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I have a 12-year-old female patient with achalasia. I would like to know the results of Heller myotomy in children.
Dr. Khawaja Qamaruddin Sediqi
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Latent celiac disease (CD) is diagnosed in subjects with high titre EmA and tTG (IgA) and normal duodenal histology. Should these patients be treated by gluten-free diet or only observed for alarm symptoms? In clinical practice, it is not uncommon to encounter patients with latent CD and mild diarrhoea and bloating responsive to gluten withdrawal. In Italy, the National Health Service (SSN) provides up to 140 and 98 Euro monthly for gluten-free foodstuffs to adult men and women respectively, only with histologically proven CD.
In your opinion, is it ethical to deny a gluten-free diet to such patients?
Carlo M. Girelli MD
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The patient is a 45-year-old woman who had a renal transplantation 5 years ago. She has hepatitis B, C, and D infections. She is under immunosuppresive treatment with cyclosporin post-transplant. Her HDV-RNA and HCV-RNA levels are both undetectable. However, she is HBV-DNA positive (3000 copies/ml). Her ALT level is within normal limits. She has no signs of liver disease.
PT, albumin and bilirubin are normal Ultrasonography is normal. How would you manage this patient?
Dr. Tarkan Karakan, Gazi University School of Medicine, Ankara, Turkey
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For the last 5 years, we have been following a relatively fit 65-year-old woman with a rather serpiginous tubular adenoma ~ 0.5x1cm - of the peri-ampullary area, which sits on the edge of a diverticulum.
Macroscopically the adenoma is only possibly slowly increasing in size during our endoscopic surveillance. She is asymptomatic and there is no dysplasia on histology. She has normal liver function tests and EUS suggests no extension beyond the mucosal layer (however views were not optimal due to the position of the lesion).
How should we deal with this? Attempt EMR (which would possibly involve papillectomy), send her for duodenectomy or continue to watch?
Russell Walmsley and Paul Frankish, Auckland, New Zealand
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The patient is a 21 year old healthy male with perianal and anal
warts which have recurred after surgery (electrocautery) over a period of 3
weeks. A fissure was also found at the most recent surgery. What treatment
would you recommend?
Jim Wells
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The patient is a 20-year-girl who is recovering from acute ulcerative colitis, treated by IV cortocsteroids (steroids were stopped 10 days ago). The patient is currently being treated with 100mg of azathioprine (weight = 48 kg) for 6 weeks.
She has developed cutaneous Herpes zoster infection of the right abdomen. Aciclovir has been given.
Does she need to stop the azathioprine? (she stopped it immediately...). After recovering from the infection, can azathioprine can be re-introduced? After what length of time?
M Schapira, Lasne, Belgium
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The patient is a 47-year-old very active male diagnosed by ERCP, EUS, secretin stimulation with chronic idiopathic pancreatitis.
This was evaluated locally and confirmed in Indianapolis, Indiana. No hypergammaglobulins, normal IgG4 AB. Had biliary and pancreatic sphincterotomies.
Before starting Sandostatin 30 mg per month the patient had an attack per month; 8 months later one every 4 months (Ransom 2).
Are there any other treatment option to curb the week long and time consuming attacks further?
Ziga Tretjak, Austin, Texas, USA
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An otherwise fit and healthy 60-year-old man presented with pain and jaundice.
Investigation demonstrated dilated ducts and an abnormality in the head of the pancreas. ERCP confirmed a double duct stricture with an abnormal segment of at least 3.5 cm. Duct brushings were normal.
Endoscopically, there was suggestion of duodenal wall invasion with loss of compliance and mucosal edema. CT and MRI suggested no vascular contraindication to resection. The entire head of pancreas appeared to be involved - approximately 5.5 cm.
At laparoscopy, there was no serosal, peritoneal or liver disease noted. There were some enlarged metastatic nodes along the porta hepatis. The patient has a palpable tender abdominal mass and epigastric and back pain.
What is the best treatment option, with a preference for quality - rather than quantity - of life?
Gresham Clapham, Australia
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A 45-year-old woman was referred to our center with acute HBV infection. She had been on prednisolone and methotrexate for 1 year for a diagnosis of rheumatoid arthritis, but she stopped the drugs 2 weeks before the recent hepatitis event. Would you start lamivudine for a healthy carrier HBV patient that is a candidate for corticosteroid therapy?
Peyman Adibi, Tehran, Iran
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The patient is a 46-year-old man with compensated cirrhosis (Child's class A), which was diagnosed after needle biopsy during surgery for intestinal obstruction. He has normal PT, Alb, ALT, AST and platelet count. No esophageal varices were found. The liver histology report was grade = 4 stage = 6; HCV-RNA was positive. No quantification or genotype testing is available.
How should he be treated?
Peyamn Adibi, Tehran, Iran
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The patient is a 47-year-old man with eosinophilic esophagitis (no peripheral eosiniphilia), who was initially treated with prednisome 20 mg/d for 14 days. A repeat EGD still showed eosinophilic esophagitis, endoscopically the same, though the patient states he feels better.
Was the treatment appropriate and for long enough? What else, if anything, should be done for the work-up and treatment of this patient?
Michele Dodman, Warren, Michigan, USA
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I have a liver biopsy on a 47-year-old man with hepatitis B and C. The biopsy shows chronic hepatitis of high grade and high stage with numerous plasma cells. The usual features of chronic hepatitis C are not present.
My differential diagnosis includes chronic hepatitis B or possibly an overlap of chronic hepatitis C with autoimmune hepatitis. Besides studies for hepatitis B surface and core antigens in tissue, is there any way to determine the likely etiology in this case so the hepatologist can treat appropriately? I find this a recurring problem in interpreting liver biopsies in patients with dual infections, and would appreciate opinions and references.
Shirin Nash
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I have a 32-year-old Asian woman with chronic HBV infection (HBeAg-positive with only minor signs at liver biopsy and ALT more than twice the upper limit of normal). She has been treated now for 1 year with lamivudine 100 mg daily. So far, she has responded well to treatment (HBV DNA level lowered by PCR from 276,000 to 10,000 copies/ml; normalization of ALT). However, she has remains positive for HBeAg.
She and her husband would like to have a child. They therefore ask whether the lamivudine could be stopped now. What can I suggest to them? Should she continue lamivudine, suspend treatment, or replace lamivudine with adefovir?
Bertrand Martinez-Aussel, Vientiane, Laos
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My patient is a 17-year-old girl. Her father had colon cancer at age 40. What type of colorectal cancer screening would you recommend for her? Is there a place for genetic testing?
Tatjana Puc Kous, Slovenia
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I performed an EGD on a 32 year old woman with dyspepsia. Her mother died at age 40 with linitis plastica. There was mild antral erythema seen at the patient's EGD, but no other abnormalites. Antral biopsies showed signet cells. This was confirmed by immunohistochemical stains. Multiple deep biopsies taken at a subsequent were negative. EUS and CT scan were also negative.
Should this patient undergo a partial gastrectomy or be followed with surveillance endoscopy?
Dave Talabiska, Lewisburg, PA, USA
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