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Diagnostic Dilemma: GI Disease

Diagnostic Dilemma: GI Disease

Test your diagnostic skills with the following endoscopic quiz.

A 45-year-old man with chronic ulcerative colitis for more than 10 years presents with diarrhea for 4 days. The diarrhea is nonbloody, watery, and associated with abdominal pain, nausea, vomiting, low-grade fevers, and chills for 2 days. The abdominal pain was diffuse, but worse in the right upper quadrant.

His last colonoscopy was 6 months ago, and the examination revealed pancolitis with mild activity. There were no polyps or masses. Biopsies demonstrated mild inflammation and no dysplasia.

At presentation, stool studies were ordered, and he was started on empiric antibiotics.

Physical exam was significant for normal vital signs, including no fever. His abdomen was soft with minimal tenderness to deep palpation in the right upper quadrant and no stigmata of chronic liver disease.

Pertinent labs included normal CBC; alkaline phosphatase (ALP) 183 U/L; GGT 1,321 U/L; AST 205 U/L; ALT 411 U/L; total bilirubin 0.8 mg/dL; albumin 3.9 g/dL; and normal prothrombin time/INR.

Imaging studies of the abdomen revealed evidence of mild biliary dilatation. The patient continued with abdominal pain despite antibiotic therapy. Endoscopic retrograde cholangiopancreatography (ERCP) was performed.

1) The photograph reveals:
a) Colitis on a barium enema
b) Common duct stones
c) Stenosis of the common bile duct
d) A biliary leak
e) A patent cystic duct

2) The possible explanations for these abnormalities include:
a) Trauma during cholecystectomy
b) Primary sclerosing cholangitis
c) Cholangiocarcinoma
d) Radiation damage
e) Medication reaction

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