WhatsApp Chat Summary: July 1 to July 18, 2025
Bi-Weekly Gastroenterology Discussion Group
Welcome to our bi-weekly recap of the lively discussions in our WhatsApp group! This summary pulls together the key threads, cases, and insights shared over the past two weeks, straight from the chat transcript. It's designed to keep everyone in the loop—whether you missed a few messages or just want a quick refresher. Remember, this is based solely on what was discussed in the group.
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Key Topics Discussed
Ascites and Thrombosis Cases: A case with ascitic fluid protein at 2.01 g/dl was debated, leaning toward subacute Budd-Chiari or mixed ascites with inflammation possibly triggering thrombosis. Recommendations included procagulant workup for long-term anticoagulant decisions (e.g., stopping after 6 months), especially with SMV thrombosis as an ongoing indication. Ascitic fluid TB PCR and lymph node assessment were suggested.
Esophageal and Gastric Findings: Several images and videos sparked talks on esophageal candidiasis (linked to continuous Fluticasone nasal spray use); portal hypertensive gastropathy without cirrhosis but with portal vein thrombosis; vascular ectasia; and diffuse lymphangiectasias with chylous fluid (advice: avoid fats). A polypoidal mass in the fundus with central umbilication was highlighted, with differentials like GIST, varix, or AVM, especially in a patient with melena history.
Colonic and Rectal Issues: Cases included a 35-year-old with per-rectal bleeding (Hb 2 g) and rectal growth; colon ulcers showing epithelioid granuloma with multinucleated giant cells (differentials: TB, Crohn's, sarcoidosis, fungal infections); ulcerative proctitis or chronic rectal prolapse (intolerant to rectal mesalamine); serpiginous ulcers; ischemic colitis with a "white stripe sign" in the sigmoid (linked to antihypertensives); and a transverse colon polyp (Paris 0-Is, NICE 1, possibly hyperplastic, lipoma, or leiomyoma—removed via cold snare).
Hepatic and Autoimmune Conditions: An 18-year-old boy on Isotretinoin for acne presented with rising transaminases (up to 500s), positive anti-smooth muscle antibody (>1/80), elevated IgG, negative ANA, and family history of liver disease. Liver biopsy revealed mHAI grade 6/18 (not warranting treatment) but bridging fibrosis as an indication. Isotretinoin was noted as a potential autoimmune hepatitis trigger.
Eosinophilic Esophagitis and Polyposis: Queries on Dupilumab dosing (300 mg/week subcutaneous) and endoscopy timing for histological response. A request for an article on polyposis syndromes was shared.
H. pylori Treatment: Discussion on repeating Pylera (this time with PPI like Pantoprazole) after a prior attempt without PPI, or opting for gastroscopy with antibiotic resistance testing. Alternatives included susceptibility testing, switching antibiotics (e.g., azithromycin, clarithromycin, ciprofloxacin, amoxicillin + PPI/PCAB), and avoiding empirical approaches due to resistance concerns.
Portal Vein Aneurysm: A 22-year-old female with epigastric pain, early satiety, nausea/vomiting, esophageal varices, and portal hypertensive gastropathy. MRI showed a 5.3 cm giant portal vein aneurysm with thrombus extending to branches, plus enlarged liver and spleen. Approaches: procagulant workup, start carvedilol and anticoagulation (no initial banding), involve surgeons, consider thrombolysis via transjugular or transhepatic routes.
Surgical and Endoscopic Techniques: Talks on recurrent dysphagia post-myotomy for achalasia (pneumatic dilation vs. POEM); foreign body removal with modified overtube; ESD for pedunculated polyps; argon plasma or stent-in-stent; mini gastric bypass; and total gastrectomy with Roux-en-Y esophagojejunostomy.
Decisions and Agreements
Esophageal candidiasis: Fluconazole 100 mg OD for 7–10 days, or 400 mg day 1 followed by 200–400 mg daily for 14–21 days.
Diffuse lymphangiectasias: Dietary fat avoidance.
Colon ulcer with granuloma: Endoscopic correlation (longitudinal ulcers for Crohn's vs. transverse for TB), infection exclusion via stains/PCR/cultures, plus biopsy/stool GeneXpert, CXR, MT, IGRA.
Rectal findings: Differentials like carcinoma vs. SRUS, but histology points to TB/Crohn's (granulomatous inflammation doesn't fit SRUS); rest of colonoscopy normal except rectum.
Autoimmune hepatitis: Standard prednisolone + azathioprine; open queries on budesonide or mycophenolate as first-line for an 18-year-old.
Fundus mass: EUS (with FNB if needed), CT; if GIST >2 cm or bleeding, remove via ESD/EFTR/surgery; tyrosine kinase inhibitors based on size/mitotic index/mutation.
Portal vein aneurysm: Initiate carvedilol/anticoagulation; surgeon consult; thrombolysis evaluation.
Action Items
Procagulant workups for thrombosis cases (before anticoagulants skew results).
Biopsies/follow-ups for pending cases (e.g., rectal growth, colon ulcers, fundus mass).
EUS for subepithelial lesions (e.g., fundus mass to guide ESD vs. surgery).
H. pylori susceptibility testing if possible.
CT angio for potential gastric AVM.
Immunosuppression selection for autoimmune hepatitis case.
Open Questions or Unresolved Items
Lymph node assessment in the ascites case.
Definitive histopathology for rectal prolapse/ulcerative proctitis.
Fundus mass size and EUS outcomes.
Optimal immunosuppression (budesonide vs. mycophenolate) for the young autoimmune hepatitis patient.
Portal vein aneurysm: Surgery, monitoring, or TIPS?
H. pylori: Repeat therapy or resistance test?
Lesion classification: JNET IIB and Kudo Vn (suggest chromoendoscopy with magnification/crystal violet).
Other Highlights
Noted over-zealous reporting in some bowel cases or subtle IBD changes pre-colonoscopy.
Thanks for being part of these insightful exchanges! If you have thoughts on any of these topics or want to share a case for the next round, drop it in the group or comments here. The next summary will cover July 19–August 1, 2025