Online Clinical Case Study (May 2017)

Clinical Cardiology Series

The content of the May Cardiology Series is provided by:
Dr. TAN GuangMing
MBChB, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology
Dr. CHEUNG Shing Him, Gary
MBBS, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology

An Unusual case of epigastric pain

Madam Ip, a 59 years old lady had history of gastric lymphoma with gastrectomy and post-op radiotherapy to abdomen 20 years ago. She complained of epigastric pain for 2-3 months. The pain usually occurred within 30 minutes after meal. She also complained of weight loss of 10 pounds in the past month. OGD showed friable mucosa and contact bleeding at the anastomasis site. A CT abdomen was arranged and the films are shown in figure 1. Subsequently a procedure was arranged, and is shown in figure 2.

Figure 1.

Figure 2.

1. What is the differential diagnosis?
A. Peptic ulcer disease
B. Biliary colic
C. Chronic Pancreatitis
D. Chronic Mesenteric Ischemia
E. Any of the above is possible
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What special investigations would you order for this patient?
A. CT abdomen
B. OGD +/- colonoscopy
D. CT angiography
E. All of the above

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What does the Figure 1 show?
A. Chronic pancreatitis
B. Stenosis of both the celiac trunk and the SMA
C. Gallstone disease
D. Aortic Dissection
E. Perforation of viscera

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What are the treatment options?
A. Medical treatment with antacid
B. Percutaneous angioplasty
C. Surgical revascularization
D. Surgical resection of small bowel
E. B or C is acceptable.

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What is the procedure shown in the Figure 2?
A. Percutaneous transluminal angioplasty of superior mesenteric artery with stenting
B. Transarterial chemoembolization
C. Transarterial coil embolization
D. Transesophageal endoscopic ultrasound
E. Transesophageal echocardiogram

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1. E, 2. E, 3. B, 4. E, 5. A.

Chronic Mesenteric Ischemia (CMI) is sometimes referred to as 'post-prandial angina' and is caused by an insufficiency of blood supply to the intestine. Symptoms of CMI include post-prandial abdominal pain, fear of eating and weight loss. These symptoms usually remain dormant unless 2 out of 3 visceral vessels (namely the celiac trunk, the SMA and the IMA) are stenotic or occluded. The commonest cause of CMI is atherosclerosis. Other rarer causes include fibromuscular disease, trauma or as in our case, previous radiotherapy. The diagnosis can be established by the typical symptomatology and imaging finding of visceral arteries stenosis. Imaging modalities such as CT angiography or arteriography (which is criterion standard) can be considered. In general, for symptomatic patient, revascularization either with open or endovascular approach is recommended. Compared with open revascularization, endovascular angioplasty with stenting is associated with lower perioperative morbidity and mortality and shorter hospital stays. However, it is also associated with higher restenotic rates.


  • Sreenarasimhaiah J. Diagnosis and management of intestinal ischaemic disorders. BMJ. 2003 Jun 21. 326(7403):1372-6.
  • Silva JA, White CJ, Collins TJ, Jenkins JS, Andry ME, Reilly JP, et al. Endovascular therapy for chronic mesenteric ischemia. J Am Coll Cardiol. 2006 Mar 7. 47(5):944-50.
  • Kougias P, Huynh TT, Lin PH. Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia. Int Angiol. 2009 Apr. 28(2):132-7.
  • Goldman MP, Reeve TE, Craven TE, Edwards MS, Corriere MA, Hurie JB, et al. Endovascular Treatment of Chronic Mesenteric Ischemia in the Setting of Occlusive Superior Mesenteric Artery Lesions. Ann Vasc Surg. 2016 Aug 28.


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Dermatology Series 皮膚科病例研究

Dermatology Series for May 2017 is provided by:
Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung, Dr. LEUNG Wai Yiu and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology

A 21-year-old man complained of itchy rash over generalized body

A 21-year-old man with previously good past health complained of newly onset itchy rash over generalized body for two days. He had fever for past three days. Physical examination showed erythematous maculo-papular lesions over generalized body.


1. What other important medical history need to be taken from this patient?
The medication history is an important medical history needed to be taken from this patient - in particular any new medication taken prior to the development of skin rash. This gentleman started to take penicillin one day prior to the onset of rash. The rash then worsen in extent in the past two days.

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2. What is the diagnosis?
The diagnosis is drug eruption. Differential diagnoses include viral exanthem, pityriasis disease, acute cutaneous lupus, etc.

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3. What are the common causes of this medical condition?
The common causes of this medical condition include antibiotics, sulfa drugs. Non-steroidal anti-inflammatory medications, chemotherapeutic agents, anticonvulsants, psychotropic drugs.

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4. How is the skin condition diagnosed?
Most drug eruptions can be diagnosed by careful medical history and general physical examination. Skin biopsy may be needed for confirmation in suspected and difficult case.

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5. What are the managements?
It is important to discontinue the offending medication immediately if possible. Treatment of drug eruption depends on the severity of reaction. Most mild to moderate type of drug eruption can be managed by antihistamines and topical steroids.

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