute serositis and serial adhesions. Ileal mucosa was normal. Rectum has inflammation, and he has symptoms of mucus, urgency, and blood. He had rectal burning and did not tolerate CANASA® suppository. He did not seem to improve with hydrocortisone suppository either.

In trying to decipher next treatment step, hepatitis panel was done, which showed positive hepatitis B core antibody (IgM). Hepatitis B viral load was undetectable. Hepatitis B surface antibody test (HBsAb) quantitative was 6 (not quite the range for immunity of greater than 10). Hepatitis B “e” antigen (HBeAg) negative and hepatitis B “e” antibody (HBeAb) positive. This patient’s hep B core total was positive and hep B surface antigen was negative.

Question: How would you treat this patient? Would you use Imuran?

Share your difficult patient case for the GI community to help you solve at community.gastro.org/quickpost.
 

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