第四季新案例(2012年3月15日)

案例四 Session 4: Real case presentation by Dr. Z. John Chen
A 73 yo female who has a mixed connective tissue disorder, scleroderma, iron-deficiency anemia, Reynaud’s phenomenon and a history of spontaneous perforation of the jejunum about 1 year ago requiring surgical repair and adhesion lysis presented with recurrent episodes of severe abdominal pain, nausea and bloating with multiple ER visits almost on a monthly basis. She was found to have dilated small intestine without a transition spot for bowel obstruction and marked pneumotosis intestinalis on multiple CT scans (see pictures). She had relatively unremarkable EGD and colonoscopy findings except for a medium hiatal hernia with negative duodenal biopsy for celiac disease and a tortuous colon with small and medium diverticula scattered throughout the entire colon and normal terminal ileum. An Agile test capsule was used before attempting a small bowel capsule endoscopy because of the concern for retained capsule and the test capsule was indeed still detected 30 hour after ingestion. Therefore, no small bowel capsule endoscopy was performed. She has tried a variety of treatment including small and frequent meals, soluble fiber supplementation, Gas-X, Colace and probiotics without significant benefit. What else would you do to help this lady?

 


第三期原文:
Original Session 3 case:
A 48 yo ethnic Chinese female living in the US has a long history of relatively stable chronic hepatitis B infection with normal liver function tests (LFT), normal alpha fetal protein (AFP) and normal liver ultrasound but a moderately high HBV titer of 256,000 IU/ml with negative surface antibody and e antigen. She was recently diagnosed with biopsy-confirmed Crohn’s colitis with marked segmental inflammation in the ascending colon and hepatic flexure associated with diarrhea and abdominal pain. She had a small bowel capsule endoscopy showing no involvement of the small bowel. Her symptoms did not respond completely to Lialda (slow release/long acting mesalamine) treatment and it was decided that Imuran (azathioprine) at a dose of 100 mg daily be added. Her diarrhea and abdominal pain symptoms responded very well to the treatment but she felt an extreme fatigue after starting Imuran. Her LFT showed a very mild elevation of total bilirubin to 2.2 mg/dL and direct bilirubin to 0.42 mg/dL with normal transaminases and alkaline phosphatase. Her blood WBC also decreased slightly to 3.6 from a baseline of 4.6. Her TPMT (thiopurine methyltransferase) level is normal at 15.9 U/ml. Her Imuran dose was decreased to 75 mg and then to 50 mg daily but her symptoms persisted and her blood test results did not change. However, her diarrhea began to increase and her abdominal pain also recurred. What would you do next?

回顾

第一期案例原文在:http://www.uschie.org/web/zh/current/96-gi-club/934--20110830

第一期案例原文与第二期案例答案:http://www.uschie.org/web/en/current/96-gi-club/1032--giclub20111010

第二期案例原文与第三期案例答案:http://www.uschie.org/web/zh/current6/96-gi-club/1106--20111126

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