Oo ai Bp © A 49-year-old female is referred to the gastroenterology out-patient clinic with a 3 month history of epigastric pain and diarrhoea. Her GP initially prescribed lansoprazole 30mg od but this didn't alleviate her symptoms. The only past medical history of note is hyperparathyroidism. Endoscopy revealed multiple duodenal ulcerations. What is the likely diagnosis? Multiple endocrine neoplasia type Il a Coeliac disease Multiple endocrine neoplasia type | Autoimmune polyendocrinopathy syndrome Crohn's disease Reference ranges ¥ ‘Camszanner a> tepal ieeeet]@ passmedicine.com/question/qu &* ¥ ODO €<€ > D Multiple endocrine neoplasia type Il a Coeliac disease Autoimmune polyendocrinopathy syndrome Crohn's disease Zollinger-Ellison syndrome: epigastric pain and diarrhoea Important forme Less important Zollinger-Ellison syndrome typically presents with multiple gastroduodenal ulcers causing abdominal pain and diarrhoea. High- dose proton pump inhibitors are needed to control the symptoms. Around a third of patients may have multiple endocrine neoplasia type | (MEN-1), explaining the hyperparathyroidism in this patient. MEN-I * parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia © pituitary (70%) * pancreas (50%, e.g. Insulinoma, gastrinoma) * also: adrenal and thyroid w | "@ | @Discuss | Improve Next questio' CCamSzanner a> tepal encaner ss pel@ | @ | @Discuss | Improve Next question > Zollinger-Ellison syndrome Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type! syndrome Features * multiple gastroduodenal ulcers * diarrhoea * malabsorption Diagnosis * fasting gastrin levels: the single best screen test * secretin stimulation test eee | Search Search textbook. | co | fel) CcamSzanner 20 tepal encaner ss peloe a2 eB © A 64-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and beclomethasone inhaler, bendroflumethiazide and amlodipine. What is the most likely cause of the presentation? Myasthenia gravis precipitated by bendroflumethiazide Oesophageal web Achalasia secondary to amlodipine Oesophageal candidiasis Oesophageal cancer Reference ranges v Score: 100% Ccamszanner a> tepal encaner ss pelVv aw Bp wT A 64-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and beclomethasone inhaler, bendroflumethiazide and amlodipine. What is the most likely cause of the presentation? Myasthenia gravis precipitated by bendroflumethiazide Oesophageal web Achalasia secondary to amlodipine ‘=_Pesophageal candidiasis Oesophageal cancer | Reference ranges v Score: 100%Dysphagia The table below gives characteristic exam question features for conditions causing dysphagia. Remember that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. Causes Notes Oesophageal Dysphagia may be associated with weight loss, anorexia or cancer vomiting during eating Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use Oesophagitis There may be a history of heartburn Odynophagia but no weight loss and systemically well Oesophageal There may be a history of HIV or other risk factors such as candidiasis steroid inhaler use Achalasia Dysphagia of both liquids and solids from the start Heartburn Regurgitation of food - may lead to cough, aspiration pneumonia etc Pharyngeal More common in older men pouch Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen Systemic Other features of CREST syndrome may be present, namely sclerosis Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia ComScore eal Ccaeaner ps blPharyngeal pouch Systemic sclerosis Myasthenia gravis Globus hystericus Heartburn Regurgitation of food - may lead to cough, aspiration pneumonia etc More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased Other symptoms may include extraocular muscle weakness or ptosis Dysphagia with liquids as well as solids There may be a history of anxiety Symptoms are often intermittent and relieved by swallowing Usually painless - the presence of pain should warrant further investigation for organic causes Causes of dysphagia - by classification As with many conditions, it's often useful to think about causes of a symptom in a structured way: ‘camSzanner 20 tepal encaner ss pelCauses of dysphagia - by classification As with many conditions, it's often useful to think about causes of a symptom in a structured way: Classification Examples Extrinsic Mediastinal masses Cervical spondylosis Achalasia Diffuse oesophageal spasm Hypertensive lower oesophageal sphincter Oesophageal wall Intrinsic Tumours Strictures Oesophageal web Schatzki rings Neurological * CVA Parkinson's disease Multiple Sclerosis Brainstem pathology Myasthenia Gravis Investigation All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies. A full blood count should be performed. Camsconer sind esa Ccaeaner ps blInvestigation All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies. A full blood count should be performed. Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery. f Ta 2) Bile @- = = & @ @ x Camsesnner es dea encaner ss pelGo a Bp © A 62-year-old woman with a history of scleroderma is reviewed. For the past few months she has suffered with recurrent bouts of diarrhoea. During these bouts her stools are pale, bulky and offensive. She drinks 14 units of alcohol/week. Bloods show the following: Hb 10.8 g/dl Platelets 231* 10/1 wec 5.4*10%/1 Ferritin 14 ng/ml Vitamin B12 170 ng/l Folate 2.2nmol/I Nat 142 mmol/I Ke 3.4mmol/| Urea 4.5 mmol/| Creatinine 77 mol/l Bilirubin 21 pmol/I ALP. 88 U/l AT 21 u/l ycT 55u/l Albumin 36 g/! CCamSzanner a> tepal encaner ss pelKt 3.4mmol/I Urea 4.5 mmol/| Creatinine 77 umol/! Bilirubin 21 umol/| ALP 8Bu/l AUT 2u/l ycT 55u/l Albumin 36 g/l Which one of the following complications is most likely to have occurred? Whipple's disease Colonic hypomotility Chronic pancreatitis Malabsorption syndrome lleal stenosis | Reference ranges ¥ CcamSzanner a0 tepal encaner ss pelreunoe re prerene Bilirubin 21 mol/l ALP. 88 u/I AT 21 u/l ycT 55u/l Albumin 36 g/l Which one of the following complications is most likely to have occurred? Whipple's disease Colonic hypomotility Chronic pancreatitis lleal stenosis Malabsorption syndrome is a very common complication of scleroderma (systemic sclerosis). The bloods show evidence of impaired absorption of some vitamins (B12, folate), nutrients (iron) and protein (low albumin). w@ | "@ | @ Discuss (5) Improve | t qu ‘camszanner a0 te pal encaner ss pelMalabsorption Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats) Intestinal causes of malabsorption * coeliac disease * Crohn's disease * tropical sprue * Whipple's disease * Giardiasis * brush border enzyme deficiencies (e.g. lactase insufficiency) Pancreatic causes of malabsorption * chronic pancreatitis * cystic fibrosis * pancreatic cancer Biliary causes of malabsorption * biliary obstruction * primary biliary cirrhosis Other causes * bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop) * short bowel syndrome « lymphoma Next qu > ‘CamSzanner a> tepal encaner ss peleo a2 p © Which one of the following medications is least associated with dyspepsia? Isosorbide mononitrate Prednisolone Aminophylline Atenolol Amlodipine Reference ranges v Score: 100% CCamSzanner a> Sepa encaner ss pelAmlodipine | @ | @ Discuss (6) improve | Drugs causing dyspepsia Causes « NSAIDs * bisphosphonates * steroids The following drugs may cause reflux by reducing lower oesophageal sphincter (LOS) pressure * calcium channel blockers* * nitrates* * theophyllines *calcium channel blockers and nitrates are occasionally used in the management of achalasia, itself a cause of dyspepsia, because of their effect on the LOS. Bie &~ iii CCamszanner a> depal encaner ss peleo a3 p © Which one of the following is least associated with Crohn's disease? Fistulae Kantor's string sign ‘Cobblestone’ pattern of mucosa Crypt abscesses Involvement of all layers of bowel wall Wyte) r Reference ranges v Score: 100% CcamSzanner a> Sepa encaner ss pelKantor's string sign ‘Cobblestone’ pattern of mucosa lement of all layers of bowel wall Crypt abscesses are sometimes seen in Crohn's disease but they are more commonly associated with ulcerative colitis ow | @ | @ Discuss Improve | Crohn's disease: investigation Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus Bloods * C-reactive protein correlates well with disease activity Endoscopy * colonoscopy is the investigation of choice « features suggest of Crohn's include deep ulcers, skip lesions Histology * inflammation in all layers from mucosa to serosa * goblet cells * granulomas ‘CamScanner a0 tepal encaner ss pelSmall bowel enema * high sensitivity and specificity for examination of the terminal ileum strictures: 'Kantor's string sign’ proximal bowel dilation * ‘rose thorn’ ulcers fistulae 4 Barium study is shown from a patient with worsening Crohn's disease. Long segment of narrowed terminal ileum in a ‘string like’ configuration in kee ith a long stricture segment. Termed 'Kantor's string sign EES Camscomer Ws eu!°o aa p © A 78-year-old woman presents with persistent diarrhoea. Her symptoms started around three months ago and she is now passing frequent ‘mucous ' like stools. There is no visible blood in the stool and her weight is stable. Bloods show the following: Hb 11.6 g/dl Platelets 222 * 10°/| WBC 7.8* 10/1 Na* 144 mmol/| Kr 3.1 mmol/| Urea 8.2 mmol/| Creatinine 101 ymol/ What is the most likely diagnosis? Diverticular disease Angiodysplasia Tubular adenoma Colon cancer Villous adenoma uel CCamSzanner a> tepal encaner ss pelWhat is the most likely diagnosis? Diverticular disease Angiodysplasia Tubular adenoma Colon cancer Diarrhoea + hypokalaemia — villous adenoma Important forme Less important & | @ | @ Discuss (5) Improve | Ne TP Villous adenoma Villous adenomas are colonic polyps with the potential for malignant transformation. They characteristically secrete large amounts of mucous, potentially resulting in electrolyte disturbances. The vast majority are asymptomatic. Possible features: * non-specific lower gastrointestinal symptoms * secretory diarrhoea may occur * microcytic anaemia * hypokalaemia CCamSzanner 20 depal encaner ss pel{ f passmedicine.com/question/qu %& ¥ OD > a Petro tla Oo - © A 54-year-old woman presents with jaundice shortly after being discharged from hospital. Liver function tests are reported as follows: Albumin 49 g/l Bilirubin 89 ymol/t Alanine transferase (ALT) 66 iu/l Alkaline phosphatase (ALP) 245 umol/| Gamma glutamyl transferase (y6T) 529 u/| Which of the following antibiotics is she most likely to have received? Flucloxacillin Gentamicin Ciprofloxacin Trimethoprim Ceftazidime yee Le | Reference ranges v Camsesnner es eaA 54-year-old woman presents with jaundice shortly after being discharged from hospital. Liver function tests are reported as follows: Albumin 49 g/l Bilirubin 89 umol/I Alanine transferase (ALT) 66 iu/| Alkaline phosphatase (ALP) 245 umol/| Gamma glutamyl transferase (y6T) 529 u/| Which of the following antibiotics is she most likely to have received? Gentamicin | costo Trimethoprim Ceftazidime Flucloxacillin is a well recognised cause of cholestasis Importance: 74 w | "@ | @ Discuss (2) Improve |Drug-induced liver disease Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed. There is however considerable overlap, with some drugs causing a range of changes to the liver The following drugs tend to cause a hepatocellular picture: . paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins . . alcohol amiodarone methyldopa nitrofurantoin . The following drugs tend to cause cholestasis (+/- hepatitis): * combined oral contraceptive pill * antibiotics: flucloxacillin, co-amoxiclav, erythromycin* * anabolic steroids, testosterones * phenothiazines: chlorpromazine, prochlorperazine * sulphonylureas * fibrates * rare reported causes: nifedipine Liver cirrhosis * methotrexate * methyldopa * amiodarone *risk may be reduced with erythromycin stearate ‘CamSzanner a> tepal encaner ss pelOo ai Bp © A 62-year-old man with a history of alcohol abuse undergoes an esophago-gastroduodenoscopy (OGD) following several episodes of unexplained epigastric pain. Several varices are identified in the lower oesophagus. It is decided that he is put on a prophylactic medication to reduce the risk of variceal bleeding. Which of the following medications would be most appropriate? Omeprazole Warfarin Unfractionated heparin Propranolol Vasopressin Reference ranges ¥ Score: 0% ‘CamSzanner a0 Sepa ieeeet]Warfarin Unfractionated heparin Vasopressin Anon-cardioselective B-blocker (NSBB) is used for the prophylaxis of oesophageal bleeding Important forme Less important This question requires you to understand the measures taken to reduce the risk of major bleeding in patients with oesophageal varices. Omeprazole - This is not the most appropriate answer. Omeprazole is used in the prevention and treatment of peptic ulcers. Warfarin - This is not the most appropriate answer. Warfarin would increase the risk of bleeding. Unfractionated heparin - This is not the most appropriate answer. Unfractionated heparin would increase the risk of bleeding. Propranolol - This is the correct answer. A non-cardioselective B blocker (NSBB) is used for primary and secondary prevention of bleeding in oesophageal varices. They act by causing splanchnic vasoconstriction, reducing portal blood flow. Vasopressin- This is not the most appropriate answer. The synthetic analogue of this medication, terlipressin, may be used to reduce acute variceal bleeding but not as a prophylactic agent. CcamSzanner a> tepal encaner ss pelVariceal haemorrhage Acute treatment of variceal haemorrhage * ABC: patients should ideally be resuscitated prior to endoscopy * correct clotting: FFP vitamin K * vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding. Octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality prophylactic antibiotics have been shown to reduce mortality in patients with liver cirrhosis. Quinolones are typically used. NICE support this in their 2016 guidelines: ‘Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.’ endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail . . Prophylaxis of variceal haemorrhage * propranolol: reduced rebleeding and mortality compared to placebo * endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. This is supported by NICE who recommend: 'Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.’ ‘CamSzanner 20 depal encaner ss pelGO 2x Bp © A71-year-old man presents with two year history of intermittent problems with swallowing. His wife has also noticed he has halitosis and is coughing at night. He has a past medical history of type 2 diabetes mellitus but states he is otherwise well. Of note his weight is stable and he has a good appetite. Clinical examination is unremarkable. What is the most likely diagnosis? Oesophageal cancer Hiatus hernia Pharyngeal pouch Oesophageal candidiasis Benign oesophageal stricture Reference ranges ¥ Score: 100% CCamSzanner a> tepal encaner ss pele a2 v p © A71-year-old man presents with two year history of intermittent problems with swallowing. His wife has also noticed he has halitosis and is coughing at night. He has a past medical history of type 2 diabetes mellitus but states he is otherwise well. Of note his weight is stable and he has a good appetite. Clinical examination is unremarkable. What is the most likely diagnosis? Oesophageal cancer Hiatus hernia Oesophageal candidiasis Benign oesophageal stricture Given the two year history and good health oesophageal cancer is much less likely wa | "@ | @ Discuss (3) Improve | CCamSzanner a> tepal encaner ss pelPharyngeal pouch A pharyngeal pouch is a posteromedial diverticulum through Killian’s dehiscence. Killian’s dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men Features * dysphagia * regurgitation * aspiration * neck swelling which gurgles on palpation * halitosis Management * surgery 4 Ccamsesaner es ealo « » oO A 67-year-old man presents with shortness-of-breath. He has a past history of aortic stenosis but is otherwise well. On examination he has a systolic murmur and a clear chest. Routine bloods are as follows: Hb 8.7 g/dl mcv 771A Pit 277*10%/I WBC 6.4*10°/1 Which one of the following investigations is most likely to explain his anaemia? Colonoscopy Renal biopsy Duodenal biopsy Gastroscopy Echocardiogram CcamSzanner a> Spal encaner ss pelA 67-year-old man presents with shortness-of-breath. He has a past history of aortic stenosis but is otherwise well. On examination he has a systolic murmur and a clear chest. Routine bloods are as follows: Hb 8.7 g/dl Mev 71f1 Plt 277*10%/1 WBC 6.4*10°/I Which one of the following investigations is most likely to explain his anaemia? Renal biopsy Duodenal biopsy Gastroscopy Echocardiogram Angiodysplasia is associated with aortic stenosis Important forme Less important This patient most likely has angiodysplasia which has a known association with aortic stenosis. w | *@ | @Discuss (5) | Improve| @ | @ Discuss (5) Improve | Angiodysplasia Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia. There is thought to be an association with aortic stenosis, although this is debated. Angiodysplasia is generally seen in elderly patients Diagnosis * colonoscopy « mesenteric angiography if acutely bleeding Management * endoscopic cautery or argon plasma coagulation * antifibrinolytics e.g. Tranexamic acid * oestrogens may also be used Bis A Search Search textbook. ‘Camszanner a0 tepal encaner ss pelYou are the F2 doctor starting a twilight shift on the acute medical unit. A 50-year-old man with known alcoholic cirrhosis presented that morning to ambulatory care for an elective ascitic drain. On clerking he described feeling generally unwell over the last 2 days with fevers and non-specific abdominal pain. There was no history of cough, shortness of breath or dysuria and no other localising infective symptoms. His temperature was 38.1°C, heart rate 130bpm but observations were otherwise normal. He was visibly jaundiced on end-of-the-bed inspection. On examination the abdomen was generally tender, distended with shifting dullness and scars from previous ascitic drains in the right iliac fossa. Bowels sounds were present and normal. ECG showed sinus tachycardia. Bloods: Hb 115 g/l Na* 129 mmol/I Bilirubin 40 pmol/I Platelets 230 * 109/1_K* 4.8 mmol/| ALP 280 u/I WBC 17.0*109/1 Urea 8.0 mmol/ ALT 65 u/I Neuts 14.5*10%/1 Creatinine 156 ymol/I_ yGT 560 u/! Lymphs 2.0 * 10°/1 Albumin 29 g/l CRP 130 mg/l Chest X-ray shows no acute abnormality. The patient was admitted and has been started on IV normal saline and broad-spectrum antibiotics. Blood cultures have been sent. During the evening handover, the consultant requests that as the evening on-call you investigate for spontaneous bacterial peritonitis (SBP) and start IV cefotaxime if SBP is confirmed. Which of the following would confirm a diagnosis of spontaneous bacterial peritonitis (SBP)? CcamSzanner a0 tepal encaner ss pelin the right illac Tossa. Bowels sounds were present and normal ECG showed sinus tachycardia. Bloods: Hb 1159/1 Nat 129 mmol/I Bilirubin 40 pmol/1 Platelets 230* 10/1 Kt 4.8 mmol/ ALP 280 u/| WBC 17.0*107/1 Urea 8.0 mmol/I ALT 65 u/1 Neuts 14.5*10%/1 Creatinine 156 ymol/I_ yGT 560 u/l Lymphs 2.0 * 109/1 Albumin 29 g/| CRP 130 mg/l Chest X-ray shows no acute abnormality. The patient was admitted and has been started on IV normal saline and broad-spectrum antibiotics. Blood cultures have been sent. During the evening handover, the consultant requests that as the evening on-call you investigate for spontaneous bacterial peritonitis (SBP) and start IV cefotaxime if SBP is confirmed. Which of the following would confirm a diagnosis of spontaneous bacterial peritonitis (SBP)? Blood cultures showing mixed growth. Paracentesis. Glucose >2.8 mmol/L in ascitic fluid Paracentesis. Neutrophil count >250 cells/uL in ascitic fluid Paracentesis. Organisms seen on Gram-stain of ascitic fluid Paracentesis. Neutrophil count >100 cells/pL in ascitic fluid ‘camSzanner 20 Sepa encaner ss pelParacentesis. Organisms seen on Gram-stain of ascitic fluid Paracentesis. Neutrophil count >100 cells/uL in ascitic fluid In suspected SBP- diagnosis is by paracentesis. Confirmed by neutrophil count >250 cells/ul Important forme Less important Diagnosis of spontaneous bacterial peritonitis (SBP) is by paracentesis with a neutrophil count >250 cells/uL in the ascitic fluid. 1. Incorrect. Blood cultures are positive for the offending organism in SBP in up to 1/3 of patients and can help guide antibiotic regime. However, by the same token, blood cultures will be negative in more than 2/3 of cases of SBP. All patients with suspected SBP should have blood cultures done but they do not form part of the diagnostic criteria. 2. Incorrect. Glucose levels in the ascitic fluid do not form part of diagnostic criteria for SBP. Neutrophils in the ascitic fluid actually consume glucose and so the concentration is often low (<2.8 mmol/L) 3. Correct. SBP is confirmed by a paracentesis showing a neutrophil count >250 cells/UL. Based on this result a diagnosis can be made and the antibiotic of choice would be IV cefotaxime (as advised by your consultant). 4. Incorrect. Though Gram-stain of the ascitic fluid will often show organisms in SBP it is not reliable as a diagnostic test. 5. Incorrect. The neutrophil count is the key measure but the threshold for diagnosis of SBP is >250 cells/L not 100. @ | @ | @Discuss (5) | Improve LcamSzanner 20 tepal encaner ss pelNext qu Spontaneous bacterial peritonitis Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis Features * ascites * abdominal pain * fever Diagnosis * paracentesis: neutrophil count > 250 cells/ul * the most common organism found on ascitic fluid culture is E. coli Management * intravenous cefotaxime is usually given Antibiotic prophylaxis should be given to patients with ascites if: * patients who have had an episode of SBP * patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome * NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’ Alcoholic liver disease is a marker of poor prognosis in SBP. Tr & @ © ‘CamSzanner a> tepal BUT @ ls encaner ss pel8 a2 p © You are asked to review a 24-year-old man who has been admitted with an exacerbation of Crohn's disease. Despite prednisolone and mesalazine therapy for the past 3 weeks he is still passing 6-7 watery stools per day. He has lost a considerable amount of weight during this period. On examination he is apyrexial, haemodynamically stable and his abdomen is soft and non-tender. What is the most appropriate next step? Metronidazole Infliximab Methotrexate Azathioprine Surgery Reference ranges ¥ Score: 100% CcamSzanner a> depal encaner ss pel_ Methotrexate Surgery & | "@ | @ Discuss (6) Improve | Next question > Crohn's disease: management Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the management of Crohn's disease in 2012. General points * patients should be strongly advised to stop smoking * some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy Inducing remission * glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients * enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) * 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective CcamSzanner 20 tepal encaner ss pel* azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine * infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate * metronidazole is often used for isolated peri-anal disease Maintaining remission as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) azathioprine or mercaptopurine is used first-line to maintain remission methotrexate is used second-line 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery Surgery * around 80% of patients with Crohn's disease will eventually have surgery * see below for further detail Surgical interventions in Crohn's disease The commonest disease pattern in Crohn's is stricturing terminal ileal disease and this often culminates in an ileocaecal resection. Other procedures performed include segmental small bowel resections and stricturoplasty. Colonic involvement in patients with Crohn's is not common and, where found, distribution is often segmental. However, despite this distribution segmental resections of the colon in patients with Crohn's disease are generally not advocated because the recurrence rate in the remaining colon is extremely high, as a result, the standard options of colonic surgery in Crohn's patients are generally; sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy. Restorative procedures such as ileoanal CcamSzanner a0 tepal encaner ss pelSurgical interventions in Crohn's disease The commonest disease pattern in Crohn's is stricturing terminal ileal disease and this often culminates in an ileocaecal resection. Other procedures performed include segmental small bowel resections and stricturoplasty. Colonic involvement in patients with Crohn's is not common and, where found, distribution is often segmental. However, despite this distribution segmental resections of the colon in patients with Crohn's disease are generally not advocated because the recurrence rate in the remaining colon is extremely high, as a result, the standard options of colonic surgery in Crohn's patients are generally; ‘sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy. Restorative procedures such as ileoanal pouch have no role in therapy. Crohn's disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management. Complications of Crohn's disease As well as the well-documented complications described above, patients are also at risk of: small bowel cancer (standard incidence ratio = 40) * colorectal cancer (standard incidence ration = 2, i.e. less than the tisk associated with ulcerative colitis) * osteoporosis *assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine ‘CamSzanner 20 tepal encaner ss pel°o a3 p © A 62-year-old woman who has recently been treated for ascending cholangitis is referred to hospital due to persistent fever and anorexia. An ultrasound scan reveals the presence of a liver abscess. What is the most appropriate antibiotic therapy to accompany drainage of the abscess? Vancomycin + meropenem Co-amoxiclav + metronidazole Amoxicillin + ciprofloxacin + metronidazole Clindamycin + metronidazole Metronidazole + vancomycin Reference ranges v Score: 100% ny 4 CCamSzanner a> tepal encaner ss pel| Arodcitin + aproforacin+meonaarle Clindamycin + metronidazole Metronidazole + vancomycin @ | @ | @ Discuss (9) | Improve Pyogenic liver abscess The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coll in adults Management « drainage (typically percutaneous) and antibiotics * amoxicillin + ciprofloxacin + metronidazole * if penicillin allergic: ciprofloxacin + clindamycin8 aa p © A 59-year-old woman presented with painful dysphagia, poor appetite and weight loss over the past nine months. She is a heavy chain smoker with a 30 pack year history. She admits to consuming alcohol excessively. An urgent barium swallow was arranged and shows the presence of a suspicious malignant oesophageal stricture. What is the best investigation to assess for mural invasion? Contrast-enhanced CT T2-weighted MRI scan Endoscopic ultrasound Conventional side-viewing duodenoscopy Positron-emission tomography (PET) scan Reference ranges ¥ Score: 66.7% CCamSzanner 20 tepal encaner ss pelinced CT T2-weighted MRI scan Conventional side-viewing duodenoscopy Positron-emission tomography (PET) scan Oesophageal/Gastric Cancer - Endoscopic ultrasound (EUS) is better than CT or MRI in assessing mural invasion Important forme Less important The endoscopic ultrasound aids the visualisation of local invasion as it can display all the layers of the wall of the oesophagus and should routinely be performed with CT or MRI scans. Overall, endoscopic ultrasound is far superior to CT or MRI when assessing mural invasion The positron-emission tomography (PET) scan is increasingly being employed by oncologists in detecting and following up the tumour progression. Duodenoscopes are essentially specialised endoscopes that are used primarily for endoscopic retrograde cholangiopancreatography (ERCP). They are side-viewing (rather than forward-viewing) endoscopes that have an advantage in being able to view the major duodenal papilla. @ | @ | @Discuss | Improve Next question > CcamSzanner a0 tepal encaner ss pelUOesopnageal cancer Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's. The majority of adenocarcinomas are located near the gastroesophageal junction whereas squamous cell tumours are most commonly found in the middle third of the oesophagus. Risk factors smoking alcohol GORD Barrett's oesophagus achalasia Plummer-Vinson syndrome squamous cell carcinoma is also linked to diets rich in nitrosamines rare: coeliac disease, scleroderma Features + dysphagia: the most common presenting symptom * anorexia and weight loss * vomiting + other possible features include: odynophagia, hoarseness, melaena, cough Diagnosis + Upper GI endoscopy is the first line test +» Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours * Staging is initially undertaken with CT scanning of the chest, CcamSzanner a> tepal encaner ss pelDiagnosis * Upper GI endoscopy is the first line test + Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours * Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary + If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound * Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed. Treatment * Operable disease is best managed by surgical resection. * The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis. The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage. In addition to surgical resection many patients will be treated with adjuvant chemotherapy. Camsesnner ss eeuBarium swallow - Som irregular narrowing of the mid-thoracic oesophagus with proximal shouldering 4 Fluoroscopy - a region of fixed, irregular stricturing is seen in the CcamSzanner a0 tepal encaner ss pel© a p © A 63-year-old male presents to the general practice with watery diarrhoea. The previous fortnight he was prescribed triple therapy consisting of omeprazole, clarithromycin and amoxicillin for a duodenal ulcer. Relevant past medical history includes a previous myocardial infarction, gastroesophageal reflux disease (GORD) and bipolar syndrome. Which of the following in the patient's history increases the risk of a Clostridium difficile infection (CDI)? Lithium therapy Omeprazole use Longstanding GORD Previous CABG >1 year ago Long term statin use Reference ranges v CCamSzanner a0 tepal ieeeet]ee ees ee Lithium therapy Longstanding GORD Previous CABG >1 year ago Long term statin use PPIs are a risk factor for Clostridium difficile infection Importance: 40 CDI occurs from disruptions in the normal gut flora increasing the colonisation of C. difficile. The increased release of toxins leads to inflammation. Established risk factors include antibiotics, protein pump inhibitors, antidepressants and a vast array of conditions that affect the immune system and/or decrease gastric acid secretion. Bowel and early emergency surgery have been associated with higher rates of CDI. There is not an established link between CDI and extraintestinal surgery though surrounding factors like antibiotic use may increase the risk more acutely. GORD, T2DM and lithium are not specifically linked with higher rates of CDI. However, there is much literature showing an association of CDI with obesity which can be linked to many conditions and medications. There are numerous studies showing that statins have a protective effect against CDI which is thought to be through alteration of the microbiota or reduction of inflammation in endothelial cells. @ | @ | @Discuss | ImproveClostridium difficile Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad- spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile. Other than antibiotics, risk factors include: * proton pump inhibitors Features * diarrhoea + abdominal pain + a raised white blood cell count is characteristic * if severe toxic megacolon may develop Diagnosis « is made by detecting Clostridium difficile toxin (CDT) in the stool * Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection Management © first-line therapy is oral metronidazole for 10-14 days « if severe or not responding to metronidazole then oral vancomycin may be used * fidaxomicin may also be used for patients who are not responding , particularly those with multiple co-morbidities * for life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used : CCamSzanner a> tepal encaner ss pelOther therapies * bezlotoxumab is a monoclonal antibody which targets Clostridium difficile toxin B - it is not in widespread use°o a p >) A 59-year-old male with a history of type 2 diabetes mellitus treated with metformin 1gram bd and modified release gliclazide 60mg od, and hypertension treated with olmesartan 40mg od and amlodipine 5mg od, presents with a 2-year history of watery, non-bloody diarrhoea and pre- defecatory abdominal pain. He denies recent travels, sick contacts, dietary changes, other medications or additional systemic symptoms. He had been on his current medications for 5 years and the only recent change is a reduction in his gliclazide dose from 120mg as his diabetic control improved following unintentional weight loss of 15kg. An abdominal/pelvis CT performed in the emergency department revealed an oedematous proximal small bowel but nil else of note. On examination he has profound muscle wasting. Results of his investigations are shown in the table below: Hb 106 | nat 138 | Bilirubin 22 | immunoglobulins | Normal wl mmol/ mols 189 Platelets * = Kt 38, Alp 229 HLADaa/DGe Negative ; mmol/ ul 10/1 9.0* ta ms WBC 10 Urea aroul ALT 33u/l C.difftoxins A/B Negative Neuts ae Creatinine sf (GT 55u/l Stool culture Negative 10/1 umol Y ai tymphs 5* cpp 23° Albumin 23.g/l_Anti-TTG AB Negative a 10/1 mg/l 9 ‘ oO 10 Vitamin 20 Anti-endomysial ‘ Fosin Oy) TSH ita. Ue Srlhaa Negative He proceeds to upper GI endoscopy and biopsies on an unrestricted gluten containing diet reveal sub-total villous atrophy. What is the most likely diagnosis? CcamSzanner 20 tepal encaner ss pelHe proceeds to upper GI endoscopy and biopsies on an unrestricted gluten containing diet reveal sub-total villous atrophy. What is the most likely diagnosis? Crohn's disease Collagenous sprue Whipple's disease Drug (olmesartan) induced enteropathy Small bowel lymphoma Reference ranges v Score: 0% All contents of this site are © 2020 Passmedicine Limited Back to top CCamSzanner a0 tepal encaner ss pelCollagenous sprue \duced enteropathy Small bowel lymphoma Although coeliac disease is the most common cause of villous atrophy, patients with villous atrophy and negative coeliac serologies are encountered, posing a diagnostic and therapeutic dilemma. Possible aetiologies associated with villous atrophy and negative coeliac serologies include common variable immunodeficiency, autoimmune enteropathy, small intestinal bacterial overgrowth, infection, intestinal lymphoma, collagenous sprue, crohn's disease, and tropical sprue. When coeliac serologies are negative on a gluten-containing diet, alternative aetiologies for villous atrophy should be considered before a diagnosis of seronegative coeliac disease, to prevent an unnecessary lifelong gluten free diet. This is particularly true when the patient is negative for HLA DQ2/DQ8. HLA DQ2/DQ8 is strongly associated with coeliac disease and a negative HLA-DQ2/DQ8 genotype has a strong negative predictive value (<1% likelihood of coeliac disease being present; although please note that the converse of this is not true, as HLADQ2/DQ8 has a high prevalence in the general population). In this scenario, although seronegative coeliac disease is a potentially valid answer, the patient is on olmesartan, an angiotensin II receptor blocker, which has a well established association with severe sprue-like enteropathy with duodenal villous atrophy. Importantly, the enteropathy associated with olmesartan can develop months to years after the medication is started. As such, the olmesartan should be discontinued and the patient followed up to see if there is resolution of his symptoms. Other medications which have been associated with villous atrophy include mycophenolate mofetil and azathioprine. w@ | *@ | @Discuss (10) | Improve CcamSzanner a> tepal encaner ss pelassociated with olmesartan can develop months to years after the medication is started. As such, the olmesartan should be discontinued and the patient followed up to see if there is resolution of his symptoms. Other medications which have been associated with villous atrophy include mycophenolate mofetil and azathioprine. @ | @ | @ Discuss (10) Improve | Jejunal villous atrophy Whilst coeliac disease is the classic cause of jejunal villous atrophy there are a number of other causes you need to be aware of Causes * coeliac disease * tropical sprue * hypogammaglobulinaemia * gastrointestinal lymphoma * Whipple's disease * cow's milk intolerance Came Big Ay == Tr & @ @ Save my notes CCamSzanner a0 tepal encaner ss pelGO wx B © You are reviewing a 45-year-old woman who has a history of coeliac disease in the gastroenterology clinic. Your consultant asks you to check that she is up-to-date with her immunisations. She is otherwise fit and well and her coeliac disease is well controlled. Why do patients with coeliac disease require regular immunisations? Reduced absorption of proteins leads to hypogammaglobulinaemia Functional hyposplenism Reduced absorption of iron, vitamin B12 and folate impairs normal immunological function Higher incidence of T-cell dysfunction in patients with coeliac disease Up to 15% of patients with coeliac disease have mild primary immunodeficiencies ubmit ans’ | Reference ranges vReduced absorption of iron, vitamin B12 and folate impairs normal immunological function Higher incidence of T-cell dysfunction in patients with coeliac disease Up to 15% of patients with coeliac disease have mild primary immunodeficiencies | "@ | @ Discuss (1) Improve | Coeliac disease: management The management of coeliac disease involves a gluten-free diet. Gluten- containing cereals include: * wheat: bread, pasta, pastry * barley: beer > whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease * rye * oats ° some patients with coeliac disease appear able to tolerate oats ‘CamSzanner 20 tepal encaner ss pelCoeliac disease: management The management of coeliac disease involves a gluten-free diet. Gluten- containing cereals include: * wheat: bread, pasta, pastry * barley: beer © whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease * rye * oats © some patients with coeliac disease appear able to tolerate oats Some notable foods which are gluten-free include: * rice * potatoes * corn (maize) Tissue transglutaminase antibodies may be checked to check compliance with a gluten-free diet. Immunisation * Patients with coeliac disease often have a degree of functional hyposplenism « For this reason, all patients with coeliac disease are offered the Pneumococcal vaccine © Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years * Currrent guidelines suggest giving the influenza vaccine on an individual basis. Ccamszanner 20 te pal encaner ss pel° a3 p © A 49-year-old male was seen in general practice with a 2 month history of lethargy, polyuria and polydipsia. He had recently been investigated for erectile dysfunction. The patient is abstinent from alcohol, a non smoker and works as an insurance broker. Examination findings showed a slender tanned man with a raised JVP. Heart sounds were normal, but his apex was at the 4th intercostal space mid axillary line. Examination of his abdomen revealed only a 4cm liver edge with pitting oedema to the knees bilaterally. Which of the following deficiencies is maybe associated with his disease? HFE ATP7B JAK-STAT Glucuronyl transferase Alpha-1 anti-trypsin Reference ranges vATP7B JAK-STAT [Ste on transferase Alpha-1 anti-trypsin This 49-year-old male has presented with symptoms of diabetes mellitus, a tan, and erectile dysfunction. This including signs of heart failure and liver disease on examination should trigger the potential diagnosis of haemochromatosis. ATP7B is the dysfunctional protein associated with Wilson's disease. JAK-STAT is the mutation associated with primary polycythaemia ruba vera. Glucuronyl transferase deficiency causes Gilbert's disease. Alpha-antitrypsin deficiency is a protease that is associated with early onset emphysema and liver cirrhosis. Iron absorption is regulated in the duodenal crypts. HFE is a protein that regulates iron absorption, it forms a complex at the basolateral membrane that if bound to transferrin + iron at the basolateral membrane of the duodenal crypt cells prevents maturation and consequently absorption of iron in the bowel. The most common form of hereditary haemochromatosis is associated with a mutation in the HFE gene, leading to failure of complex formation and constant maturation of duodenal crypt cells and subsequent unregulated uptake of iron. CcamSzanner 20 depal encaner ss pelhHaemocnromatosis: features Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia Epidemiology * 1 in 10 people of European descent carry a mutation in the genes affecting iron metabolism, mainly HFE * prevalence in people of European descent = 1 in 200, making it more common than cystic fibrosis Presenting features * early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands) ‘bronze’ skin pigmentation diabetes mellitus liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition) cardiac failure (2nd to dilated cardiomyopathy) hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism) arthritis (especially of the hands) Questions have previously been asked regarding which features are reversible with treatment: Irreversible complications * Cardiomyopathy Liver cirrhosis** ‘camSzanner a0 tepal encaner ss pelQuestions have previously been asked regarding which features are reversible with treatment: Reversible complications Irreversible complications * Cardiomyopathy * Liver cirrhosis** * Skin pigmentation * Diabetes mellitus * Hypogonadotrophic hypogonadism * Arthropathy *there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene **whilst elevated liver function tests and hepatomegaly may be reversible, cirrhosis is not Biles K~ By &@ @ Xx HEemocneomatosis Camscenne es dea Ccaeaner ps blOo ai Bp © A 34-year-old male is admitted with central abdominal pain radiating through to the back and vomiting. The following results are obtained: Amylase 1,245 u/di Which one of the following medications is most likely to be responsible? Phenytoin Sodium valproate Metoclopramide Sumatriptan Pizotifen Reference ranges ¥ Score: 0% ‘CamSzanner a> Sepa ieeeet]°o a x p © A 34-year-old male is admitted with central abdominal pain radiating through to the back and vomiting. The following results are obtained: Amylase 1,245 u/dl Which one of the following medications is most likely to be responsible? Phenytoin Metoclopramide Sumatriptan [ rons Sodium valproate induced pancreatitis is more common in young adults and tends to occur within the first few months of treatment. Asymptomatic elevation of the amylase level is seen in up to 10% of patients @ | "@ | @ Discuss Improve | ‘camSzanner a> tepal encaner ss pelThe vast majority of cases in the UK are caused by gallstones and alcohol Popular mnemonic is GET SMASHED Gallstones Ethanol * Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)Note the diffuse CT from a patient with acute pancreatit parenchymal enlargement with oedema and indistinct margins. *pancreatitis is 7 times more common in patients taking mesalazine Next question > =~ Ti Be lcd than sulfasalazine Save my notes Search arch textbook. camseaner WeQe a2 p © A 31-year-old woman is admitted to hospital. As part of a liver screen the following results are obtained: Anti-HBs Positive Anti-HBc Positive HBs antigen Negative Anti-HBs = Hepatitis B Surface Antibody; Anti-HBc = Hepatitis B Core Antibody; HBs antigen = Hepatitis B Surface Antigen What is the patient's hepatitis B status? Previous immunisation to hepatitis B Chronic hepatitis B - highly infectious Previous hepatitis B infection, not a carrier Chronic hepatitis B - not infectious Acute hepatitis B infection { Reference ranges v Score: 0% CcamSzanner a> tepal encaner ss pelQ a2 x pe © A 31-year-old woman is admitted to hospital. As part of a liver screen the following results are obtained: Anti-HBs Positive Anti-HBc Positive HBs antigen Negative Anti-HBs = Hepatitis B Surface Antibody; Anti-HBc = Hepatitis B Core Antibody; HBs antigen = Hepatitis B Surface Antigen What is the patient's hepatitis B status? Previous immunisation to hepatitis B nic hepatitis B - highly infectious carrier Chronic hepatitis B - not infectious Acute hepatitis B infection HBsAg negative, anti-HBs positive, IgG anti-HBc positive - previous infection, not a carrier Importance: 66 CCamSzanner a0 tepal encaner ss pelHepatitis B serology Interpreting hepatitis B serology is a dying art form which still occurs at regular intervals in medical exams. It is important to remember a few key facts: * surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs + HBsAg normally implies acute disease (present for 1-6 months) « if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective) * Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease * Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists * HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity Example results * previous immunisation: anti-HBs positive, all others negative * previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative * previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive HBsAg = ongoing infection, either acute or chronic if present > 6 months anti-HBe = caught, i.e. negative if immunized ‘CamSzanner 20 tepal encaner ss pela p © A 26-year-old man with a history of speech and behavioural problems presents with lethargy. On examination he is noted to have jaundiced sclera. What is the most likely diagnosis? Wiskott-Aldrich syndrome Haemochromatosis Friedreich's ataxia Wilson's disease Acute intermittent porphyria | Reference ranges ¥ Score: 0% CcamSzanner a0 depal encaner ss pelAcute intermittent porphyria A combination of liver and neurological disease points towards Wilson's disease Important forme Less important & | °@ | @Discuss (2) | Improve Wilson's disease Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13. The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: basal ganglia degeneration, speech, behavioural and psychiatric problems are often the first manifestations. Also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings renal tubular acidosis (esp. Fanconi syndrome) haemolysis . CcamSzanner a0 tepal encaner ss pelWilsons disease Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13. The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: basal ganglia degeneration, speech, behavioural and psychiatric problems are often the first manifestations. Also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails Diagnosis * reduced serum caeruloplasmin * reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) * increased 24hr urinary copper excretion Management * penicillamine (chelates copper) has been the traditional first-line treatment * trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future * tetrathiomolybdate is a newer agent that is currently under investiaation CcamSzanner a0 tepal encaner ss pel8 aa p © A 55-year-old male presents with mild abdominal pain, distention and accompanying flatulence. He explains over a year ago he presented similarly and was treated with rifaximin which resolved the symptoms. Looking at the notes it states a prior diagnosis of small bowel overgrowth syndrome (SBOS) was made. What is the first-line investigative choice for diagnosis of this condition? Bile acid breath test Hydrogen breath test Culture of small bowel aspirate Endoscopy or colonoscopy Stool sample Reference ranges ¥ Score: 33.3% Camszanner a> tepal encaner ss pelall bowel aspirate Endoscopy or colonoscopy Stool sample Hydrogen breath testing is an appropriate first line test for diagnosis of small bowel overgrowth syndrome Important forme Less important All the answers can be used to investigate SBOS. The hydrogen breath test is first-line for the diagnosis as it is simple, non-invasive and relatively specific. Patients are fasted for 8 to 12 hours and then given glucose or lactulose. Colonic bacteria ferment these substrates to hydrogen and methane. Most of the gas is absorbed into the bloodstream and exhaled. In theory, the hydrogen and methane correlate to the amount of colonic bacteria. Samples of their breath are analysed typically every 15 minutes for results. The bile acid breath test is when the patient is given conjugated bile acid labelled with radioactive carbon. Bacterial enzymes deconjugate the substrate. The detection of higher than normal amounts of radioactive carbon would indicate bacterial overgrowth. The gold standard investigation is the culture of the small bowel aspirate, which has a high sensitivity and is commonly performed. Bloods, imaging and stool sample may show features associated with bacterial overgrowth and can aid in the diagnosis. | @ | @ Discuss Improve | Teed Ccamszanner 20 depal encaner ss peler Small bowel bacterial overgrowth syndrome ‘Small bowel bacterial overgrowth syndrome (SBBOS) is a disorder characterised by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms. Risk factors for SBBOS * neonates with congenital gastrointestinal abnormalities * scleroderma * diabetes mellitus It should be noted that many of the features overlap with irritable bowel syndrome: * chronic diarrhoea * bloating, flatulence * abdominal pain Diagnosis * hydrogen breath test * small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce * clinicians may sometimes give a course of antibiotics as a diagnostic trial Management * correction of underlying disorder * antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients Next que: amseamer ses ep encaner ss pel