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A rare cause of gastric outflow obstruction

24 Jul, 17 | by abhichauhan

A 78-year old lady with a previous history of oesophagectomy for adenocarcinoma, was referred with symptoms of epigastric pain, post-prandial vomiting and weight loss. OGD after a prolonged fast revealed erosions in the gastric conduit (image A) and the impression of external indentation at the antrum but no stenoses. Biopsies revealed chronic inflammation with no evidence of dysplasia or malignancy. A barium meal and CT abdomen were ordered and the results are shown in image B and C respectively.
What is the cause of gastric outflow obstruction?



Dr Isabel Carberry 1, Dr Jim Zhong 2, Dr Nick E Burr 1, Dr Damian JM Tolan 2

and Dr Venkat Subramanian 1

Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS trust, Leeds, United Kingdom 1

Department of Clinical Radiology, St James’s University Hospital, Leeds Teaching Hospitals NHS trust, Leeds, United Kingdom 2

Corresponding author

Dr Venkataraman Subramanian

Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF


The OGD and barium meal showed a dilated gastric conduit with large amounts of food residue. There was transient hold-up of contrast caused by extrinsic compression of the first part of the duodenum by a 2cm, rim-calcified mass. The subsequent CT scan showed a heavily calcified common hepatic artery aneurysm (HAA) which indented the pylorus and was the cause of her gastric outlet obstruction.


HAA are rare and asymptomatic in 75% of patients. Unfortunately, around 15% of patients present with a rupture.[1] In symptomatic patients, epigastric pain and jaundice are the most common features.[2] HAA are more frequent in males, associated with hypertension, smoking and alcohol intake, malignancy[1] and previous biliary surgery.[2] When suspected CT angiography can characterise the lesion and inform future treatment decisions which can include stenting, embolisation, ligation and vascular reconstruction.[2]


We could not find any other reports of HAA causing gastric outlet obstruction, although a case involving a pancreaticoduodenal artery aneurysm has been described.[3] Although rare, visceral artery aneurysms should be recognised in the aetiology of gastric outlet obstruction. Our patient’s symptoms have eased with conservative management including dietary modification and proton pump inhibitor therapy. She is awaiting a review by the local surgical MDT.

#FGDebate: Liver Biopsy is Critical for Managing Fatty Liver Disease

23 Jun, 17 | by Kelly Horwood, BMJ

Liver Biopsy is Critical for Managing Fatty Liver Disease

Date: Tuesday 25th July
Time: 8-9pm GMT
Guest: Professor Rob Goldin @robdgol

Rob Goldin is Professor of Gastro-intestinal and Liver Pathology at Imperial College and the Clinical Lead for Gastro-intestinal Pathology in the North-West London Pathology Group. He also works at the Ludwig Institute for Cancer Research in the University of Oxford. His particular interest is in developing new ways of imaging and analysing tissue.

A Macroscopic Sign of an Often Unseen Diagnosis

2 Jun, 17 | by abhichauhan

A 72 year old lady presented with new, non-bloody diarrhoea. She was intermittently using Ibuprofen and had a family history of colorectal cancer. She underwent colonoscopy.
What is the classical feature observed at the ceacum? How can the diagnosis be confirmed? How should this be treated?


Submitted by PR Harvey, RA Boulton.

Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK.

An unusual cause for hyperamylasaemia

17 Apr, 17 | by abhichauhan

A 79-year-old man with an extensive previous heart history was admitted electively for investigation of weight loss and deterioration of renal function.
Whilst an inpatient he developed severe epigastric pain and an initial blood test revealed an acutely raised amylase (> 2000) and deranged liver function tests. A non-contrast CT scan was done.
What is the diagnosis ?

Dr Vasileios Galanakis


  • Due to the close anatomical proximity between the gastroduodenal artery and the common bile duct, an aneurysm or a sealed hematoma can result in extrinsic bile duct pressure leading to obstructive jaundice and hyperamylasaemia.

#FGDebate: The Role of Critical Care in Cirrhosis: Futility vs Opportunity?

7 Apr, 17 | by Kelly Horwood, BMJ

The Role of Critical Care in Cirrhosis: Futility vs Opportunity?

Date: Tuesday 11th April
Time: 8-9pm GMT
Guest: Dr Philip Berry @philabery


Philip Berry is a consultant hepatologist at Guy’s & St Thomas’ NHS Foundation Trust, London. His interests include the management of decompensated cirrhosis and approaches to ethical dilemmas on the ward. He writes a regular blog on medical ethics and the psychology of doctors.





  • Identifying which patients will benefit from escalation to ICU
  • The place of early palliative care in hepatology
  • ‘Rescue’ situations
  • Alcohol dependence and its influence on medical decision making
  • Futility thresholds on ICU



A simple IBD flare?

1 Mar, 17 | by abhichauhan

33 year old male with ulcerative colitis presents with a 5-day history of fever, night sweats, abdominal pain and increased stool frequency. Medications include mesalazine M/R 1g once daily, 6-mercaptopurine 75mg once daily and a two week course of prednisolone 40mg once daily. Bloods revealed a leukopenia and c-reactive protein of 23. Based on the flexible sigmoidoscopy (figure) findings what is the most likely diagnosis? How would this change your management?

Submitted by Matthew Armstrong, Tom Thomas, Tariq Iqbal, Ralph Boulton and Jason Goh .

Gastroenterology department, University Hospital Birmingham, Birmingham, UK.

Another portal vein thrombosis?

13 Jan, 17 | by abhichauhan


Figure 1

Figure 2

A 62 year old male was undergoing antiviral therapy for HCV cirrhosis. He was asymptomatic with normal liver function tests and a normal alpha fetoprotein level. Routine liver ultrasound suggested a new portal vein thrombosis. CT imaging (figure1) and subsequent pathology specimen (figure 2) demonstrate a unique lesion. What’s in the portal vein?

Submitted by

J.Doherty, C.Braniff, S.Oon, J. O’ Neill, P A. Mc Cormick.

Liver transplant Unit, St Vincent’s University Hospital, Dublin.

#FGDebate: How to Get the Most Out of Your Endoscopic Training

6 Jan, 17 | by Kelly Horwood, BMJ

How to Get the Most Out of Your Endoscopic Training: Ask the Experts

Date: Thursday 12th January 2017
Time: 8-9pm GMT
Guest: Dr Brian McKaig @braincmckaig

Dr Brian McKaig
MBChB, PhD, PGCMEDr Briandr-mckaig McKaig is a Consultant Gastroenterologist working at the Royal Wolverhampton NHS Trust since 2002, having qualified from Glasgow University in 1991 and training in Nottingham gaining a PhD in 2001.
His clinical interests lie in lower GI endoscopic therapy and Bowel Cancer Screening.
He has a long standing interest in education and endoscopy training and was awarded PGCME from Wolverhampton University 2004. He has been the Director of the West Midlands Endoscopy Training Centre since 2005 delivering over 20 courses per year. He is a member of the JAG QA-T workgroup, currently focusing on development of training pathways within endoscopy. He has previously been Chair of the Federation of Training Centres and has delivered endoscopy training throughout the UK and has led JAG / BSG / WGO international training developments in Europe and Africa. He has worked in collaboration to develop many of the current JAG approved endoscopy courses currently run in the UK.
Brian is the current Colonoscopy Professional Clinical Advisor for the West Midlands BCSP and sits on the BCSP Accreditation Panel and National BCS QA committees.

Case of the month: Jelly belly?

15 Nov, 16 | by abhichauhan


Case of the month:

A 75 year old man presents with a 2 month history of abdominal distension and lethargy. Clinical examination demonstrates shifting dullness and investigations reveal he has a microcytic anaemia with raised tumour markers (CA19-9-208 U/ml , CEA-88 µg/L)  Ascitic aspiration yields a gelatinous fluid, the coronal section of his abdominal CT scan is shown above. What is the diagnosis (hint:the arrows point to the primary pathology)

Submitted by N. Patodi

#FGDebate GI Consequences of Cancer

30 Sep, 16 | by Kelly Horwood, BMJ

GI Consequences of Cancer: Cancer cured – all back to normal now?’

Date: Tuesday 4th October 2016
Time: 8-9 BST
Guest: Dr Ana Wilson @GIWolfsonunit

Dr Ana (Ignjatovic) Wilson BA(Hons) MD MRCP
Consultant Gastroenterologist and Endoscopist

Dept:   Wolfson Unit for Endoscopy
Tel:      020 8869 5277

wilson-ana-1Dr Ana Wilson is out featured guest for this months #FGDebate on GI consequences of cancer. Dr Ana Wilson is a luminal gastroenterologist and specialist gastrointestinal endoscopist. Her specialist interests include early diagnosis, prevention and treatment of pre-cancerous lesions and cancer, through colonoscopy, in patients with inflammatory bowel disease and those at increased risk of developing colorectal cancer. Dr Wilson specialises in advanced endoscopic imaging and complex therapeutic

endoscopy. She has a special interest in managing patients with gastrointestinal consequences of cancer treatment (eg. Low anterior resection syndrome, pelvic radiation disease) and leads the service at St Mark’s Hospital.

Dr Wilson qualified from University of Oxford in 2002. She obtained Membership of the Royal College of Physicians in 2005 and trained in gastroenterology and general internal medicine in Oxford Deanery. She spent three years at the Wolfson Unit for Endoscopy, St Mark’s Hospital undertaking research in the use of colonoscopy in diagnosis and assessment of dysplasia under the supervision of Prof Brian Saunders that led to an MD thesis at the Imperial College, London, and has published widely on the subject. After completing her training, Dr Wilson specialised further in management of complex inflammatory bowel disease and endoscopy at University College Hospital, London. She was appointed as Consultant Gastroenterologist and Specialist Endoscopist at St Mark’s Hospital in December 2012.

She has been an invited speaker at numerous national and international meetings and has contributed to a number of guidelines on the use of advanced imaging in lesion recognition including in inflammatory bowel disease.


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