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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2948_Библиотеки_им_академика_М_И_Перельмана
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62 Suspected Gilbert’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Jose Franco
63 The Significance of AST > ALT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Francisco Durazo
64 Marked Hyperbilirubinemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Kia Saeian
65 Suspected NAFLD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
James Esteban
66 Treatment of NAFLD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Francisco Durazo
67 Treatment of MASLD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Achutan Sourianarayanane
68 Alcohol and Liver Disease in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Veronica Loy
69 Alcoholic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Francisco Durazo
70 Fatty Liver on Ultrasound with Normal LFTs . . . . . . . . . . . . . . . . . . . . 325
Francisco Durazo
71 Evaluation for Liver Damage from Chronic ETOH Use . . . . . . . . . . . . 327
Francisco Durazo
72 Ascites in a Patient Without Obvious Cirrhosis . . . . . . . . . . . . . . . . . . . 329
Jose Franco
73 Ascites in Cirrhosis of Unclear Etiology with Increased
Mononuclear Cells
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Jose Franco
74 Low SAAG Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Jose Franco
75 Banding Esophageal Varices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Kia Saeian
76 Gastric Varices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Kia Saeian
77 Increased Ascites in a Stable Cirrhotic . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Kia Saeian
78 Complications Related to Managing Ascites . . . . . . . . . . . . . . . . . . . . . 345
James Esteban
Contents
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79 Portal Vein Thrombosis in Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
James Esteban
80 PVT and Budd Chiari as a Complication of UC . . . . . . . . . . . . . . . . . . 351
Kia Saeian
81 HCC Management, Solitary Lesion in a Child’s A Cirrhosis . . . . . . . . 353
Francisco Durazo
82 Management of Unresectable HCC in a Cirrhotic . . . . . . . . . . . . . . . . 355
Francisco Durazo
83 HCC in NAFLD Without Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Francisco Durazo
84 Managing Primary Biliary Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . 359
Juan Trivella
85 Advanced PBC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Juan Trivella
86 Autoimmune Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Francisco Durazo
87 Autoimmune Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
James Esteban
88 Primary Sclerosing Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Juan Trivella
89 PBC-AIH Overlap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Juan Trivella
90 Immune-Tolerant Chronic HBV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
James Esteban
91 Immune-Active Chronic HBV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
James Esteban
92 HBV Treatment Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
James Esteban
93 Differentiating Acute HBV from an Acute Exacerbation
of Chronic HBV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
James Esteban
94 Acute HBV and Risk of HBV Reactivation . . . . . . . . . . . . . . . . . . . . . . 397
James Esteban
95 Complicated HCV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Kia Saeian
Contents
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xiii
96 Acute Liver Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Kia Saeian
97 Delayed Presentation of Tylenol Overdose . . . . . . . . . . . . . . . . . . . . . . . 405
Kia Saeian
98 Candidates for Liver Transplant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Veronica Loy
99 Frustrations with Waiting for a Transplant . . . . . . . . . . . . . . . . . . . . . . 411
Veronica Loy
100 Complications Posttransplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Veronica Loy
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Contents
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Contributors
Helmut Ammon Division of GI and Hepatology/Department of Medicine—GI,
Medical College of Wisconsin, Milwaukee, WI, USA
Poonam Beniwal-Patel Medicine, Gastroenterology/Hepatology Division,
Medical College of Wisconsin, Milwaukee, WI, USA
GI and Hepatology Division, Medical College of Wisconsin, Milwaukee, WI, USA
WilliamBerger Division of Gastroenterology and Hepatology, Medical College
of Wisconsin, Milwaukee, WI, USA
KeelyBrowning Madison Medical Afliates, Milwaukee, WI, USA
Department of Gastroenterology, Medical College of Wisconsin, Milwaukee,
WI, USA
PhillipChisholm Department of Medicine, GI/Hep Division, Medical College of
Wisconsin, Milwaukee, WI, USA
Kulwinder Dua Division of Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
GI and Hepatology Division, Dept. of Medicine, Medical College of Wisconsin,
Milwaukee, WI, USA
FranciscoDurazo Division of Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
Francis Edeani Division of Gastroenterology and Hepatology, Department of
Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
James Esteban Division of Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
Salina Faidhalla Department of Medicine Division of Gastroenterology and
Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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xvi
Jose Franco Department of Medicine-Division of Gastroenterology and
Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
Ben George Division of Hematology and Oncology, Department of Medicine,
Medical College of Wisconsin, Milwaukee, WI, USA
Jon Gould Department of Surgery, Medical College of Wisconsin,
Milwaukee, WI, USA
Veronica Loy Division Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
Srivats Madhavan Department of Medicine, Division of Gastroenterology and
Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
Benson Massey Division of Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
LingMei Department of Medicine, GI/Hepatology Division, Medical College of
Wisconsin, Milwaukee, WI, USA
Matt Mohorek Department of Gastroenterology, GI Associates,
Wauwatosa, WI, USA
Jim Nelson Department of Medicine, Division of Gastroenterology and
Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
WilfredoPagani Division of Gastroenterology and Hepatology, Medical College
of Wisconsin, Milwaukee, WI, USA
Amir Patel Dept. of Medicine, Division of Gastroenterology and Hepatology,
Medical College of Wisconsin, Milwaukee, WI, USA
Division of Gastroenterology and Hepatology, Department of Internal Medicine,
Medical College of Wisconsin, Milwaukee, Milwaukee, WI, USA
KrupaPatel Methodist Medical Group, Dallas, Texas, USA
Elizabeth Pieper Department of Gastroenterology and Hepatology, Froedtert
Hospital, Milwaukee, WI, USA
Kia Saeian Division of Gastroenterology & Hepatology, Medical College of
Wisconsin, Milwaukee, WI, USA
PatrickSanvanson Division of Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
PreetikaSinh Division of Gastroenterology and Hepatology Medical College of
Wisconsin, Milwaukee, WI, USA
ZacharySmith Division of GI and Hepatology, Department of Medicine, Medical
College of Wisconsin, Milwaukee, WI, USA
Contributors
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W.HarleySobin Division of Gastroenterology and Hepatology, Medical College
of Wisconsin, Milwaukee, WI, USA
Achutan Sourianarayanane Division of Gastroenterology and Hepatology,
Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
DanielStein Division of Gastroenterology and Hepatology, Department of Internal
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
Juan Trivella Division of Gastroenterology and Hepatology, Department of
Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
Contributors
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Part I
General GI
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3© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
W. H. Sobin et al. (eds.), Managing Complex Cases in Gastroenterology,
https://doi.org/10.1007/978-3-031-48949-5_1
Chapter 1
Introduction to the General GI Section
W.HarleySobin
In the General GI section, we start with the case-based management of complicated
eosinophilic esophagitis. The use of PPIs, budesonide, uticasone, and dupilumab
are outlined. Dosage and prolonged duration of therapy are discussed. Management
of severe strictures and brostenotic disease is outlined.
Next is a case discussing the diagnosis and management of oropharyngeal dys-
phagia, including how to direct the correct questions in taking a history and how to
work with your speech therapist.
In reviewing achalasia, the author discusses the tendency to misdiagnose achala-
sia as GERD. He differentiates the management of types 1, 2, and 3 achalasia and
discusses the advantages of Heller myotomy and POEM.Diagnosis and manage-
ment of achalasia in the elderly are discussed, as are the diagnosis of pseudoachala-
sia and difculties in diagnosing achalasia in someone on opioids.
Multiple examples of motility disorders of the esophagus including non- achalasia
cases are provided. Some of the issues discussed include the evaluation of a patient
with chest pain and dysphagia; use of esophageal manometry in diagnosing motility
disorders; diagnosis and treatment of jackhammer esophagus and ineffective esoph-
ageal motility disorders; opioid-induced esophageal motility disorders; and the
diagnosis and treatment of corkscrew esophagus.
There are case examples of some of the intricacies in the treatment of GERD and
pH testing in the diagnosis and management of GERD.There is a review of various
options to treat refractory GERD, as well as the management of patients with func-
tional heartburn and reux hypersensitivity.
W. H. Sobin (*)
Division of Gastroenterology and Hepatology, Medical College of Wisconsin,
Milwaukee, WI, USA
e-mail: hsobin@mcw.edu
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4
An esophageal surgeon, using case examples, discusses the complex decisions
about whether to operate in GERD.He reviews the benets of the LINX and Toupet
procedures over the Nissen fundoplication; who is a candidate for magnetic sphinc-
ter augmentation (MSA), performing an MRI in someone with an MSA; surgical
management of GERD in the obese patient; and issues with transoral incisionless
fundoplication (TIF).
There are case examples of Barrett’s esophagus with and without dysplasia.
Surveillance guidelines in patients with Barrett’s with and without dysplasia are
discussed. Endoscopic modalities for the treatment of dysplasia are reviewed, as
well as the pros and cons of performing ablation, techniques of performing ablation,
and EMR of esophageal nodules. Newer techniques for screening and diagnosing
Barrett’s are outlined.
Case examples of problems in the management of PEG tubes are discussed
including: dealing with a PEG tube that won’t stop draining; PEG tube tracts that
won’t close; dealing with clogged G tubes and J tubes; techniques for placing a G-J
tube; controversies in placing a PEG in someone who has ENT cancer; avoiding
complications inserting PEG tubes; and how to manage those complications should
they occur. Issues with replacing a PEG tube are discussed, as are the management
of a prematurely pulled-out PEG tube and managing a buried bumper.
Case examples of the diagnosis of pernicious anemia (PA) are provided.
Pathophysiology of autoimmune metaplastic atrophic gastritis (AMAG), surveil-
lance for gastric cancer in AMAG, HP, and the development of environmental meta-
plastic atrophic gastritis (EMAG) are discussed, as are the distinctions between
EMAG and AMAG and techniques of gastric mapping and its use in PA, AMAG,
and EMAG.
In the section on subepithelial lesions and NETs, we provide case examples of
gastric submucosal lesions and how to determine their etiology. The management of
gastric GISTs, neuroendocrine tumors of the gut, and treatment of a small rectal
carcinoid are reviewed. There are three types of gastric carcinoids, and their evalu-
ation and treatment are outlined.
There is a chapter on viewpoints on managing common clinical GI disorders
from a practitioner with over 50 years of “real-world” experience. He discusses case
examples of difculties managing: chronic constipation, IBS-D, gastroparesis,
GERD, microscopic colitis, fecal incontinence, and diverticulitis.
A case of severe SIBO and its management is discussed. Clinical ndings, diag-
nosis, pathophysiology, predisposing mechanisms, and antibiotic choice are
reviewed. How should you manage a patient with SIBO where antibiotics are no
longer working?
A case of a patient with a functional GI disorder who has an abnormal breath test
is discussed. Problems with interpretation of breath tests, a comparison of glucose
and lactulose breath tests, and the benet of adding scintigraphy to breath testing
are highlighted. The problem of frequent false positive breath tests is delved into
and explained. A strong case for limiting breath testing to patients who have a pre-
disposing reason to have SIBO is made.
W. H. Sobin
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5
Unusual causes of abdominal pain and controversies in the diagnosis of chronic
abdominal pain are the subject of another chapter. Case examples of difcult-
to- make diagnoses in the determination of an etiology of chronic abdominal pain
are reviewed. These include acalculous cholecystitis, median arcuate ligament com-
pression syndrome, disorders of gut-brain interaction, narcotic bowel syndrome,
microscopic colitis, chronic mesenteric ischemia, sphincter of Oddi dysfunction,
endometriosis, chronic abdominal wall pain, epiploic appendagitis, porphyria, scle-
rosing mesenteritis, and abdominal migraine. Conicts about ordering CT scans for
chronic abdominal pain are discussed. The peculiar circumstance of peptic ulcer
disease and cholecystitis rst presenting as complicated disease in previously
asymptomatic elderly and RA patients is highlighted.
Case examples of patients with-acute mesenteric insufciency, mesenteric vein
thrombosis, chronic mesenteric ischemia, non-occlusive mesenteric ischemia, colon
ischemia, and median arcuate ligament syndrome are reviewed. Difculties in diag-
nosis and management are discussed.
There are case examples that describe the pros and cons of cold snare and hot
snare polypectomy. Other topics discussed in the chapter on polypectomy include
the use of cold snares for removing large laterally spreading granular tumors; choice
of snare in doing a polypectomy in a patient receiving anticoagulation; use of clips
in cold snare vs hot snare polypectomies; and whether or not to hold anticoagulation
or antiplatelet agents prior to elective colonoscopy. There is also a discussion of
injection technique and other recommended maneuvers in EMR, including a review
of obstacles encountered. The authors also discuss which polyps to send to the sur-
geon; endoscopic features that suggest deep submucosal invasion; management of
pedunculated polyps, including polyps with a thick stalk; and how to deal with post-
polypectomy bleeding.
In a chapter on rectal incontinence, the authors provide case examples describing
the management of passive, urge, and seepage incontinence. They describe the best
techniques for rectal examination in the incontinent patient. They extensively dis-
cuss the evaluation of fecal incontinence and examples of etiologic causes. This
includes diagnosing fecal incontinence due to overow and its management.
Managing diarrhea in fecal incontinence is extensively reviewed including the use
of biofeedback therapy, surgery, and sacral nerve stimulation in various patients
with incontinence. Incontinence in the post-stroke patient is discussed, as is manag-
ing the patient with intermittent involuntary seepage.
In the chapter on diverticulitis, we provide case examples discussing controver-
sies in the management of diverticulitis including whether all patients need to
receive antibiotics; how to manage smoldering diverticulitis; when to recommend
elective surgery; and how to avoid recurrent diverticulitis. The entities of symptom-
atic uncomplicated diverticular disease (SUDD) and segmental colitis associated
with diverticulosis (SCAD) and their management are reviewed.
There are case studies that demonstrate when (and how) to evaluate a pancreatic
cyst, including the use of EUS and FNA, the analysis of amylase and CEA in cyst
uid, and the evaluation of pancreatic IPMNs. Other subjects reviewed include how
1 Introduction to the General GI Section
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