A patient presents with gastrointestinal symptoms. Which one of the following features in the history would be least consistent with making a diagnosis of irritable bowel syndrome?
Correct Answer C: Onset after 60 years of age is considered a red flag in the new NICE guidelines.
Irritable bowel syndrome: diagnosis: NICE published clinical guidelines on the diagnosis and management of irritable bowel syndrome (IBS) in 2008.
The diagnosis of IBS should be considered if the patient has had the following for at least 6 months:
A positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis.
Red flag features should be enquired about:
Suggested primary care investigations are:
A 27-year-old woman with a history of depression presents to the Emergency Department. She reports taking 50 paracetamol tablets yesterday. Bloods are taken on admission.
Which one of the following would most strongly indicate the need for a liver transplant?
Correct Answer E: The arterial pH is the single most important factor according to the King's College Hospital criteria for liver transplantation.
Paracetamol overdose: management: The following is based on the current BNF guidance. The National Poisons Information Service/TOXBASE should always be consulted for situations outside of the normal parameters.
Activated charcoal should be given if:
Patients presenting within 8 hours:
Patients presenting 8-24 hours after ingestion:
The following groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose and hence are considered 'high-risk':
King's College Hospital criteria for liver transplantation (paracetamol liver failure):
Arterial pH < 7.3, 24 hours after ingestion or all of the following:
A 64-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and becotide inhaler, bendrofluazide and amlodipine.
What is the most likely cause of the presentation?
Correct Answer D: Pain on swallowing (odynophagia) is a typical of oesophageal candidiasis, a well documented complication of inhaled steroid therapy.
Dysphagia:
The table below gives characteristic exam question features for conditions causing dysphagia:
According to recent NICE guidelines, which one of the following may have a role in the management of irritable bowel syndrome?
Correct Answer E:
Irritable bowel syndrome: management:
The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients.
NICE issued guidelines in 2008: First-line pharmacological treatment - according to predominant symptom:
Second-line pharmacological treatment:
Other management options:
General dietary advice:
Which one of the following investigations is considered the gold standard for the diagnosis of gastrooesophageal reflux disease?
Correct Answer B: 24hr oesophageal pH monitoring is gold standard investigation in GORD.
GORD: investigation:
Overview:
Indications for upper GI endoscopy:
If endoscopy is negative consider 24-hr oesophageal pH monitoring (the gold standard test for diagnosis).
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