Gastro Case Challenge: A Coffee Drinker With Chronic Diarrhea, Epigastric Pain, and Fever

Sarah El-Nakeep, MD


November 09, 2022

Physical Examination and Workup

The patient's vital signs include a temperature of 102.2 °F (39 °C), a blood pressure of 100/70 mm Hg, and a pulse of 110 beats/min.

Upon general examination, jaundice and yellowish skin discoloration are noted. He also has mild bilateral lower limb edema, and his skin texture shows decreased elasticity caused by dehydration. The abdominal examination shows tenderness in the epigastrium and right hypochondrium, with a negative Murphy sign.

Laboratory investigations reveal these values:

  • White blood cell count: 13,000 cells/µL (reference range, 4500-11,000 cells/µL)

  • Hemoglobin level: 9 g/dL (reference range, 12-17 g/dL)

  • Mean corpuscular volume: 85 fL (reference range, 80-100 fL)

  • Platelet count: 400,000 cells/µL (reference range, 150,000-450,000 cells/µL)

  • Gamma glutamyl transferase level: 500 U/L (reference range, 5-40 U/L)

  • Alanine aminotransferase level: 100 U/L (reference range, 7-56 U/L)

  • Aspartate aminotransferase level: 110 U/L (reference range, 8-33 U/L)

  • International normalized ratio (INR): 1.3 (reference range, ≤1.1)

  • Creatinine level: 1.8 mg/dL (reference range, 0.7-1.3 mg/dL)

  • Blood urea nitrogen (BUN) level: 200 mg/dL (reference range, 6-20 mg/dL)

  • Total bilirubin level: 10 mg/dL (reference range, 0.3-1.0 mg/dL)

  • Direct bilirubin level: 8 mg/dL (reference range, < 0.3 mg/dL)

  • Alkaline phosphatase level: 400 IU/L (reference range, 44-147 IU/L)

  • Albumin level: 2.5 g/dL (reference range, 3.4-5.4 g/dL)

  • Amylase level: 190 U/L (reference range, 30-110 U/L)

  • Lipase level: 160 U/L (reference range, 10-140 U/L)

  • Fasting blood glucose level: 90 mg/dL (reference range, < 100 mg/dL)

  • Fecal calprotectin level: 40 µg/mg (reference range, 10-60 µg/mg)

  • Antiendomysial antibody immunoglobulin A (IgA) level: 0.1 U (reference range, 0-0.1 U)

A urinalysis reveals that the urine is free of protein, glucose, and ketones, with no microalbuminuria. A stool analysis shows no parasitic infestations or the presence of occult blood.

An abdominal ultrasound shows dilation of the biliary radicals and dilation of the common bile duct, which measures 8 mm in diameter. The gallbladder wall and thickness are normal, with no stones inside. These findings are shown in Figure 4, Figure 5, and Figure 6.

Figure 4.

Figure 5.

Figure 6


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