Interesting Clinical Cases in Medicine Girish Mathur, KK Pareek
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdomen
computed tomography 169f
pain of 151
Abdominal discomfort 9, 265
Abdominal epilepsy 265
differential diagnosis 266
treatment 266
Abdominal examination 237
Abdominal migraine 265
Abdominal pain 9, 9t
Abdominal ultrasound 257
Abetalipoproteinemia 10
Acid-fast bacillus, 107, 170
Acquired immunodeficiency syndrome 79
Actinomycosis 52
Acute coronary syndrome 43
Acute respiratory distress syndrome 66, 270
Adenoma 158
Adenosine deaminase 241
Adenosine deaminase activity 107
Adrenal gland 158, 168
Adrenal incidentaloma 158f
Adrenal insufficiency 170
Adrenal mass, bilateral 168
Adrenaline 244
Adrenocorticotropic hormone 179, 244
Afebrile 119
Alanine aminotransferase
Alanine transaminase 239, 270
Albumin 270
Albumin globulin reversal 35
Alcoholism 270
Aldosterone
calculation of 261
plasma levels 263
to-renin ratio 260
Aldosteronism, primary 260
Alkali supplementation 232
Alkaline phosphatase 239
Allergic disorders 243
Allergic reaction to human insulin 18
Allergic rhinitis 243, 246
Alpha-1-antitrypsin 184
Alph-fetoprotein 159
Aluminium phosphide poisoning 65
Alzheimer's disease 162, 165, 166
Amaurosis fugax 221
Amebic meningoencephalitis, primary 50t
Amenorrhea, primary 172
American Association of Clinical Endocrinology guidelines 225
American College of Cardiology 41
American College of Rheumatology 136
American Diabetes Association 223, 224fc
guidelines 41
Amikacin 127
Aminotransferase levels 82, 83
Amitriptyline 14
Amlodipine 241
Amnesia 254
Amoxicillin 127
Amphotericin B 50
Ampitum 127
Amyotrophic lateral sclerosis 56, 157
Androgen insensitivity, signs of 56
Anemia 9
Angina 135
unstable 113
Angiotensin-converting enzyme inhibitor 41, 187
Angular cheilitis 10, 81
Angular stomatitis 9
Ankylosing spondylitis 193, 196
Anticardiolipin antibody 133
Anticitrullinated peptide antibodies 129
Anti-cyclic citrullinated peptide 61, 209
Antidiabetic drugs, oral 199
Anti-double stranded deoxyribonucleic acid 208
Antihistamines 245
Anti-liver kidney microsome 184
Anti-Müllerian hormone 173
Anti-neuronal antibody 231
Antineutrophil cytoplasmic antibody 61
Antinuclear antibody 31, 50, 133, 151, 184, 208, 209, 231
profile 61
Antiphospholipid antibody syndrome 151, 132
Antiretroviral therapy 79, 83
Antitissue transglutaminase 11
Antituberculous, treatment 199, 242
Antrum of stomach 4
Aortic regurgitation 135
Arrhythmia 127
Arterial and venous thromboembolism 125
Arterial blood gas 65, 72, 75, 190
analysis 72, 153
Arterial bruit 135
Arterial thrombosis 127
Arterial thrombosis, risk factors for 127
Arthralgias 135
Aspartate aminotransferase 239, 270
Association of Neuropsychiatric Systemic Lupus Erythematosus 229
Asthma 113
Ataxic gait, except for 117
Atazanavir 83
Atherosclerosis, severe 45
Atherosclerotic cardiovascular disease 224, 225
Atorvastatin 127, 223
Atrioventricular 43
Augmentin 127
Autoimmune disease 128
Autoimmune disorder 69
Autoimmune hepatitis 184
Autoimmune lymphoproliferative syndrome 144
Autonomic dysfunction 122
Autonomic dysregulation 216
Autonomic epilepsy 265
Autonomic instability 101, 216, 217
Autonomous nervous system 207
Azathioprine 123, 138
Azithromycin 50, 127
Aztreonam 127
B
Basal insulin
dose determination 226
initiation 223
Basilar artery syndrome 254
Behçet's disease 274, 275
Benign adrenal lesion 158
Bepotastine 245
Beta blockers 68
Beta-human chorionic gonadotropin 159
Biochemical investigations 30
Biopsy 102, 159
non-Hodgkin's lymphoma 103f
stained with hematoxy 184f
Bitot's spots 9
Bleeding
active 2
cause of 2
lesion 2t
manifestations 9
Blood glucose 226
Blood loss
amount of 1, 1t
and resuscitation 1
Blood pressure 153
diastolic 265
systolic 3
Blood sugar levels 226t
Blood urea 3
Body mass index 10, 153, 168, 175, 223, 244
low 88
Body weight 226t
Bony deformity 58
Brachioradialis muscle 56f
Bradycardia 191
Brain and neck vessels, angiography 221f
Brain, CT 99f
Brain, MRI 100f
Breathlessness 109
Bromocriptine 215
Bronchi 81
Bulbospinal muscular atrophy 56
C
Calcium and vitamin D3 supplementation 232
Calcium channel blocker 41, 68
Calculation problem 164
Captopril 223
Carbamazepine 123
Carbenicillin 127
Carbimazole 205
Carbohydrate malabsorption 9
Cardiac arrhythmias 66, 122
Cardiac autonomic nerve dysfunction, sign of 42
Cardiac conditions 219
Cardiac enzymes 113
Cardiac failure 66
Cardiac manifestations 136
Cardioacceleratory center 43f
Cardioinhibitory center 43f
Cardiomegaly with fluid 114f
Cardiomyopathy 187
Cardiorenal syndrome 112
Cardiothoracic vascular surgery 188
Cardiovascular anomaly 188
Cardiovascular disease 224
Cardiovascular events, risk of 40f
Cardiovascular examination 236
Cardiovascular outcomes trials 224
Cardiovascular risk factors 40
Cardiovascular system 153, 202
Carnitine deficiency 120
Carotidynia 135
Cartridge-based nucleic acid amplification 107
Caspr2 antibodies 123
Cefepime 127
Cefotaxime 127
Ceftriaxone 15, 117, 127
Celiac disease 9, 10, 12
Celphos 65
Central nervous system 202, 241, 265, 274
dysfunction 122
examination 70, 164
infections 166
toxoplasmosis 81
Cephalexin 127
Cepheid 93
Cerebral artery, middle 219, 221
Cerebral atrophy, moderate diffuse 102
Cerebral autosomal dominant arteriopathy 219
Cerebral venous sinus thrombosis 276
Cerebrospinal fluid 71, 214, 275
analysis 98
examination 213
routine 164
Cerebrovascular accidents 222
diagnosis of 117
Cetirizine 245
Challenging status epilepticus 98
Charcot's joints 62
Cheilosis 9
Chest discomfort 109
Chest leads, prominent in 154
Chest pain in emergency room, lateral 106
Chest, CT 107f
Chloroquine 68
Cilostazol 127
Ciproflox 127
Ciprofloxacin 36
Citrobacter species 15
Clavulanic acid 127
Clindamycin 127
Clostridium perfringens 202
Coccidioidomycosis 81
Cognitive domains 162
Colitis 3
Coma 66
Complete blood count 44, 82
Concept, proof of 45
Congestive heart failure 188, 205
Conidiobolus coronatus 52
Conjunctival erythema 209f
Connective tissue disorders 207, 219
Consciousness
loss of 98, 117
recovery of 119
Continuous subcutaneous insulin infusion 25
Contrast-enhanced computed tomography 158
Copper deposition 35
Coronary angiography 115f, 133
Coronary artery bypass graft 252
Coronary artery calcification scanning 44
Coronary artery calcium 45
Coronary artery disease 40
incidence of 43
tests available for screening for 44
Coronary occlusion, severe 114
Coronavirus disease 19 pandemic 90, 117
Corticobasal syndrome 165
Costochondritis 113
Cotrimoxazole 127
therapy 82
Cramps, multiple 56
Cranial nerve 157
dysfunction 207
examination 70
palsies, multiple 207
Cranium and spine 241
Creatine phosphokinase 71, 193, 208, 215
Creutzfeldt-Jakob disease 255
Crohn's disease 9, 10
Cryptosporidium 10
Cushing's syndrome 175, 176, 243, 244
diagnosis of 179fc
differential diagnosis 175
directed hormonal tests 176t
treatment 178
Cyclophosphamide 38, 138, 231
Cyproheptadine 245
Cystic fibrosis 258
Cytomegalovirus infection 81
Cytotoxic 21
D
Deep tendon reflexes 70, 153
Deep vein thrombosis 221
Degenerative disk disease 104f
Dehydroepiandrosterone sulfate 179
Dementia 193
causes of 166
Dengue fever 248
case management 248
differential diagnosis 248
Dengue myositis 250
Depression 44
Depressive disorder 162
Dermatophagoides farinae 245
Dermatophagoides pteronyssinus 245
Derum insulin assay 31t
Desloratadine 245
Desmopressin 147
Desogesterol 146
Dexamethasone 50
Dexamethasone suppression test, high-dose 179
Diabetes education 87
Diabetes mellitus
type 1 20, 43
type 2 18, 24, 41, 199, 226
uncontrolled 223
Diabetic kidney disease 224
Diarrhea
associated with abdominal pain 9
case presentation 7
chronic, common causes of 10t, 10
classification of 9t
due to functional 8t
inflammatory/noninflammatory type 8
of predominantly secretory type 9
secondary to small intestine/large intestine 8t
secretory 7
small-bowel type 8
symptom of 7
Diethylcarbamazine citrate 245
Dieulafoy's lesion 3
Dipeptidyl peptidase-4 inhibitors 224226
Diplopia 70
Disability-adjusted life year 218
Disease, course of 208t
Disease-modifying antirheumatic drugs 63, 138
Disseminated mycosis 81
Dolutegravir 82, 83
Doxycycline 117
Dressing difficulty 164
Drug susceptibility testing 90
Drug-induced thrombotic microangiopathy 144
Drug-resistant tuberculosis 93
Dry gangrene 126f
Dual insulin desensitization 22
Duchenne muscular dystrophy 120
Duke treadmill score 44
Duodenal folds, computed tomography 11f
Dysarthria 56
Dysautonomia 123
Dyslipidemia 36
Dysphagia 56
Dyspnea 135
differential diagnosis of 235
Dystonia hypertension 101
E
Eating problem 164
Ebastine 245
Echocardiographic assessment 254
Ectopic adrenocorticotropic hormone secretion 175
Efavirenz 83
Electrocardiogram 42f
Electrochemiluminescence assay 173
Electrolyte disorders 263
Emergency department 119
Encephalitis 98, 248
Endocarditis 205
Endogenous hyperinsulinemia, cause of 148
Endogenous hyperinsulinemic hypoglycemia 31
Endoscopic
examination 1
methods for control of bleeding 5t
Endothelial damage 127
Enoxaparin, subcutaneous 127
Enterococcus species 15
Entomophthoromycosis 51, 52
Entomophthoromycotina 51
Enzyme-linked immunosorbent assay 249
Epigastric region 269
Episodic memory, loss of 164
Epithelial membrane antigen 177
Erythrocyte sedimentation rate 130, 208, 275
Escherichia coli 15, 92, 203
Esophageal candidiasis 79, 81
Estimated glomerular filtration rate 31, 208
Ethambutol 92
Ethinyl estradiol 146
European Association for Study of Diabetes 45
European Society of Cardiology 45
Extracorporeal membrane oxygenation 65, 67
Extrapulmonary cryptococcosis 81
Extrapulmonary histoplasmosis 81
Extrapulmonary tuberculosis 81
F
Fabry's disease 219
Face mask 118
Facial puffiness 7
Familial hypercholesterolemia 132
Fasting blood glucose 19, 226
Fasting plasma glucose 169, 223, 225, 227
Fat malabsorption 9
Fatigue to fungus 168
Fexofenadine 245
Fibromuscular dysplasia 220
Fine needle aspiration cytology 79, 201
Fish gallbladder ingestion, bane or boon 235
Fixed-dose combination 243
Flaccid quadriparesis, acute onset 71fc
Flavivirus 254
Fluconazole 50, 82
Fluid attenuated inversion recovery 196
Follicle-stimulating hormone 173, 176
Follicular cancer 27
Follicular thyroid carcinoma 27
Forgotten lead 114
Forrest classification 4, 4t
Free thyroxine 176
Frontotemporal dementia 162, 165
Fungal nail infections 81
G
Gallium 68 DOTANOC PET-CT scan 178f
Gas gangrene 202
Gastric erosions: drugs 3
Gastric outlet obstruction 102
Gastric ulcer 4f
Gastritis 271
Gastroesophageal reflux disease 113
Gastrointestinal
and renal manifestations 38
bleeding, causes of upper and lower 3t
Gastroscopy 102, 103f
Generic drugs 117
Genes encoding 86
GeneXpert MTB/RIF 90, 92, 93, 94
Genotypic assays 95
Gentamycin 127
Gestational diabetes mellitus 18
Giardia lamblia 10, 11
Giardiasis 9
Glargine 21, 24
Glasgow Coma Scale 215, 252
Glasgow-Blatchford score 2, 3t
Glimepiride 223
Gliptin 227
Glomerular damage 221
Glucagon-like peptide 1 receptor agonist 225, 226
Glucocorticoids 243
Glucose profile 44
Glucose tolerance test 31t
Glutamate oxaloacetate transferase, serum 176
Glutamate pyruvate transferase, serum 176
Glutamic oxaloacetic transaminase, serum 212
Glutamic pyruvic transaminase, serum 82, 83, 212
Glutathione 67
Glycated hemoglobin 44, 224
Glycemic control 225
Glycine binding 101
Glycogen hepatopathy 184
Gram stain 107
Graves’ disease 27, 28
investigations 28
treatment 28
Grocott methenamine-silver stain 52
Guillain-Barré syndrome 157, 212, 250
Gynecomastia 56
H
Haemophilus influenzae 138
Hand deformity 129f
Hand hygiene 118
Hands, radiograph of 130f
Harris platelet syndrome 141
Hearing loss 214
Heart failure 135
left 113
Helicobacter pylori 5
Hematemesis 38
Hematochezia 38
Hematology autoanalyzer 141, 142
Hemiparesis, acute 274
Hemodialysis 269
Hemodilution, effect of 2
Hemodynamic response 1
Hemoglobin 169
Hemophagocytic lymphohistiocytosis 143
diagnosis of 144b
secondary 143
Hemophagocytosis 144f
Hemostatic imbalance 128
Hepatitis C virus 82
Hepatotoxicity 66
Herpes zoster 81
Hirata's disease 148
treatment 149
Hirayama disease 55, 56, 58
differential diagnosis 56
rare neurological disease 55
treatment 57
Homocysteine metabolism 220
Hook erosions 131
Hormonal and radiological parameters 173t
Hospital, management in 19
Human immunodeficiency virus 79, 82, 84, 164, 200, 242, 249, 275
management 79
testing algorithm 80
Human insulin 20
desensitization 22
Human leukocyte antigen 196
Huntington's disease 165
Hydroxyzine 245
Hyperaldosteronism
clinical signs of 172
primary 260
Hypercarbia 190
Hypercellular marrow 144f
Hypercoagulable disorders 132
Hypercoagulable state 127
Hyperexcitation 122
Hyperglycemia 185
Hyperhidrosis 123
Hyperhomocysteinemia 218
Hyperintensity marrow changes 194f
Hyperparathyroidism, primary 257
Hypertension 36, 216
causes of 260
primary 260
secondary 153
Hyperthyroidism 205
differential diagnosis for pyrexia of unknown origin 204
Hypochromic anemia 15
Hypoglycemia 149, 185, 190, 191
evaluation of 149fc
recurrent 148
time of 32
Hypoglycemic agents, oral 18
Hypokalemia 76, 153, 263
severe 155
Hypokalemic
paralysis 248
periodic paralysis 249
quadriparesis 69, 248
Hyponatremia 190, 191
Hypopigmented patches 60f
Hypotension 191
Hypothermia 126
Hypoxia-hypercarbia 191
I
Iatrogenesis, case of 243
Idiopathic primary vasculitis of aorta 152
Illness 235
Immune complex-mediated 25
Immune thrombocytopenia 141
Immunofixation electrophoresis 196
Immunoglobulin 36, 37, 209
Immunoglobulin M 249
Immunoglobulin therapy 159
Immunohistochemistry 159
Immunoproliferative small intestinal 9
Immunosuppressive drugs 38, 141
Immunotherapy, specific 22
Incidentaloma 158
Indigo and Indirubin, formation of 16
Indomethacin 14
Infectious meningoencephalitis 275
Inflammatory bowel disease 79
Inflammatory demyelinating polyradiculoneuropathy, acute 248
Inflammatory diseases 9t
Infliximab 209
Inherited giant platelet disorder 142
Initiativeness, lack of 164
Injudiciously steroids, use of 141
Insomnia 123
Insulin allergy 24
clinical presentation of 20
management of 21
mechanism 20
mild cases of 21
prevalence of 18
severe 22
types of 21
Insulin autoimmune syndrome 30, 148, 150t
case report 30
Insulin dose 19
during desensitization 19t
Insulin initiation, comorbidities for 223
Insulin therapy 186
Insulin to C-peptide ratio 150
Insulinoma 31, 32
Insulinoma syndrome 150t
Intense exercise 120
Intensive care unit 15
Interesting gastric outlet obstruction 102
Internal carotid artery 218, 219
Internal transcribed spacer 52
International Diabetes Federation 226
International normalized ratio 270
Interstitial edema, bilateral 110f
Interstitial nephritis 110
Interventricular septal thickness 261
Intracranial pressure, raised 163
Intravascular volume 2
Intriguing infections 48
diagnosis 49
treatment 49
Irritable bowel syndrome, case of 79
Ischemic heart disease 40, 127
Ischemic stroke, acute 275
Isoniazid 90, 92
Isonicotinic acid hyadrazide 90
Italian Society for Haemostasis and Thrombosis 128
Ivermectin 117, 118
J
Jaccoud's arthritis 130
causes of 130f
Jaccoud's arthropathy 131
Japanese encephalitis 254
Jugular venous pressure 187
K
Kaposi sarcoma 81
Kayser-Fleischer ring 35
Ketones production 185
Ketosis activates 185
Ketotifen 245
Kidney biopsy 237, 239f
Kidney damage 120
acute 237
differential diagnosis of 110
chronic 224, 225
symptoms of 120
Klebsiella oxytoca 15
Klebsiella pneumoniae 15, 202
Kumaon region 213
L
Lactate dehydrogenase deficiency 120
Lactic acidosis 65
Lamivudine 82
Language problem 164
Leflunomide 138
Leprosy 52, 60
musculoskeletal manifestation 62b
relapse in 63b
Leucine-rich, glioma-inactivated 99
Leukoencephalopathy 219
Levocetirizine 245
Liebermann-Burchard test 244
Life-threatening manifestations 38
Limb claudication 135
Linezolid 127
Lipid panel 44
Lipid profile 223
Lipoprotein
high-density 41
low-density 41
Lispro protamine 21, 24
Liver enzymes 212
Liver function test 72, 83, 117, 154, 204, 212, 241, 269
hepatitis Eon annual follow-up with 117
Lopinavir 83
Loratadine 245
Lorazepam 123
Lower limb 70
Lower motor neuron 55
Lucio leprosy 62
Lumbar puncture 241
Lumbar spondylosis 104f
Lung
atelectasis of 126
collapsed 113
Luteinizing hormone 173, 176
Lymph nodes 143
multiple 177
Lymphoma 9, 52, 81
Lymphoproliferative disorder 159
Lyon's hypothesis 147
M
Magnetic resonance imaging 196, 219, 253
Main coronary artery, left 114
Malabsorption 11t
secondary, clinical manifestations 9t
tests to confirm 11
Malignant cells 241
Mallory-Weiss tear 3
Mantoux test 200, 204
Maturity-onset diabetes of young 86
Mauriac syndrome 185, 186
in type 1 diabetes mellitus 182
McArdle's disease 120
Mean corpuscular volume 141
Mean platelet volume 141
Mediastinal widening 158f, 177f
Medulla oblongata 43f
Meningitis 98
Menstrual cycles, irregular 146
Meropenem 127
Metabolic alkalosis 263
Metacarpophalangeal joints 60
Metformin 117, 223, 227
Methotrexate 123, 138
Methylenetetrahydrofolate reductase 218, 219
case management 219
differential diagnosis 219
Micronutrient deficiency 9
Microspora 10
Miller Fisher syndrome 157
Miltefosine 50
Mini-mental state examination 164
Mitochondrial cytochrome C oxidase 66
Mixed connective tissue disease 207
Monocular blindness 221
Monogenic diabetes 86
diagnostic journey of 86
Monomelic amyotrophy 55, 56
Montelukast 245
Montreal cognitive assessment 164
Morganella morganii 15
Morvan syndrome 123
Morvan's fibrillary chorea 122
Morvan's syndrome 122
Motor neuron disease 55
Motor system examination 70
Moyamoya disease 219
Multiple organ dysfunction syndrome 237
Multiple pathologies and polypharmacy 193
Muscle bulk, inspection of 70
Muscle power 75
Muscle tenderness 120
Muscle tissue breakdown 120
Muscle wasting 10
Musculoskeletal component 193
Musculoskeletal pains 196
Myalgias 120, 135
Myasthenia gravis 156, 159
Myasthenic crisis 159, 160
Mycobacteria growth indicator tube
Mycobacterium leprae 62
Mycobacterium tuberculosis 90
Mycophenolate mofetil 138
Myocardial infarction 40
Myocardial ischemia 43
Myoglobin 120
Myokymia 123
Myxedema coma 190, 191
management of 191
N
Naegleria fowleri 51
Naegleria species trophozoites 49f
Nalidixic acid 127
Navigational problem 164
Neck muscle 70t
Necrotizing pancreatitis, acute 257, 258f
Neonatal diabetes mellitus 86
Neoplastic etiology 170
Nephropathy 88
Nephrotoxicity 66
Nerve conduction
studies 57, 212
velocity 71, 157
Netilmicin 127
Neuroleptic malignant syndrome 215
Neurologic monitoring 98
Neurologic symptoms 135
Neurological examination 274t
Neuropathic pain 123
Neuropathy 88
Neuropsychiatric systemic lupus erythematosus 210
Neurosarcoidosis 275
Nitrofurantoin 127
Nitroglycerine 127
Nonalcoholic fatty liver disease 184
Noncaseating granuloma 62f
Noncontrast computed tomography 190, 241
Non-Hodgkin's lymphoma 102
Nonsteroidal anti-inflammatory drugs 38
Norflox 127
Nucleic acid amplification test 82, 90
O
Obstructive sleep apnea 36
Ofloxacin 127
Oligoarthritis 62
Olopatadine 245
Ophthalmic examination 205
Organic disease 8
Orthostatic hypotension 123
Oxacillin 127
Oxcarbazepine 266, 267
P
Pain, severe 36
Pancreatitis
acute 257
chronic 9
Panhypopituitarism-hypothyroidism 190
Papular pruritic eruption 81
Paracetamol 205
level, serum 271
Paracetamol poisoning 272
acute 269
case of 270
effect of over dose 273
level in plasma 269
nomogram 272f
over dose 269, 272
related asked questions 272
uncommon complication 269
Parasitic infections 10
Paravertebral abscess 168
Parkinson's disease 193
Parkinsonian features 216
Pedal edema 61f
Pentoxifylline 127
Peptic ulcers 3, 113
Percheron infarction, artery of 252
Perigastric lymph nodes, multiple 103f
Perinuclear antineutrophil cytoplasmic antibodies 231
Periodic acid-Schiff stain 52, 171f, 184
Perioral region 56
Peripheral arterial disease 221
Peripheral arterial thromboembolism 125
Peripheral demyelination 212
Peripheral distal arterial thrombosis 127
Peripheral neuropathy 9, 193
Persistent oral candidiasis 81
Phenacetin 14
Pheniramine maleate 245
Phenothiazine 14
Phenytoin 14
Piperacillin 127
Planning and organized activities, loss of 164
Plasma glucose, self-measured 227
Plasmapheresis 123, 209
Platelet count 169
Pleural effusion 108
left-sided 126f
mild bilateral 239f
Pleural fluid 107
analysis 106
culture sensitivity report 127t
Pneumocystis jirovecii 81, 138
Poliomyelitis 56
Polymerase chain reaction technology 91
Polymorphism 220
Polymorphonuclear leukocyte infiltration 36
Polyneuropathies 212
Positron emission tomography 165f, 178, 194, 195
Postpolio syndrome 57
Postsynaptic autoimmune disorder, chronic 156
Potassium supplementation 72
Prandial insulin 227
Pregnancy test 82
Presyncopal episodes 98f
Promethazine 245
Prostate
measuring, enlarged 193
MRI of 194f
specific membrane antigen 194, 195
Protamine 25
Protein malabsorption 9
Proteus species 15
Providencia rettgeri 15
Providencia stuartii 15
Pseudomonas aeruginosa 15
Psychosis 101
Ptosis, bilateral 253f
Pulmonary artery 133
Pulmonary function test 244
Pulmonary hypertension, mild 110
Pulse methylprednisolone 231
Purple urinary bag syndrome 14
Pyrazinamide 92
Pyrexia of unknown origin 201
Q
Quinine dihydrochloride 241
R
Radionuclide myocardial perfusion imaging 44
Rebleeding, risk of 4t
Reflex examination 70
Reflexes, superficial 70
Refractory heart failure 187
Remdesivir 118
Renal disease 111f
Renal function test 126, 270
Renal toxicity 269
Renal tubular acidosis 72, 75
manage 77
type 1 229
types of 76
Research Society for Study of Diabetes in India 226
Resistant hypertension 260
Resorcinol 14
Respiratory examination 236
Respiratory symptoms 135
Retinopathy 88
Retroperitoneal lymph nodes 193
Revealed koilonychia 7
Rhabdomyolysis 119, 120
diagnosis 120
etiology 120
investigations 119
treatment 120
Rheumatoid arthritis 204, 207
mimic 129
Rheumatoid factor levels 31
Rheumatological symptoms to leprosy 60
Rhinoscleroma 52
Rhinosporidiosis 52
Rickettsial infections 213
Rifampicin 14, 50, 90, 92
resistance, detection of 90
Rigidity 216
Rituximab 123, 209
Road less travelled 156
S
Salivary gland biopsy 75f
Schirmer's test 72
Scleroderma 207
Sclerosis, multiple 275
Scrub infection 212
Scrub typhus 213
Seborrheic dermatitis 81
Seizure-specific abnormalities 265
Sensory examination 70
Sensory system 274
Sepsis, severe 127, 128
complication of 125
Septic arthritis 62
Septic shock 125, 127
Sinoatrial 43
Sitagliptin 117
Sjögren's syndrome 69, 207
diagnose 76
manifestation of 69
prevalence of 69
primary 69, 72
secondary 69
Skin prick test 244
Social distancing 118
Sodium and potassium, serum 169
Sodium bicarbonate 65
solution 72
Sodium-glucose cotransporter-2 225, 226
Somatic protein 9
Somatostatin receptor 178
Space occupying lesion 178
Spinal muscular atrophy 56
Splenic and hepatic abscesses 199
Spondyloarthropathy 62
Spontaneous nonclostridial gas gangrene 202
Status epilepticus 98, 101
Steroid-sparing agent 137
Stomatitis 10
Streptococcus species 15
Stress testing 44
Stress ulcers 3
Stroke 40
prevention 218
Strongyloides 10
Subcortical infarcts 219
Subphylum 51
Sulfasalazine 14
Sulfonylurea 225
Supranuclear palsy, progressive 165
Swollen hands and feet 62
Systemic corticosteroid 243
Systemic examination 204
Systemic glucocorticoids 137
Systemic hypertension 110
Systemic lupus erythematosus 129, 207
Systemic lupus erythematosus 275
T
Tachycardia 122
Takayasu arteritis 132, 151, 152
classification of 136f, 136t, 136
clinical features 135
differential diagnosis 132
imaging 135
management 136
medical management 137
pulmonary manifestations of 137
treatment 137
Targetoid lesion 37f
Tazobactam 241
Tenofovir 82, 83
Tenosynovitis 62
Thalamic infarction, bilateral 253f, 254
Thalamoperforate branches 254f
Thalamus 252
Thalidomide, use of 172
Thiazolidinedione 225
Thrombocytopenia, diagnose 141
Thrombocytosis 126
Thrombotic thrombocytopenic purpura 144
Thromboxane 128
Thymic neuroendocrine tumor 175
Thymoma 123, 158f, 159
histopathology of 159
Thyroid carcinoma 27, 28
Thyroid function tests 28, 35, 44
Thyroid malignancy 27
Thyroid-stimulating hormone 176
Tinea corporis 176f
Titration 223
inertia 224
recommendation on 227t
Tobramycin 127
Tocilizumab 118
Tongue, fasciculations of 56
Total iron-binding capacity 92
Total leukocyte count 83, 275
Trachea, candidiasis of 81
Transfusion-associated graft-versus-host disease 144
Triamterine 14
Tricarboxylic antidepressants 68
Tricuspid regurgitation 187
Tropical sprue 9, 10
Trucut biopsy histopathology 177f
Trypsinogen activation 258
Tubercular meningitis 241
Tuberculosis 168, 199
global burden of 90
multidrug-resistant 90
Tuberculous meningitis 242
Tubulointerstitial nephritis 69
Tumor necrosis factor-alpha 277
U
Upper and lower limbs, distal muscle of 70t
Upper gastrointestinal 2
Upper limb 70
Upper motor neuron, signs of 55
Urinary bag 15f
Urination, causes of decreased 236t
Urine analysis 72
Urine anion gap 72
Urology perspective 197
V
Valvular heart disease 127
Vancomycin 127
Vascular dementia 166
Vascular endothelial growth factor 174
Vasculitides 132
Vasculitis 52, 132
Venereal disease research laboratory 82
Venoarterial extracorporeal membrane oxygenation 65
Ventricular ejection fraction, left 66
Ventricular hypertrophy, left 187
Ventricular systolic dysfunction, left 239
Vertebral arteries 220
Vesiculobullous lesions 37f, 38
Vildagliptin 223
Viral hepatitis 184, 271
Visceral protein 9
Visual blurring 70
Visual impairment 135
Vital signs 98, 236
Vitamin B12 141
Vitamin C 14
Vitamins deficiencies 166
Voglibose 117
von Willebrand disease 146
von Willebrand gene 147
W
West Nile virus encephalitis 254
Whipple's disease 9, 10
Whole blood clotting test 71
Wilson's disease 34, 35, 184, 255
diabetes, case report 34
investigations 35
treatment 35
X
Xerophthalmia 9
Xpert MTB/RIF 90, 91, 94, 170
Z
Zidovudine 83
Ziehl-Neelsen staining 91, 92, 199
×
Chapter Notes

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Massive Hematemesis in a Middle-aged ManCHAPTER 1

Varun Teja,
Soumya Jagannath Mahapatra,
Govind K Makharia
 
CLINICAL SCENARIO
A 55-year-old gentleman presented to the emergency department with an episode of massive hematemesis. He was diabetic for 10 years and was taking oral hypoglycemic agent for the past 10 years. He has suffered acute anterior wall myocardial infarction last year. He has undergone primary coronary intervention including coronary stenting. Following that he was maintained on aspirin and beta blockers. On examination, his pulse rate was 126 beats/min and blood pressure in the left arm in the supine posture was 94/60 mm Hg. He appeared pale and very anxious. His abdominal examination was unremarkable and there was no splenomegaly.
 
MAIN CLINICAL QUESTIONS
There are three main issues to be considered at this point: Assessment of volume of blood loss and appropriate resuscitation, identification of the source of bleeding, and to determine if bleeding still active or it has ceased.
 
Assessment of Severity of Blood Loss and Resuscitation
Assessment of severity of bleeding should be done as soon as the patient is received in emergency. Heart rate and blood pressure are good indicators of amount of blood loss. As reflected by the presence of tachycardia and supine hypotension, it is clear that the index patient is hemodynamically unstable and lost approximately 30% of blood volume already (Table 1). Hence, the first objective is resuscitation of the patient. Two large bore intravenous (IV) cannula or a central venous line should be inserted and crystalloids should be infused at a rate of 25–30 mL/kg. A nasogastric tube should be placed to look for ongoing bleeding and also to lavage the stomach for decreasing the risk of aspiration and also prior to endoscopic examination. Blood should be given to maintain hemoglobin at least 7–8 g/dL. Higher threshold is needed in hemodynamically unstable patient and patients with cardiac illness.
Table 1   Clinical signs and volume of loss of blood.
Amount of blood loss
Hemodynamic response
Mild bleeding (<10% of blood volume)
Resting tachycardia
Moderate bleeding (10–30% blood volume)
Orthostatic hypotension
Severe bleed (30% of blood volume)
Supine hypotension
The initial hemoglobin level in patients with acute gastrointestinal (GI) bleeding may not reflect the amount of blood loss as whole blood is lost (both plasma and RBC). The loss of volume is compensated by activation of aldosterone–renin–angiotensin cascade which conserves the salt and water loss and help in increasing intravascular volume. At this point of time (say 24–48 hours), the hemoglobin level may decline because of the effect of hemodilution. The hemodilution also occurs because of infusion of crystalloids as part of initial resuscitation. Hence, one should interpret the hemoglobin report appropriately. For example, the hemoglobin level may remain normal even with the loss of a liter of blood while the patient shows the signs of tachycardia and hypotension.
Goals of resuscitation should be to achieve systolic blood pressure at least >100 mm Hg and heart rate <100 beats/min.
Is the bleeding active?
Although most bleeding episodes stops spontaneously, it is important to know if the bleeding is still ongoing. This can be assessed by persistence of tachycardia and low blood pressure. The activity of upper gastrointestinal (UGI) bleeding is also assessed on the return of gastric contents through the nasogastric tube. While fresh blood through nasogastric tube suggests active bleeding, altered blood or coffee ground blood suggests that the bleeding might have stopped. We should also remember that bleeding can occur intermittently and bleeding from duodenum and below may not regurgitate into the stomach and hence cannot be assessed through nasogastric tube aspirate. A nasogastric tube was placed in the index patient and it showed that the bleeding was still active.
What is the cause of bleeding?
Bleeding from esophagus to the ligament of Treitz at the duodenojejunal flexure is defined as UGI bleeding. The bleeding may manifest as hematemesis (vomiting of blood, bright red blood suggestive of recent or ongoing bleeding whereas coffee-ground emesis suggests old bleeding) or melena (black tarry stool). If the rate of bleeding is high, large amount of fresh blood can traverse through the GI tract and passed as red blood/altered blood in the stool (hematochezia). Hematochezia refers to passage of bright red- or maroon-colored blood per rectum and generally suggests lower GI as the source of bleeding.
A quick history and clinical examination may point towards a cause of bleeding lesion (Table 2). The usual causes of upper and lower GI bleeding are summarized in Table 3.
To assess: who are the patients at high risk of morbidity?
All patients with GI bleeding should be assessed for the risk which guides triaging for requirement of admission and the risk of re-bleeding after initial control. Pre-endoscopy risk scoring system includes the Glasgow–Blatchford Score (GBS), the Clinical Rockall Score, an artificial neural network score, and the AIMS65 score, of which GBS is commonly used. If the GBS is ≥6, >50% of patients will need endoscopic therapy (Table 4). Patients with UGI bleeding and having a GBS 0–1 can be managed on an outpatient basis.
Table 2   Showing the clinical indicators for a possible bleeding lesion.
Clinical indicator
Possible cause of bleeding
Splenomegaly
Ascites
Portal hypertension
History of abdominal pain
Peptic ulcer
Use of NSAID
NSAID induced gastric erosions
Retching and vomiting
Mallory–Weiss tear
Hospitalized patient with comorbid illnesses
Stress ulcers
(NSAID: nonsteroidal anti-inflammatory drug)2
3
Table 3   Causes of upper and lower gastrointestinal (GI) bleeding.
Etiology of upper GI bleeding
Etiology of lower GI bleeding
Peptic ulcer disease
Anorectal causes (hemorrhoids, rectal ulcers)
Portal hypertension: Esophageal and/or gastric varices
  • Cirrhosis
  • Extrahepatic portal venous obstruction
  • Noncirrhotic portal fibrosis
Colitis:
  • Inflammatory bowel disease
  • Ischemic colitis
  • Infectious colitis
  • Radiation colitis
Gastric erosions: Drugs
Neoplasia (polyps and cancers)
Stress ulcers
Diverticulosis
Mallory–Weiss tear
Angiodysplasia
UGI tract neoplasm
Postpolypectomy bleeding
Dieulafoy's lesion
Small bowel ulcers, polyps, mass
(UGI: upper gastrointestinal)
When to consider for endoscopy?
After initial resuscitation and initiation of intravenous proton pump inhibitors and/or, UGI endoscopy should be planned based on risk assessment. Patients with hemodynamic instability should be shifted to intensive care unit and endoscopy should be done at the earliest after initial resuscitation. In all other patients, endoscopy examination should be done as soon as possible, preferably within 24 hours.
 
COMING BACK TO THE INDEX PATIENT
As discussed earlier, that the index patient was hypotensive, suggesting that he had a massive UGI bleeding and the estimated loss of blood volume was >30% of total blood volume. The aspirin which he was taking was withheld. He was immediately resuscitated with intravenous crystalloids. The hemoglobin at the time of presentation was 14.5 g/dL (same as his baseline value) in spite of massive bleeding. Three packed cell RBC were arranged and transfused rapidly. Simultaneously, a nasogastric tube was placed and it showed active bleeding. On quick clinical evaluation, he did not have clinical pointer toward any specific disease (Table 2). He was also given 80 mg of pantoprazole intravenously and then pantoprazole was continued at a rate of 8 mg/h infusion using infusion pump. With crystalloids and blood transfusion, his blood pressure rose to 124/74 mm Hg.
Table 4   Glasgow–Blatchford Score.
Admission risk marker
Score value
Blood urea (mg/dL)
<39
0
39–48
2
48–60
3
60–150
4
>150
6
Hemoglobin (g/dL) for men
>13
0
12–13
1
10–12
3
<10
6
Hemoglobin (g/L) for women
>12
0
10–12
1
<10
6
Systolic blood pressure (mm Hg)
>109
0
100–109
1
90–99
2
<90
3
Pulse
≥100 beats/min
1
History of comorbidities
Presentation with melena
1
Presentation with syncope
2
Liver disease
2
Cardiac failure
24
His blood was also sent for complete blood count, liver function test, INR, and renal function test. He was then wheeled into the endoscopy theater. Before shifting to endoscopy theater, a good gastric lavage was given to clean the stomach which would allow clear visualization of the mucosa and also decrease the risk of aspiration.
On endoscopic examination, there was some amount of liquid blood in the stomach, which was sucked using the endoscopic suction. He was found to have a gastric ulcer, approximately 1.5 cm with a nonbleeding visible vessel at the base of the ulcer. There was no active bleeding at this point of time. Based on the type and stigmata of peptic ulcers, the peptic ulcers are classified as per Forrest classification. Types I and II have high risk of bleeding whereas type III has low risk of rebleeding (Table 5). Various forms of endoscopic therapeutic strategies are now available and they are effective in controlling not only the active bleeding but also the recurrence of bleeding.
Since he had a gastric ulcer with visible vessel at the base of the ulcer, he had high chances of recurrence of bleeding, hence he needed an endotherapy even though the lesion was not bleeding actively. The lesion appeared most amenable to endoscopic application of hemoclips and hence two hemoclips were applied over the visible vessel successfully (Figs. 1A and B). There are multiple endoscopic methods for control of bleeding from peptic ulcer, which are summarized in Table 6.
Table 5   The characteristics of peptic ulcer and the risk of rebleeding: Forrest classification.
Endoscopic stigma of ulcer bleed
Risk of rebleeding
Active arterial spurt (IA)
80–100%
Active arterial ooze (IB)
30%
Nonbleeding visible vessel (IIA)
50%
Adherent clot (IIB)
30%
Flat spot (IIC)
<10%
Clean base (III)
3%
After observing for a few minutes for any active bleeding after application of hemoclips, four pieces of biopsies were obtained from the antrum of the stomach.
zoom view
Figs. 1A and B: Gastric ulcer with nonbleeding visible vessel (arrow) and endoscopic hemoclip application.
5
Table 6   Endoscopic methods for control of bleeding.
Principles
Endoscopic methods
Injection therapies
  • Diluted epinephrine (1:10,000 or 1:20,000)
  • Cyanoacrylate glue
Thermal coagulation
  • Heater probes
  • Argon plasma coagulation
Mechanical methods
Hemoclips:
  • Cap-mounted clips:
    • OTSC® system (Ovesco endoscopy)
    • Padlock system (Steris endoscopy)
  • Endoscopic band ligation device
Topical agents
  • Hemospray
  • EndoClot
One piece was used to urea breath test, which was observed to be positive and three pieces in 10% formalin was sent to pathology laboratory for histopathological examination, which later confirmed presence of Helicobacter pylori (H. pylori) and chronic active gastritis.
Over next 72 hours, he was monitored closely using a monitoring chart including pulse, blood pressure, activity of melena, hemoglobin, and hematocrit. He remained stable and there was no recurrence of bleeding. At this time intravenous pantoprazole was stopped and he was put on oral pantoprazole. Since his rapid urease test was positive, suggesting infection by Helicobacter pylori. H. pylori should be tested in all patients with peptic ulcer and if found to be positive, they must be eradicated. Therefore, he was prescribed anti-H. pylori therapy. He was prescribed triple therapy including clarithromycin 500 mg twice a day, capsule amoxycillin 1 g twice a day and capsule pantoprazole 40 mg twice a day, all for total of 14 days. The pantoprazole in the dose of 40 mg was used further for 2 weeks to complete 4 weeks of therapy.
He was subsequently discharged on day 5. Since he had gastric ulcer, he underwent a repeat endoscopic examination for confirmation of healing of ulcer and indeed the ulcer had healed completely. Malignant gastric ulcers do not heal with proton pump inhibitor (PPI) and hence demonstration of healing is essential after 4–8 weeks. The biopsies were also taken from antrum again to look for eradication of H. pylori, both the rapid urease test and the histopathological examination confirmed eradication of H. pylori.
Summary of management of a patient with bleeding peptic ulcer has been described in Box 1.
 
CONCLUSION
  • Hemoglobin may remain normal (as baseline) in patients with active GI bleeding.
  • The three principles of treating patients with UGI bleeding include initial appropriate resuscitation and stabilization, assessment for the activity of bleeding, identification of bleeding lesions and then institution of appropriate therapeutic strategies to handle the bleeding lesion.
  • Testing and eradication of H. pylori should always be done in patents with peptic ulcer.6
SUGGESTED READINGS
  1. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021;116:899–917.
  1. Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019;171:805–22.