Step 1: View clinicals

A 74 year old Bangladeshi man presents with anorexia, nausea, vomiting, and intermittent upper abdominal pain for 3 weeks. His medical history is significant for an episode of gram negative meningitis 12 months ago, and chronic obstructive pulmonary disease for 15 years, with numerous exacerbations, the most recent of which was 2 months earlier. He is currently on inhaled corticosteroid therapy, and also consumes antacid tablets frequently, due to recurrent dyspeptic symptoms. He does not drink, and stopped smoking 13 years ago, with a total pack-history of 11 years. He is currently visiting his son, who is employed in your country.

Step 2: Order all relevant investigations

Complete Blood Count

Hb: 10.2 g/dL (11.5-17.5) WBC: 15,900/mm3 (4,500-10,500) N: 75% L: 22% E: 2.5% Platelets: 320,000/mm3 (150,000-450,000)

Liver Profile + Pancreatic Enzymes

AST: 16 U/L (<35) ALT: 17 U/L (<35) Total Bilirubin: 0.8 mg/dL (0.3-1.9) Direct Bilirubin: 0.1 mg/dL (0.0-0.3) Total protein: 55.4 g/L (66-87) Albumin: 15.8 g/L (34-54) INR: 1.0 (0.9-1.1) Serum Lipase: 80 U/L (0 - 160) Serum Amylase: 37 U/L (23 - 85)

Ultrasound Abdomen

There is marked thickening of the small bowel walls. The liver, pancreas, gallbladder, and biliary tree are sonographically normal. No gallstones are visualized. No other abnormalities are present.

Upper GI Endoscopy

The stomach and duodenum show erythema, whitish mottling, and multiple erosions. An elevated lesion is seen on the greater curve of the stomach, at the junction of the antrum and pylorus. Biopsies of the gastric and duodenal mucosa reveal the presence of eggs, rhabditiform larvae, filariform larvae, and adult forms of Strongyloides stercoralis in the glands and crypts. Biopsies of the lesion reveal superficial fragments of gastric antral mucosa with surface erosions, congestion, ectatic blood vessels and dense infiltration of the lamina propria by lymphocytes, plasma cells, neutrophils and few eosinophils. Tests for Helicobacter pylori are negative.

Step 3: Select appropriate management

Nil Per Oral
IV Cefotaxime

Score: ★★☆