CASE PRESENTATION

Dr.M.I.Yasawy
Assistant Prof. MD, DTM, AFIM
Consultant Internist
Gastroentrologist
College Of Medicine
King Faisal University
Dammam, KSA
 Case Presentation
• 38 years old Philipino gentleman known as
having GERD, married with children,
works as a lab technician in K.F.H.U “in
microbiology”
• Presented to ER with 4 months H/o
recurrent upper abdominal worse for 4 days
(more severe and recurring on daily basis)
 Case Presentation
PMH
• Patient was in his usual state of health till 4 days
before presentation.
• Developed Epigastric pain, severe in nature
radiating occasionally to the back, associated with
vomiting (what ever he eats) and it was associated
with last of appetite.
• There was no aggravating factor, pain was
relieving partially by Zantac
 Case Presentation

• No history of diarrhea or change in bowl

habits
• He gave history of darkening of urine color
(light tea)
• No history of contact with febrile or
Jaundice patient, pruritis or accidental prick
 Case Presentation
PMH

• Known as having GERD grade B for last 4

years (Endoscopy May 2000)
• Was on PPI & Zantac on and off
• But the pain never completely subsided and
used to get episodes of attack, diagnosed as
Gall stone and was managed conservatively.
No history of blood transfusion.
 Case Presentation

Family and Social History

• Married with children
• Not a smoker, rarely takes ethanol
• No history of drug abuse or…
• Recent history of travel to Philippines and
USA. (Dec 2003)
Review Symptoms
 Case Presentation
• On Examinations:
Young man, well built, lying in bed, in mild pain.
Mildly Jaundiced, no paller or cyanosis, well
oriented and alert.
Vital signs:
Afebrile BP
Puls
RR
Not pale & no skin stigmata of chronic liver
disease. No Lymphadenopathy
 Case Presentation
On Examination:
Chest
CVS
Abdomen, epigastric tenderness no
Organomegaly
Joints – G.U
Neurological
Impression
???
Cholestatic
Jaundice
? Cause
 Case Presentation
Investigational Results:
C.B.C - Hb 14.8 WBC 5.0 plt 223
RFT
ESR 15 mm/hr
Urineanalysis – bilirubinurea
PT 11.4/10.7
Amylase & Lipase F.B.S
Lipid profile
C. x-rays, ECG
 LFT Investigational Results
T. D. T. Alb ALP S S LDH G
Bili Prot GOT GPT GTP

D1 6.4 4.5 8.0 4.4 167 153 372 268 529

(5/3)

D5 6.5 5.0 7.0 3.6 165 99 298 185 390

(9/3)

D13 3.2 2.2 7.3 3.7 118 176 442 195 204
(17/3

D19 1.4 1.1 7.7 4.2 134 54 246 136 150

(23/3
)
 Case Presentation
Investigational
results
Hepatitis Profile
HAV- IgM AB non reactive
HBV core Ab negative
HBV s Ab reactive
HBV s Ag negative
HCVAB non reactive
 Case Presentation

Investigational Results
• Stool Ova and Parasites & C/s

• U.S on 4.3.04 Reported fatty liver – G.B

stones with CBD – 4.8mm
Now…What could
be the diagnosis
 Case Presentation
Investigational Results:
Repeated ultrasound on 8.3.04
Case Presentation
Case Presentation
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Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
And now what could be the diagnosis??

Cholestatic
Jaundice with
longitudinal
filling defect
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
Case Presentation
ERCP
ERCP BEFORE and AFTER
 Endoscopic extraction of living
fasciola hepatica: Case report
and literature review
Canli fasiola hepatikanm endoskopik
cikarilmasi: Vaka raporu ve literatur derlemesi

Birol Ozer, Ender Serin, Yuksel Gumurdulu, Gurden

Gur, Ugur Yilmaz, Sedat Boyacioglu
Baskent University Faculty of Medicine,
Department of Gastroenterology, Adana
Teaching and Medical Research Center;
Ankara hospital
Turk J Gastroenterol 2003; 14 (1): 74-77
 Biliary Obstruction
Background

• Disorders of the biliary tract affect a significant

portion of the worldwide population, and the
overwhelming majority of cases are attributable to
cholelithiasis (gallstones).
• In the United States, 20% of persons older than 65
years have gallstones and 1 million newly
diagnosed cases of gallstones are reported each
year.
 Biliary Obstruction
Background
• To better understand these disorders, a brief
discussion of the normal structure and function of
the biliary tree is needed.
• Bile is the exocrine secretion of the liver and is
produced continuously by hepatocytes.
• It contains cholesterol and waste products, such as
bilirubin and bile salts, which aid in the digestion
of fats.
 Biliary Obstruction
Background

• Half the bile produced runs directly from the liver

into the duodenum via a system of ducts,
ultimately draining into the common bile duct
(CBD).
• The remaining 50% is stored in the gallbladder. In
response to a meal, this bile is released from the
gallbladder via the cystic duct, which joins the
hepatic ducts from the liver to form the CBD.
 Biliary Obstruction
Background

• The CBD courses through the head of the

pancreas for approximately 2 cm before
passing through the ampulla of Vater into
the duodenum.
 Role of
Endoscopy in
Hepatobiliary
and G.I
parasites
 Role of Endoscopy in
Hepatobiliary and G.I
parasites
Helminthic and protozoal infestation of the
alimentary tract are endemic in tropical
and subtropical areas.

Recent estimates of world wide prevalence

of intestinal nematodes infections suggest
that one billion people are infected of
which millions have clinical disease.
 Role of Endoscopy in
Hepatobiliary and G.I
parasites

The diagnosis of G.I parasites is usually

made by stool examination.

Larva or adult worms can be

incidentally found during endoscopy
examination or diagnosed by
endoscopic procedures and biopsies
 Role of Endoscopy in
Hepatobiliary and G.I
parasites

Parasites may also present as acute

abdomen and these parasites can be
diagnosed during different forms of
endoscopic procedures ,lapratomy or
from surgical specimens
 Role of Endoscopy in
Hepatobiliary and G.I
parasites
Parasites of G.I tract have various and wide
spectrum of presentation as parasites infest
and inhabit upper or lower G.I.T, pancreas,
liver,G.B and biliary tree.

Parasites cause different type of mucosal

lesions in the G.I.T ,larva or adult worms as a
result from injury and invasion, cause
mechanical damage.
 Role of Endoscopy in
Hepatobiliary and G.I
parasites

Endoscopy plays an important role in

diagnosis, treatment and follow up as in
gastric anisakiasis,chronic
Giardiasis,strongyloides, hepatosplenic
and intestinal schistosomiasis.
 Role of Endoscopy in
Hepatobiliary and G.I
parasites

ERCP is diagnostic in biliary tree

obstruction due to parasites or
associated stones or
cholangiocarcinoma,worm extraction will
lead to biliary decompression and gets
significant therapeutic value.
Obstructive Jaundice

Hydatid
 ERCP

D. Cyst in dilated CBD due to ruptured hydatid

cyst
 ERCP

CBD after extraction of

D. Cyst in dilated CBD
daughter cyst
 ERCP

Papillatomy and protruding hydatid

Endoscopically evacuated D. cysts
Endoscopically removed hydatid
membranes
 Prospects in Medical
Management of
Echinococcus
MI Yasawy MD,DTM,AFIM,MA AlKarawi FA,
granulosus
Abdel Rahman E Mohammed FRCP, DTM&H
Department of Gastroenterology, Armed forces
Hospital, Riyadh, Saudi Arabia

Hepato-Gastroenterology 2001; 48:1467 - 1470

 …. Another
Patient with
Cholestatic
Jaundice
 Ascaris
Lumbricudis
Biliary Strictures and cholangitis secondary
to ascariasis: endoscopic management

M.AlKarawi,MD, Faisal M, Sanai, MD, MI Yasawy,

MD, Abdulrahman E.M,FRCP

Gastrointestinal Endoscopy; Volume 50, NO.5, 1999

pg: 695- 697
And yet…
Another
Parasite …
 Gastrointestinal parasites
presentations and histological
diagnosis from endoscopic
biopsies and surgical specimens
A.E Mohamed, Zuhal M Ghandour, MA-
AlKarawi, MI Yasawy, Basam Sammak

Saudi Medical Journal; 2000 Volume 21(7) 629-634

 Guess
what ??
Another
Parasite !!!
ERCP view of cholangio carcinoma due
to colonorchis
This is clonorchis
Bile bag showing clonorchis
sinensis drained through
N.B.T
 N.B.T in a patient
with
cholangiocarcinoma
induced by
clonorchis sinensis.
 Modern Techniques on the
diagnosis and Treatment of
Gastrointestinal and Biliary Tree
Parasites
A.R.ElSheikh, MA AlKarawi,
MI Yasawy

Hepato- Gastroenterol.38(1991) 180 - 188