A 68-year-old woman comes back to rheumatology clinic for review. Two weeks ago she was referred with pain in her left knee and the clinical impression at the time was osteoarthritis. As her pain was not responding to paracetamol she was commenced on diclofenac 50mg tds and lansoprazole 30mg od. Shortly afterwards she developed some indigestion which seems to resolve if she skips the diclofenac dose. She is otherwise asymptomatic and got good pain relief from diclofenac. Clinical examination is normal.
What is the most appropriate action?
Correct Answer B: When NICE first published their dyspepsia guidelines there was a policy of referral for any older patients with new onset dyspepsia. This led to a deluge of referrals and amended guidelines were published in 2004. This modified approach seems to be supported by a large trial demonstrating a minimal effect on mortality of routine referral.
This question gives an example of a scenario where NICE would recommend not initially referring a patient when there is an obvious trigger (NSAID use).
Dyspepsia: In 2004 NICE published guidelines for the management of dyspepsia in primary care. These take into account the age of the patient (whether younger or older than 55 years) and the presence or absence of 'alarm signs':
Deciding whether urgent referral for endoscopy is needed: Urgent referral (within 2 weeks) is indicated for patients with any alarm signs irrespective of age Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs is not necessary, however Patients aged 55 years and over should be referred urgently for endoscopy if dyspepsia symptoms are:
Managing patients who do not meet referral criteria ('undiagnosed dyspepsia') : This can be summarized at a step-wise approach:
*It is unclear from studies whether a trial of a PPI or a 'test and treat' should be used first.
Which one of the following is most associated with oesophageal cancer?
Correct Answer A:
Oesophageal 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 tumours are in the middle third of the oesophagus.
Risk factors:
A 23-year-old man is investigated for chronic diarrhoea associated with raised inflammatory markers. A bowel biopsy is taken.
Which one of the following findings is most suggestive of ulcerative colitis?
Correct Answer B:
Inflammatory bowel disease: key differences: The two main types of inflammatory bowel disease are Crohn's disease and Ulcerative colitis. They have many similarities in terms of presenting symptoms, investigation findings and management options. There are however some key differences which are highlighted in table below:
Which one of the following is not a feature of Peutz-Jeghers syndrome?
Correct Answer D: Osteomas are a feature of Gardner's syndrome, a variant of familial adenomatous polyposis.
Peutz-Jeghers syndrome: Peutz-Jeghers syndrome is an autosomal dominant condition characterized by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles.
Around 50% of patients will have died from a gastrointestinal tract cancer by the age of 60 years.
Genetics:
Features:
Management:
A 29-year-old woman who is 30 weeks pregnant is admitted to the Emergency Department with central abdominal pain. Initial blood tests show the following:
What is the most likely cause of this presentation?
Correct Answer C: Pancreatitis occurs in around 1 in 2,000 pregnancies. Most cases of pancreatitis in pregnancy are gallstone related.
Acute pancreatitis: causes:
The vast majority of cases in the UK are caused by gallstones and alcohol.
Popular mnemonic is GET SMASHED:
*Pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine
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