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Clinical Challenges & Images in GASTROENTEROLOGY — A Diagnostic Guide

Digestive diseases have always been a major threat to global health. Despite the
rapid advances in various diagnostic modalities, many a time the final verdict can Clinical Challenges
& Images in
be elusive and present a diagnostic challenge for the attending doctor.

Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide presents

45 real‐life cases to illustrate an evidence‐based approach to the diagnosis,
investigation and management of gastrointestinal diseases commonly
encountered in everyday practice, with a special focus on the interpretation of
GASTROENTEROLOGY
endoscopic and radiological images.
A Diagnostic Guide
This book provides a pragmatic approach for medical students, residents, specialist
trainees and specialists alike who have an interest in gastroenterology. We also
believe that other healthcare providers, such as general practitioners, nurses and
dieticians, will also benefit from these case illustrations.

The authors of this book are based at the Institute of Digestive Disease, The
Chinese University of Hong Kong. This institute has contributed to major
breakthroughs that have improved the clinical management of digestive diseases
including, but not limited to, the advent of endoscopic therapies and minimally
invasive surgery, molecular diagnostic tools for cancers and inflammatory bowel
disease, and the development of novel treatments for acid peptic disease and viral
hepatitis.

ISBN 978-1-910079-03-4

Siew C Ng
Heyson CH Chan
9 781910 079034
tf m Rashid NS Lui
Clinical Challenges
& Images in
GASTROENTEROLOGY
A Diagnostic Guide

Siew C Ng
Heyson CH Chan
Rashid NS Lui
i
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

tfm Publishing Limited, Castle Hill Barns, Harley, Shrewsbury, SY5 6LX, UK
Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192
E-mail: info@tfmpublishing.com
Web site: www.tfmpublishing.com

Editing, design & typesetting: Nikki Bramhill BSc Hons Dip Law

First edition: © 2018

Paperback ISBN: 978-1-910079-03-4

E-book editions: 2018

ePub ISBN: 978-1-910079-04-1
Mobi ISBN: 978-1-910079-05-8
Web pdf ISBN: 978-1-910079-06-5

The entire contents of Clinical Challenges & Images in Gastroenterology — A

Diagnostic Guide is copyright tfm Publishing Ltd. Apart from any fair dealing for the
purposes of research or private study, or criticism or review, as permitted under the
Copyright, Designs and Patents Act 1988, this publication may not be reproduced,
stored in a retrieval system or transmitted in any form or by any means, electronic,
digital, mechanical, photocopying, recording or otherwise, without the prior written
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Neither the authors nor the publisher can accept responsibility for any injury or damage
to persons or property occasioned through the implementation of any ideas or use of
any product described herein. Neither can they accept any responsibility for errors,
omissions or misrepresentations, howsoever caused.

Whilst every care is taken by the authors and the publisher to ensure that all
information and data in this book are as accurate as possible at the time of going to
press, it is recommended that readers seek independent verification of advice on
drug or other product usage, surgical techniques and clinical processes prior to their
use.

The authors and publisher gratefully acknowledge the permission granted to

reproduce the copyright material where applicable in this book. Every effort has
been made to trace copyright holders and to obtain their permission for the use of
copyright material. The publisher apologizes for any errors or omissions and would
be grateful if notified of any corrections that should be incorporated in future
reprints or editions of this book.

Printed by Gutenberg Press Ltd., Gudja Road, Tarxien, Malta, GXQ 2902
Tel: +356 218 97037; Fax: +356 218 00069
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Web site: www.gutenberg.com.mt
ii
Contents
Page

Preface vi

Abbreviations viii

Acknowledgements xiii

Dedication xiv

Case 1 1

Case 2 9

Case 3 17

Case 4 25

Case 5 31

Case 6 36

Case 7 43

Case 8 49

Case 9 55

Case 10 62

Case 11 69

iii
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

Case 12 74

Case 13 82

Case 14 87

Case 15 94

Case 16 102

Case 17 110

Case 18 118

Case 19 124

Case 20 132

Case 21 138

Case 22 146

Case 23 153

Case 24 158

Case 25 164

Case 26 171

Case 27 179

Case 28 186

Case 29 194

Case 30 203
iv
 Contents

Case 31 210

Case 32 217

Case 33 222

Case 34 229

Case 35 237

Case 36 245

Case 37 253

Case 38 260

Case 39 267

Case 40 273

Case 41 279

Case 42 285

Case 43 291

Case 44 297

Case 45 305

Case index 313

Index 317

v
 Preface
Digestive diseases have always been a major threat to global health.
Despite the rapid advances in various diagnostic modalities, many a time
the final verdict can be elusive and present a diagnostic challenge for the
attending doctor. “Clinical Challenges & Images in Gastroenterology — A
Diagnostic Guide” presents 45 real-life cases to illustrate an evidence-
based approach to the diagnosis, investigation and management of
gastrointestinal diseases commonly encountered in everyday practice,
with a special focus on the interpretation of endoscopic and radiological
images. This book provides a pragmatic approach for medical students,
residents, specialist trainees and specialists alike who have an interest in
gastroenterology and hepatology. Other healthcare providers, such as
general practitioners, nurses and dieticians, will also benefit from these
case illustrations.

A unique feature of this book is that virtually all of the cases were
managed by a multi-disciplinary team at the Prince of Wales Hospital,
Hong Kong. The Editors of this book are based at the Institute of Digestive
Disease, The Chinese University of Hong Kong. Our Institute founded by
Professor Joseph Sung a decade ago has contributed to major
breakthroughs that have improved the clinical management of digestive
diseases including, but not limited to, the advent of advanced endoscopic
therapies and minimally invasive surgery, molecular diagnostic tools for
cancers and inflammatory bowel disease, and the development of novel
treatments for acid peptic disease and viral hepatitis. The past directors of
our Institute, Professor Francis Chan and Professor Henry Chan, are
leaders in the fields of gastroenterology and hepatology.

This book aims to promote integrative and interdisciplinary medicine in

digestive diseases. Our vision was to provide a variety of GI cases
accompanied by diagnostic and management approaches to achieve the
best outcomes for patients in day-to-day practice. Key take home
messages for each case are highlighted under the sections of “Clinical
pearls” and “Impress your attending”.
vi
 Preface

We were fortunate to have received excellent training in the United

Kingdom and Hong Kong. The opportunity to work together on this book
was a unique one — an idea that was developed during weekly GI rounds.
We not only enjoy each other’s stimulating ideas, but also share the same
passion in advancing and pioneering practice for GI diseases.

Our thanks go to Dr. Raymond Tang (Institute of Digestive Disease),

Professor Anthony Chan and Dr. Maribel Lacambra (Department of
Anatomical and Cellular Pathology), Dr. Esther Hung and Dr. Eric Law
(Department of Imaging and Interventional Radiology) for providing
important pathology and imaging input. We are also grateful to our fellow
gastroenterologists, Dr. Joyce Mak and Professor Sunny Wong, for
providing valuable comments on the cases.

Importantly, this endeavour would not have been possible without our
publisher, Nikki Bramhill (Director, tfm publishing Ltd). It has been a real
pleasure and delight to work with Nikki. Her energy, efficiency and vision
to transfer knowledge in the most effective way have allowed this
partnership to flourish with much happiness.

Siew C Ng MBBS (UK), FRCP (Lond, Edin), PhD (Lond), AGAF, FHKCP, FHKAM (Medicine)
Professor and Honorary Consultant
Institute of Digestive Disease
Department of Medicine and Therapeutics
Prince of Wales Hospital, The Chinese University of Hong Kong

Heyson CH Chan MBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine)

Associate Consultant and Honorary Clinical Assistant Professor
Institute of Digestive Disease
Department of Medicine and Therapeutics
Prince of Wales Hospital, The Chinese University of Hong Kong

Rashid NS Lui MBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine)

Resident Specialist and Honorary Clinical Tutor
Institute of Digestive Disease
Department of Medicine and Therapeutics
Prince of Wales Hospital, The Chinese University of Hong Kong

vii
 Abbreviations
AAA Abdominal aortic aneurysm
AASLD American Association for the Study of Liver Diseases
ACG American College of Gastroenterology
ADPKD Autosomal dominant polycystic kidney disease
AFB Acid-fast bacilli
AFP Alpha-fetoprotein
AGA American Gastroenterological Association
AIDS Acquired immunodeficiency syndrome
AIH Autoimmune hepatitis
ALP Alkaline phosphatase
ALT Alanine aminotransferase
AMA Anti-mitochondria antibody
ANA Anti-nuclear antibodies
ANC Acute necrotic collection
APC Adenomatous polyposis coli
APC Argon plasma coagulation
APFC Acute peripancreatic fluid collection
ASCA Anti-Saccharomyces cerevisiae antibody
ASGE American Society for Gastrointestinal Endoscopy
ASMA Anti-smooth muscle antibody
AST Aspartate aminotransferase
AXR Abdominal X-ray
BCG Bacillus Calmette-Guerin
BCLC Barcelona Clinic Liver Cancer
BE Base excess
BP Blood pressure
CA Carbohydrate antigen/Cancer antigen
CBC Complete blood count
CBD Common bile duct

viii
 Abbreviations

CD Crohn’s disease
CDAD Clostridium difficile-associated colitis
CE Capsule endoscopy
CEA Carcinoembryonic antigen
CIPO Chronic intestinal pseudo-obstruction
CLT Cadaveric liver transplantation
CMV Cytomegalovirus
CRC Colorectal carcinoma
CRP C-reactive protein
CT Computed tomography
CTE Computed tomography enteroclysis or enterography
CVVH Continuous veno-venous haemofiltration
CXR Chest X-ray
DCP Des-gamma-carboxy prothrombin
DLBCL Diffuse large B-cell lymphoma
DM Diabetes mellitus
EASL European Association for the Study of the Liver
ECCO European Crohn’s and Colitis Organisation
ECG Electrocardiography
ECMO Extracorporeal membrane oxygenation
EIM Extra-intestinal manifestations
ELISA Enzyme-linked immunosorbent assay
EMR Endoscopic mucosal resection
ENKL Extranodal NK/T-cell lymphoma
ERCP Endoscopic retrograde cholangiopancreatography
ESD Endoscopic submucosal dissection
ESR Erythrocyte sedimentation rate
ESWL Extracorporeal shock-wave lithotripsy
EUS Endoscopic ultrasound
FAP Familial adenomatous polyposis
Fe Iron
FGP Fundic gland polyps
FMT Faecal microbiota transplantation
FNA Fine-needle aspiration

ix
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

FNAC Fine-needle aspiration for cytology

FOB Faecal occult blood
GAVE Gastric antral vascular ectasia
GCS Glasgow Coma Scale
GGT Gamma-glutamyltransferase
GI Gastrointestinal
GIB Gastrointestinal bleeding
GIST Gastrointestinal stromal tumour
GOJ Gastro-oesophageal junction
GOO Gastric outlet obstruction
GORD Gastro-oesophageal reflux disease
Hb Haemoglobin
HBV Hepatitis B virus
HCC Hepatocellular carcinoma
HCV Hepatitis C virus
HER-2 Human epidermal growth factor receptor type 2
HIV Human immunodeficiency virus
HNPCC Hereditary non-polyposis colorectal cancer
HP Helicobacter pylori
HR Heart rate
HRM High-resolution manometry
HS Heart sounds
HS Hyperinfection syndrome
HTLV-I Human T-lymphotropic virus type I
IBD Inflammatory bowel disease
ICU Intensive care unit
IEE Image-enhanced endoscopy
IgG Immunoglobulin G
IGRA Interferon- release assays
IHD Intrahepatic duct
INR International Normalised Ratio
IPMN Intraductal papillary mucinous neoplasm
ITB Intestinal tuberculosis
IV Intravenous

x
 Abbreviations

K+ Potassium
LDH Lactate dehydrogenase
LDLT Living donor liver transplantation
LFT Liver function test
LN Lymph node
LOS Lower oesophageal sphincter
MALT Mucosa-associated lymphoid tissue
MCN Mucinous cystic neoplasm
MCV Mean corpuscular volume
MEN Multiple endocrine neoplasia
ML Mechanical lithotripsy
MPD Main pancreatic duct
MRE Magnetic resonance enteroclysis or enterography
MRI Magnetic resonance imaging
MTB-PCR Mycobacterium tuberculosis — polymerase chain reaction
Na+ Sodium
NAFLD Non-alcoholic fatty liver disease
NET Neuroendocrine tumour
NME Necrolytic migratory erythema
NSAID Non-steroidal anti-inflammatory drug
NSF Nephrogenic systemic fibrosis
OA Osteoarthritis
OC Occlusion cholangiogram
OGD Oesophagogastroduodenoscopy
OGIB Obscure gastrointestinal bleeding
OGJ Oesophagogastric junction
OTC Over the counter
PAS Periodic acid Schiff
PBC Primary biliary cirrhosis
PCLD Polycystic liver disease
PD Pneumatic dilatation
PDAC Pancreatic ductal adenocarcinoma
PEI Percutaneous ethanol injection
PET-CT Positron emission tomography with computed tomography

xi
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

PG Pyoderma gangrenosum
PHG Hypertensive gastropathy
POEM Peroral endoscopic myotomy
PPI Proton pump inhibitor
PRRT Peptide receptor radionuclide therapy
PSC Primary sclerosing cholangitis
PST Performance status test
PWON Pancreatic walled-off necrosis
RA Room air
RFA Radiofrequency ablation
RFS Recurrence-free survival
RFT Renal function test
RPC Recurrent pyogenic cholangitis
RUT Rapid urease test
SCC Squamous cell carcinoma
SCN Serous cystic neoplasm
SEMS Self-expandable metallic stent
SMA Smooth muscle antibody
SPT Solid pseudopapillary tumour
SSA Somatostatin analogue
sTSH Serum thyroid-stimulating hormone
TACE Transarterial chemoembolisation
TB Tuberculosis
TIBC Total iron-binding capacity
TNF Tumour necrosis factor
UC Ulcerative colitis
USG Ultrasonography
WBC White blood cell
WHO World Health Organization
ZN Ziehl-Neelsen

xii
Acknowledgements
We would like to acknowledge our mentors, brother and sisters within
the gastroenterology and hepatology team, CUHK, for their care and
dedication to the patients.

Professor Joseph Sung

Professor Francis Chan

Professor Henry Chan

Professor Justin Wu

Professor Vincent Wong

Professor Grace Wong

Professor Sunny Wong

Dr. Raymond Tang

Dr. Joyce Mak

Dr. Ting Ting Chan

Dr. Louis Lau

Dr. John Wong

Dr. Moe Kyaw

xiii
 Dedication
To my wonderful family — where would I be without your support and
love. To my little ones Olivia and Oscar — your growth is my constant
source of joy and pride. To my teachers, Francis, Joseph and Justin —
your vision enriched me with hope and wisdom. To my students —
with you I learn more every day.

~
SCN

Dedication of this book goes to my gorgeous wife, Agnes, for always

standing beside me through my ups and downs, for her endless,
unconditional love and for being my soulmate. I would also like to
dedicate this book to my wonderful family — my amazing dad and mum
for their unfailing support and guidance through every phase of my life
and my lovely brother for being my best mate. Last but not least,
dedication goes to my mentors, fellow colleagues, students and
patients for constantly inspiring me to be a better doctor.

~
HC

To my lovely daughter, Kaylee and loving wife, Tina,

who bear witness to this writing journey coinciding with
several of life’s most important milestones.

~
RL

xiv
Case 1
History

A 53-year-old Chinese man with previous good health presented with

a 6-month history of diarrhoea, weight loss, poor appetite and
malaise. Colonoscopy showed a 40cm long segment of
cobblestoning, with circumferential narrowing and ulceration in the
descending colon highly suspicious for colorectal malignancy (Figure
1.1). A left hemicolectomy was performed. Histology showed ulcer
exudates with granulation tissue. It was negative for malignancy and
tuberculosis. He was well for 3 months after the operation, but now
presents again with increasing diarrhoea up to 3-4 times per day,
together with painful swallowing and tongue pain.

1
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

Figure 1.1.

What is your differential diagnosis?

The differential diagnosis includes Crohn’s disease, malignancy,

tuberculosis of the intestinal tract and Behçet’s disease.

Physical examination

• Temperature 37.7°C, pulse 80 bpm, BP 120/75mmHg, SaO2 99%

on RA.
• Mild pallor.
• Examination of the hands reveals no clubbing and normal-appearing
palmar creases.
• On examination of the head and neck, there is a left tongue base
mass with ulceration and right supraclavicular lymph nodes which
are firm in consistency and around 1cm in size.
• Cardiovascular: HS dual, no murmur.
• His chest is clear on auscultation.
• Abdominal examination reveals a midline laparotomy scar. The
abdomen is soft, non-tender, with no definite abdominal mass palpable.
• No signs of oedema.
2
 Case 1

Does this narrow your differential diagnosis?

Recurrence of colorectal malignancy is less likely in this context as

metastatic lymph nodes will more commonly cause enlargement of the left
supraclavicular lymph node, i.e. Virchow’s node (Troisier’s sign). However,
the lymph nodes and tongue base lesion are also atypical for Crohn’s
disease. Initial testing for tuberculosis is also negative and there are no
other features suggestive of Behçet’s disease.

Investigations

• CBC:
- WBC 11.9 x 109/L;
- haemoglobin 10.9g/dL (microcytic, hypochromic picture);
- platelets 348 x 109/L.
• ESR 67mm/hr.
• CRP 64.5mg/L.

What other blood tests would you order?

• Liver and renal function tests.

• Bone profile.
• Iron profile. This shows an iron deficiency picture.

What do these laboratory data suggest?

These laboratory findings suggest active inflammation with suspected

iron deficiency anaemia.

What imaging test would you order?

With the presence of a tongue base mass with ulceration, it is important

to arrange for imaging to assess any deep tissue involvement. For better
3
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

soft tissue resolution, magnetic resonance imaging (MRI) of the neck is

arranged (Figure 1.2).

a b

Figure 1.2.

Please describe what you see

An MRI of the neck shows a left tongue base mass measuring 4cm x
2.7cm x 3.4cm, with unusual findings of ulceration and an exophytic frond-
like appearance. There is also inferior extension involving the lower left
lateral oropharyngeal wall and valleculae. Bilateral enlarged nodes in the
upper, mid and lower internal jugular chains are also noted.

How would you proceed?

An excisional biopsy of the right neck lymph node should be arranged.

4
 Case 1

Histology shows multiple patches of necrosis surrounded by

lymphohistiocytic infiltrate, superficially resembling necrotising
granulomatous inflammation.

What is your differential diagnosis for necrotising

lymphadenitis?

Infection
• Disseminated mycobacterium infection.
• Cat scratch disease.
• Yersinia infection.

Autoimmune
• Crohn’s disease.
• Vasculitis, i.e. eosinophilic granulomatosis with polyangiitis,
granulomatosis with polyangiitis.
• Sarcoidosis.
• Kikuchi-Fujimoto disease.

Malignancy
• Lymphoma.

In view of the atypical history, physical examination and

histopathological features, further immunostaining and investigations are
done.

Immunostain for CD56 (natural killer NK cell marker) shows moderate

numbers of small- to medium-sized lymphoid cells in the interfollicular
zone, which are easily overlooked in light microscopy. These atypical
lymphoid cells co-express for CD3 and CD2 but not CD5 and CD7, and
are also highlighted with in situ hybridisation for Epstein-Barr virus (EBV)
encoded RNAs.

Review of the original colonic resection also demonstrates

lymphomatous infiltrates (Figure 1.3).

5
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

Figure 1.3.

What is the diagnosis, and how would you proceed?

Overall, the features are mostly consistent with NK/T-cell lymphoma.

The next step would be for timely referral to an oncologist for further
work-up and management.

Clinical pearls

• Although rare, extranodal NK/T-cell lymphomas are more common in

East Asia and South America. It is an uncommon differential
diagnosis for inflammatory bowel disease especially in the older
patient. A high index of clinical suspicion is required.
• Staging of a lymphoma is usually done with positron emission
tomography with computed tomography (PET-CT)(Figure 1.4).

PET-CT shows right cervical lymph node involvement, lymphoma

infiltrates at the base of the tongue, a hypermetabolic sigmoid tumour,
nodal metastases in the left para-aortic region and generalised marrow

6
 Case 1

hypermetabolism. A subsequent bone marrow exam is negative for

lymphomatous infiltration.

Malignant tumour
Malignant tumour
at tongue base
Malignant at tongue base
Malignant
cervical LNs
cervical LNs

Generalised marrow
Generalised marrow
hyperactivity
hyperactivity

Nodal metastases at para-

Nodal metastases at para-
aortic level
aortic level

Physiological Suspicious malignant

Physiological Suspicious malignant
colonic activity sigmoid tumour
colonic activity sigmoid tumour

Injection site
Injection site

FigureFigure
1.4. 1.4.

Impress your attending

What virus is implicated as a possible cause for NK/T-cell

lymphoma?
Epstein-Barr virus infection 1.

7
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

What is the prevalence of extranodal NK/T-cell lymphomas in

East Asia?
Extranodal NK/T-cell lymphoma (ENKL) has a greater prevalence in
East Asia and South America 2 compared with other parts of the world,
with an occurrence rate in Asia of 3.3-8%. The majority of tumours arise
from the nasal and paranasal areas. Gut involvement is rare.

What is the prognosis of non-nasal NK/T-cell lymphoma?

Prognosis is generally poor despite treatment with chemotherapy, with
clinical remission in less than 15% of patients.

What do you know about the SMILE regimen?

It is a regimen using dexamethasone, methotrexate, ifosfamide, L-
asparaginase and etoposide for the treatment of NK/T-cell lymphoma. It
can be used in combination with radiotherapy in selected patients 3.

References

1. Kwong YL, Chan AC, Liang R, et al. CD56+ NK lymphomas:

clinicopathological features and prognosis. Br J Haematol 1997; 97:
821-9.
2. Chan JK, Quintanilla-Martilla L, Ferry JA, et al. Extranodal NK/T-cell
lymphoma, nasal type. In: Swerdlow SH, Campo E, Harris NL, et al,
Eds. WHO classification of tumours of haematopoietic and lymphoid
tissues. Lyon, France: IARC Press; 2008: 285-8.
3. Kwong YL, Kim WS, Lim ST, et al. SMILE for natural killer/T-cell
lymphoma: analysis of safety and efficacy from the Asia Lymphoma
Study Group. Blood 2012; 120(15): 2973-80.

8
Case 2
History

A 27-year-old Chinese gentleman with previous good health

presents to a private physician with a 6-month history of cramping
abdominal discomfort, diarrhoea up to 5-6 times per day and rectal
bleeding. This is associated with weight loss of around 3-4kg over
the past 6 months. He is a non-smoker and non-drinker. There is no
family history of colorectal cancer or inflammatory bowel disease.
He has no significant travel history. There are no recent significant
life stressors.

9
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

Physical examination

• Afebrile, pulse 74 bpm, BP 110/60mmHg, SaO2 98% on RA.

• Appears well.
• Examination of the hands reveals no clubbing and normal-appearing
palmar creases.
• Head and neck examination is unremarkable.
• Cardiovascular: HS dual, no murmur.
• His chest is clear on auscultation.
• Abdominal examination reveals a soft abdomen, with no focal
tenderness and no organomegaly.
• No signs of oedema.

Investigations

• CBC:
- WBC 8.3 x 109/L;
- haemoglobin 12.3g/dL (microcytic hypochromic picture);
- platelets 255 x 109/L.
• ESR 31mm/hr.
• CRP 32mg/L.

What is your differential diagnosis?

The differential diagnosis includes inflammatory bowel disease and

infectious colitis.

What other blood tests would you order?

• Liver and renal function tests

• Bone profile.

All are within normal limits.

10
 Case 2

What do these laboratory data suggest?

The blood work is highly suggestive of an active inflammatory process.

What other tests would you order?

An oesophagogastroduodenoscopy (OGD) and a colonoscopy are

arranged.

Colonoscopic findings show multiple irregular ulcers at the transverse

colon, descending colon, sigmoid colon and upper rectum. There is also
terminal ileum ulceration.

Multiple biopsies are taken which show granulomatous inflammation but

no acid-fast bacilli on Ziehl-Neelsen stain. No Mycobacterium tuberculosis
polymerase chain reaction (MTB-PCR) had been performed by the
previous referring hospital.

Oesophagogastroduodenoscopy shows gastritis only.

What imaging test would you order?

A CT of the abdomen and pelvis with contrast (Figure 2.1).

Figure 2.1.

11
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

Please describe what you see

A CT of the abdomen and pelvis with contrast shows circumferential
wall thickening and oedema at the hepatic flexure, ascending colon,
caecum and terminal ileum (arrow). The hepatic flexure and ascending
colon are most severely affected. There is associated hypervascular
mesentery and reactive mesenteric lymph nodes. These features are
suggestive of active inflammatory change.

There is no evidence of abscess or fistula formation.

What is your diagnosis, and how would you proceed?

The clinical picture is compatible with ileocolonic Crohn’s disease.

He is started on prednisolone and azathioprine, and is planned for early

clinic follow-up for review of progress.

The patient has good compliance to medications, but there is no

improvement in his symptoms for 1 month. He then develops fever,
increasing cough and sputum, with worsening abdominal pain and
diarrhoea for 3 weeks prior to hospital admission. There is subjective
weight loss and poor appetite. Symptoms of night sweats, fever and
haemoptysis are negative.

Physical examination shows a fever of 38°C. Chest examination reveals

right upper zone inspiratory crepitations.

What would you do next?

The new onset of chest symptoms and fever after the use of
immunosuppressives warrant thorough investigation and treatment. There
is also a lack of response to treatment with worsening abdominal
symptoms.

Admission and a chest X-ray are arranged (Figure 2.2).

12
 Case 2

Figure 2.2.

Please describe what you see

A chest X-ray (Figure 2.2) shows right upper lobe infiltrates. Repeat
bloods also show an erythrocyte sedimentation rate of up to 70mm/hr.

What is your differential diagnosis?

Secondary chest infection due to immunosuppression and

disseminated tuberculosis.

How would you manage this patient?

• Stop the immunosuppressants.

• Start empirical antibiotics.
• Save sputum for culture, acid-fast bacilli staining and TB culture.

13
 Clinical Challenges & Images in Gastroenterology — A Diagnostic Guide

• Arrange for bronchoscopy and bronchoscopic alveolar lavage.

• Repeat colonoscopy.

Bronchoscopy shows whitish lesions over the right basal segment.

Lavage is sent for Gram stain and culture, acid-fast bacilli and tuberculosis
culture (AFB and TB culture), MTB-PCR, fungal cultures and cytology.

Repeat colonoscopy shows similar findings as before. Multiple biopsies

are taken again. Histology shows necrotising granulomas. Specimens are
also sent for Gram stain and culture, AFB and TB culture, and MTB-PCR.

AFB stains were negative all along. Subsequently, Mycobacterium

tuberculosis DNA is positive from both colonic and lung specimens, and
tuberculosis cultures are also positive after 8 weeks.

Anti-tuberculosis treatment is initiated. The patient is seen in clinic

around 1 month later. Gastrointestinal symptoms are improving with less
abdominal pain and diarrhoea, and no more per rectal bleeding. His body
weight increases to 47kg from 40kg and his inflammatory markers are on
a downward trend.

Clinical pearls

• The differentiation of Crohn’s disease and tuberculosis of the

intestinal tract, especially in endemic regions and in the early phase,
is challenging.
• Close monitoring and follow-up with a high index of suspicion is often
required to arrive at the definitive diagnosis.

Impress your attending

How common is tuberculosis of the intestinal tract?

Tuberculosis of the gut is uncommon. In 2011, there were a total of
4794 new cases of tuberculosis in Hong Kong, of which 91 had

14
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1870–1871. Navy yard, New York.
1871. Worcester, home station.
1872. Promoted to commander. Receiving ship, New York.
1873–1874. Commanding side-wheel steamer Wasp in the Rio de
la Plata.
1875–1876. Navy yard, Boston.
1877–1880. Naval Academy, Annapolis.
1880–1883. Navy yard, New York.
1883–1885. Commanding steam sloop Wachusett, South Pacific
Squadron.
1885. Assigned to Naval War College, as lecturer on naval history
and strategy.
1886–1889. President of Naval War College.
1889–1892. Special duty, Bureau of Navigation. Member of
commission to choose site for navy yard in Puget Sound.
1892–1893. President of Naval War College.
1893–1895. Commanding cruiser Chicago, flagship of Rear
Admiral Erben, European station.
1895–1896. Special duty at the Naval War College.
1896. November 17, retired as captain on his own application after
forty years’ service.
1896–1912. Special duty in connection with Naval War College.
1898. Member of Naval War Board during Spanish War.
1899. Delegate to Hague Peace Conference.
1906. June 29, rear admiral on the retired list.
1914. December 1, died at the Naval Hospital, Washington.

Academic Honors
 D.C.L., Oxford, 1894; LL.D., Cambridge, 1894; LL.D., Harvard,
1895; LL.D., Yale, 1897; LL.D., Columbia, 1900; LL.D., Magill, 1909;
President of the American Historical Association, 1902.

PUBLISHED WORKS

1883. “The Gulf and Inland Waters.”

1890. “The Influence of Sea Power upon History, 1660–1783.”
1892. “The Influence of Sea Power upon the French Revolution
and Empire, 1793–1812.” Two volumes.
“The Life of Admiral Farragut.”
1897. “The Life of Nelson: the Embodiment of the Sea Power of
Great Britain.” Two volumes.
“The Interest of America in Sea Power, Present and Future.”
1899. “Lessons of the War with Spain.”
1900. “The Problem of Asia, and its Effect upon International
Policies.”
“The Story of the War with South Africa, 1899–1900.”
1901. “Types of Naval Officers, Drawn from the History of the
British Navy.”
1902. “Retrospect and Prospect: Studies in International
Relations, Naval and Political.”
1905. “Sea Power in its Relations to the War of 1812.” Two
volumes.
1907. “Some Neglected Aspects of War.”
“From Sail to Steam: Recollections of a Naval Life.”
1908. “Naval Administration and Warfare.”
1909. “The Harvest Within: Thoughts on the Life of a Christian.”
1910. “The Interest of America in International Conditions.”
 1911. “Naval Strategy, Compared and Contrasted with the
Principles and Practice of Military Operations on Land.”
1912. “Armaments and Arbitration: the Place of Force in
International Relations.”
1913. “The Major Operations of the Navies in the War of American
Independence.”

Uncollected Essays

“Reflections, Historical and Other, Suggested by the Battle of the

Sea of Japan,” U. S. Naval Institute, June, 1906; Reprinted in
Journal of the Royal United Service Institution, November, 1906.
“The Battleship of All Big Guns,” World’s Work, January, 1911.
“Misrepresenting Mr. Roosevelt,” Outlook, June 17, 1911.
“Importance of Command of the Sea,” Scientific American,
December 9, 1911.
“Was Panama a Chapter of National Dishonor?” North American
Review, October, 1912.
“Japan among Nations,” Living Age, August 2, 1913.
“Twentieth Century Christianity,” North American Review, April,
1914.
“Macdonough at Plattsburg,” North American Review, August,
1914.
“The Panama Canal and the Distribution of the Fleet,” North
American Review, September, 1914.

REFERENCES

There is at present no printed source for the life of Mahan except

his autobiographical record “From Sail to Steam,” which is confined
almost entirely to the period preceding his retirement in 1896. Aside
from book reviews, the more important critical essays and tributes
are as follows:
 “Mahan’s Counsels to the United States,” G. S. Clarke, Nineteenth
Century, Review, February, 1898.
“Mahan on Sea Power,” S. G. W. Benjamin, New York Times Book
Review, January 18, 1902.
“La Maîtrise de la Mer,” Auguste Moireau, Revue des Deux
Mondes, October, 1902.
“Some American Historians,” Professor H. Morse Stephens,
World’s Work, July, 1902.
“Lee at Appomattox and Other Papers,” Charles Francis Adams,
1903, p. 356 ff.
“The Writings of Mahan,” New York Nation, December 10, 1914.
“A Great Public Servant,” Theodore Roosevelt, Outlook, January
13, 1915. See also Outlook, December 9, 1914.
“Alfred Thayer Mahan—In Memoriam,” United States Naval
Institute, January–February, 1915.
“The Influence of America’s Greatest Naval Strategist on the War
in Europe,” Current Opinion, February, 1915. (Taken from Paris
Figaro.)
“Naval History: Mahan and his Successors,” Military Historian
and Economist, January, 1918.
 INDEX

Aden, #$1#, 152

Admiralty, British, organization of, 118–122, 194, 195
Adriatic Sea, 26, 306
Africa, 46.
See South Africa
Alabama, Confederate cruiser, 96
Alaska, 40
Alava, Spanish admiral, 215
Alexander the Great, campaigns of, 4, 14
Alexander I, of Russia, 224–226
Algeciras Conference, 306
Alliances, military weakness of, 60, 61, 315.
See Entente; Triple Alliance
Alsace-Lorraine, 326, 349
American Independence, War of, 23, 85, 343;
unwise policy of England in, 143–144;
influence of sea power in, 164–170.
Amsterdam, 34, 39.
Antilles, Lesser, strategic value of, 102, 105, 107, 108
Antwerp, 30, 306
Arbitration, #$1#, inadequacy of, 293–295, 344–347
Armenia, 345, 347
Armored cruiser, a faulty type, 260
Asia. See China; Japan; Far East
Atlantic Coast, of United States, 35, 65–67, 111–112, 274, 285
Australia, 148, 149, 350
Austria, in Thirty Years’ War, 50 ff.;
in Napoleonic Wars, 76, 191, 228;
in Seven Years’ War, 147;
an ally of Germany, 304–306, 317, 322, 323, 327

Balkan States, 306

Baltic Sea, 31, 82, 186, 188, 191, 273, 274, 313
Barbados, 60, 196
Bases, naval, for permanent operations, 28;
in the Caribbean, 29;
exposed to land attack, 71;
useless without a navy, 287.
See Ports; Strategic Positions
Battleships, design of, 61–62.
See Speed
Beachy Head, battle of, 81, 155, 157
Belgium, ports of, closed, 30;
a possession of Spain, 38, 50, 57, 60, 67
Berlin Decree, 95, 331
Bermuda, 105
Biscay, Bay of, 192
Bismarck, Prince, #$1#, 326
Blockade, in the Civil War, 41–42, 94;
military, 86;
commercial, 94–99, 330–331;
defense against, 129–132;
of Santiago, 251–255;
 of France, in Napoleonic Wars, 300–311
Bombardment, defense against, 129–132
Bombay, #$1#, 153
Boulogne, 191, 192, 194, 197
Bourrienne, Napoleon’s secretary, 13, 14
Boyne, battle of, 37
Brest, 23, 24, 31, 154, 174, 192–194, 196, 222
Brock, General, 233, 234
Brunswick, British ship, 180–182
Bucentaure, French ship, 215–219
Bulgaria, 345
Byng, British Admiral, 85, 86, 158

Cadiz, 26, 58;

Villeneuve at, 197–202, 208–211, 219–222
Cæsar, campaigns of, 4, 14
Calder, British Admiral, 196
Cámara, Spanish Admiral, 252
Canada, 143, 147, 154;
in War of 1812, 229–240, 307
Cape Verde Islands, 241
Caribbean Sea, strategic importance of, 27–29, 289, 325;
features of, 100–112;
map of, 100;
hurricane in, 244
Cartagena, 26
Central Line, or Position, defined and illustrated, 50–67, 103;
of Germany, 53
Cervera, Spanish Admiral, squadron of, 59, 88, 89;
 approach of, 241–249;
blockaded at Santiago, 251–255
Champlain, Lake, battle of, 235, 239
Channel, British, 23, 24, 25, 52, 53, 69, 140;
defenses in, against Napoleon, 191–195;
controlled by England, 312–315
Charles, Archduke, campaigns of, 11 ff
Chauncey, Commodore, 235–236
Chemulpo, 256, 267
Cherbourg, 31, 174
Chesapeake Bay, British forces in, 31;
battle off, 164–170
China, at war with Japan, 296;
and foreign powers, 300, 345;
emigration from, 349, 352.
See Open Door
Cienfuegos, 59, 88, 89, 103, 241, 246, 247
Civil War, American, Mahan’s service in, #$1#;
blockade in, 41–42, 94–96;
Farragut in, 76;
results of, 292
Clausewitz, Karl von, quoted, 89
Clinton, Sir Henry, 164, 167
Coasts, influence of, on naval development, 28–32, 40–42;
defense of, 89, 129–133;
fortification of, 261.
See Frontiers
Codrington, Sir Edward, 178, 183, 201
Colbert, French Minister, 138, 139
Collingwood, British Admiral, at battle of June First, 178;
off Rochefort, 192;
at Trafalgar, 197, 201, 206, 213–217, 220
Colonies, national policies regarding, #$1#, 45–46;
as motives for a navy, 20;
British, 22;
Germany’s desire for, 319, 323
Commerce, easier by sea than by land, 16;
importance of foreign, 17, 148;
as a motive for naval power, 18–19, 355–357;
routes of, 69–70, 76–78
Commerce Warfare, operations of, discussed, 5, 91–99;
a weapon of the weaker sea power, 24;
requires distant bases, 25, 154;
in the Napoleonic Wars, 198, 223–228.
See Blockade; Private Property
Communications, facility of, by sea, 16, 77, 286, 331–332;
between England and Ireland, 37, 38;
importance of, in warfare, 52–60, 75–78, 92;
maintained by naval forces, 154;
altered by interoceanic canals, 288–290
Compromise, evils of, 259–262;
in Rozhestvensky’s plans, 281
Concentration, defined and illustrated, 60–67;
disregarded by Russia in war with Japan, 270–275, 277–282
Continental System, Napoleon’s, 198, 223–228
Contraband, 99
Convoys, 17
Copenhagen, Nelson’s campaign of, 184–191
Corbett, Sir Julian, quoted, 85, 89
Corfu, 287
Cornwallis, British Admiral, 192, 194, 196
Cornwallis, General, at Yorktown, 159, 164–170
Corsica, 26
Corunna, 52
Crete, 58, 70, 347
Cronstadt, 273
Cuba, strategic value of, 59, 74, 79, 100–112;
in Spanish War, 243, 245, 345, 348, 349
Culebra Island, 111
Curaçao, 241, 248
Curieux, British brig, 196
Curtis, British Captain, 178, 179, 183
Cyprus, 153

D’Aché, French Admiral, 153

Danube, central position on, 50, 53–56, 60, 67
Dearborn, General, 236, 238
De Barras, French Admiral, in the American Revolution, 164–168
Defensive, limited rôle of, in naval warfare, 87–90, 309–311;
in the War of 1812, 228 ff
De Grasse, French Admiral, at Saints’ Passage, 160;
off the Chesapeake, 164–170
Du Guichen, French Admiral, engaged with Rodney, 159–163
Denmark, trade of, 25;
waters of, 51;
Nelson’s campaign against, 184–190
De Ruyter, Dutch Admiral, 207
Detroit, 233, 238, 239
Dewey, Admiral, #$1#
Dominica, 160
Dumanoir, French Admiral, at Trafalgar, 218–220

Egypt, Napoleon in, 58, 127, 192;

 British rule in, 152, 191, 343
England. See Great Britain
Entente, Triple, 53, 304–306, 317–318
Erie, Lake, operations on, 232, 233, 235–236, 238, 240

Far East, political conditions in, 289–291, 296–297.

See China; Japan; Open Door
Farragut, Admiral, his place as a naval leader, #$1#;
at Mobile, 64, 251;
on the Mississippi, 76;
quoted, 340
Ferrol, 192, 196, 197
Fighting Instructions, of the British Navy, 157–158
Fleet in Being, theory of, 81;
illustrated by Cervera’s fleet, 242–248;
in Russo-Japanese War, 258–269
Florida, exposed position of, 36, 65, 66;
Straits of, 69, 147
Flying Squadron, in Spanish War, #$1#, 59, 88, 89, 241, 246
Fortress Fleet, 258–269
Française, Cape, 165, 166
France, a rival of Great Britain, #$1#;
geographical conditions affecting, 22–25;
ports of, 31, 32;
in Napoleonic Wars, 43–44, 171–174;
colonial policy of, 46;
in Thirty Years’ War, 50–57;
exhausted under Louis XIV, 137–140;
in American Revolution, 143–144;
in Seven Years’ War, 147, 153–154;
opposed to Germany, 305, 317–318, 320;
arrested growth of, in population, 307, 322;
Channel coast of, 312–313.
 See Navy, French
Franklin, Benjamin, quoted, 350
Frederick the Great, 14, 147
French Revolution, 152;
effect on French navy, 171–174, 178
Frontiers, advantage of seaboard, 30;
of United States, regarded as a line, 65–67, 112;
warfare on, in 1812, 229–234.
See Coasts

Genoa, 67
Germany, recent naval policy of, #$1#–xv, 51;
trade of, 25;
rivers of, 33, 69;
central position of, 53;
possible acquisitions in West Indies, 288;
political character and aims of, 292, 302–308, 317–327;
and Far East, 299;
her sea routes threatened by Great Britain, 312–316, 333, 336.
See Navy, German
Gibraltar, an important base, 20, 22, 58, 69, 74, 152, 154;
acquired by Great Britain, 26, 147, 157;
siege of, 85, 86, 107, 178;
Nelson at, 196, 199, 209
Good Hope, Cape of, 20, 26, 33, 51, 152, 290, 314
Graves, British Admiral, off the Chesapeake, 160, 164–170
Gravina, Spanish Admiral, at Trafalgar, 210–211, 214, 219–220
Great Britain, growth of, in naval power, #$1#, 32–34, 43–44;
colonial policy of, 45, 46, 343;
naval policy of, 47–48, 141–146;
community of interests with United States, 111, 291–295, 318–332;
in American Revolution, 143–144;
gains of, in Seven Years’ War, 147–154;
 navy her first line of defense, 191–195;
in commerce warfare with Napoleon, 223–228, 310–311;
and problem of imperial federation, 293;
threatened by Germany, 302–308;
policy of, relating to seizure of private property at sea, 333–338.
See Navy, British
Guadeloupe, 25, 143
Guantanamo, 58, 103–107, 111

Hague, The, 155–157, 165, 166.

See Peace Conferences
Haiti, 105, 108
Halifax, 105
Hamilton, Lady Emma, 200
Hampton Roads, #$1#, 59, 66, 89, 241, 246
Hannibal, campaigns of, 4, 14
Havana, 39, 59, 88, 89, 105, 106, 110, 143, 166, 241, 246, 247
Havre, 174
Hawaiian Islands, value of, to the United States, 285–287, 356, 357;
Japanese in, 301
Hawke, British Admiral, 155
Heligoland, #$1#
Holland, dependent on commerce, 161;
as a sea power, 22, 23;
trade of, 25;
closes Belgian ports, 30;
raids Chatham, 30;
naval rivalry with England, 32–34, 312, 313;
at war with Spain, 37–38, 342;
colonial policy of, 45–46;
rivers of, 69;
in wars of Louis XIV, 137–140;
 in Napoleonic Wars, 193;
possible union with Germany, 320
Hood, British Admiral, 167, 168
Hotham, British Admiral, 81
Howe, British Admiral, policy of, 5;
in the battle of June First, 175–183
Hudson River, 31, 166

India, British in, 147, 151, 317, 343;

route to, 152, 153
Interior Lines, value of, in warfare, 51–67;
illustrated, 103, 314
International Law, regard for, in Napoleonic Wars, 227–228;
inadequate to check national aggressions, 300
Ireland, 37, 313
Italy, position of, 26;
exposed by sea, 36–37;
in wars of France and Austria, 50, 56, 60;
unification of, 292;
interests of, opposed to those of Germany and Austria, 305–306,
317

Jamaica, lost by Spain, 39;

threatening position of, 58;
strategic value of, 100–112
James II, of England, 38, 277;
fighting instructions issued by, 157–158
Japan, influenced by Mahan’s writings, #$1#;
in war with Russia, 56, 57, 60;
influence in Asia, 76–78, 82–84;
coerced by the European powers, 291–292;
growth of, 296–297, 326;
and the Open Door Policy, 299–301;
 compared with Germany, 303, 324;
and Great Britain, 306–307, 318, 320;
emigration from, 349–352.
See Russo-Japanese War
Jervis. See St. Vincent
Jomini, on strategy, 11, 12, 49, 321;
on strategic lines, 64, 65, 238;
on Napoleon, 80;
on British sea power, 141
June First, battle of, 175–183

Kamimura, Japanese Admiral, 66

Kamranh Bay, 83
Keith, British Admiral, 194
Key West, 29, 36, 111, 241, 269
Kiel Canal, #$1#, 51
Kingston, in Canada, 231–240;
in Jamaica, 107
Korea, 256, 300, 346
Kuropatkin, Russian General, 256, 257

Lafayette, General, 164, 169

La Hogue, battle of, 155–157, 165, 166
Levant, trade of, 33
Line of Battle, of fleets, 62, 156, 158, 162, 163.
See Strategic Lines
Logistics, defined, 49
London, 30
Louis XIV, of France, 37, 155;
wars of, 137–141
Louis XVI, of France, 172
Louisburg, 20, 154

Macdonough, Commodore, 142

Madagascar, #$1#, 82
Madrid, 81, 209
Magellan, Straits of, 51, 67, 290
Malta, 20, 26, 58, 70, 107, 152, 287
Manchuria, 56, 57, 267, 300
Manila, 39, 143
Mantua, 76, 80
Marengo, battle of, 13, 14, 76, 257
Marlborough, Duke of, 142
Martinique, 25, 74, 104, 143, 154, 160, 161, 196, 241
Masampo Bay, 66
Mauritius, 20, 152
Mediterranean Sea, position of France on, 22, 59, 140;
importance of, as a trade route, 27, 31, 39, 289–290;
Villeneuve ordered to, 198–199;
bases in, 287, 314
Metz, 71
Mexico, Gulf of, 29, 31, 35, 36, 65, 66;
strategic features of, 100–112, 325
Milan, 50, 53
Minorca, 39, 107, 147, 154, 158
Mississippi River, importance of, 29, 31, 35, 69, 100, 101;
in the Civil War, 42, 76, 143
Mobile Bay, battle of, 64, 251
Mona Passage, 102
Monroe Doctrine, 102, 111, 149, 288–291, 318, 320–322, 325, 356
Montreal, 231, 233, 234, 238, 240
Moore, Sir John, 81
Morocco, 306, 318, 320
Mukden, battle of, 56, 256

Naples, 38, 39
Napoleon, as a strategian, 11;
anecdote of, 12–14;
quoted, 4, 14, 55, 58, 70, 78, 110, 155, 173, 241, 271, 287, 296, 335;
at Marengo and Mantua, 76, 257;
a believer in the offensive, 80, 81, 152, 153;
in commerce warfare with Great Britain, 92, 93, 95, 223–228, 331;
armies of, 172;
and the northern neutrals, 184, 187;
his plan for the invasion of England, 191–198;
and the Trafalgar campaign, 221–223, 248;
downfall of, 237;
at Waterloo, 239
Napoleonic Wars, 12, 31, 80, 81, 142, 307, 310, 343
Naval Administration, civil vs. military, 113–115;
in peace and war, 115–118;
British, 118–122;
United States, 122–124.
See Admiralty
Naval Training, 8–15
Naval War College, Mahan at, #$1#;
aims of, 10–15
Navarino, battle of, 178
Navies, motives for, 18, 355–357;
a protection for commerce, 19;
fighting order of, 61;
 an offensive weapon, 71–73
Navigation Acts, British, 337
Navy, British;
training of officers in, 8–9;
compared with French, 43;
maneuvers of, 72;
tactics of, in the 18th century, 156–158;
protection afforded by, 306–308;
French:
training of officers in, 8–9;
compared with British, 43;
weakness of, in Revolutionary Wars, 146, 171–174, 178;
faulty policy of, 155–158;
German: growth and purpose of, 111, 299, 307, 317–320;
United States:
interested chiefly in material, 8;
in Civil War, 41;
insufficient, 44;
in Spanish War, 59–60, 245, 250–253;
concentration of fleet of, 60, 274–275;
administration of, 122–124;
requirements of, 128–134
Nebogatoff, Russian Admiral, 83
Nelson, British Admiral, his place as a naval leader, #$1#;
in the Trafalgar campaign, 5, 62, 63, 196–223;
his pursuit of Napoleon in the Mediterranean, 58;
on concentration, 61;
quoted, 80, 82, 85, 175, 253;
and the rule of obedience, 126–127;
in the Copenhagen campaign, 184–190;
in command of channel forces, 191–192, 195
Netherlands. See Belgium; Holland
Neutrality, League of Armed, 184–190
Newport, Rhode Island, #$1#, 164, 166
New York, 31, 69, 73, 164–167
Niagara frontier, warfare on, 231–232, 235–236
Nile, battle of, 153
North Sea, 23, 25, 51, 313–316
Nossi-Bé, 82, 83

Offensive, advantage of, in war, 128–133, 229, 309–311;

operations of, discussed, 79–86;
navy chiefly useful for, 70–73
Ontario, Lake, campaign on, in War of 1812, 229–240
Open Door Policy, 299–301, 325, 356, 357
Oregon, United States ship, 59, 60
Oswego, 232

Pacific Coast, of United States, 35, 40, 67, 111, 112, 285, 289;
immigration to, 350, 356
Pacific Ocean, interest of the United States in, 289, 299–301
Panama Canal, its effect on naval policy, 18, 27–29, 325;
an interior line, 51, 301;
central position of, 67, 70, 77;
strategic importance of, 100–112, 149, 150, 356–357;
need of controlling approaches to, 285–287;
and the Monroe Doctrine, 288–291, 318
Paris, Treaty of, 147–148;
Declaration of, 99, 337;
city of, 198
Parker, British Admiral, 184–190
Peace Conferences, at The Hague, #$1#, 132, 331, 342, 346
Peninsular War, 81, 82
Pensacola, 29
Philippine Islands, 252, 349
Pitt, Sir William, British Prime Minister, 143, 151
Plevna, 56, 57
Plymouth, England, 24, 31
Pondicherry, 78, 154
Population, affecting sea power, 43–44;
of Pacific Coast, 301
Port Arthur, threatening Japanese communications, 56, 57;
attacked by siege, 71, 82;
squadron based on, 256–271, 275
Port Mahon, 289
Porto Rico, 241, 349
Ports, in Gulf and Caribbean, 128, 29;
flanking communications, 56–58
Portsmouth, England, 31
Preparation, for war, 128–134, 229–230, 237–238, 357
Private property at sea, immunity of, 78, 93, 98, 99, 328–341;
Rule of 1756 regarding, 227–228
Prussia, 147, 153, 189, 191, 228
Puget Sound, 67
Pyrenees, 52, 65

Ratisbon, 50
Red Sea, 152
Resources, affecting strategic value of positions, 68, 69, 74
Revel, 188–190
Rhine River, 50, 52, 53, 55, 56, 60, 197.
Richelieu, Cardinal, 31, 60
Rions, Commodore de, 174