Which one of the following patients is most likely to require screening for hepatocellular carcinoma?
Correct Answer A: Patients with liver cirrhosis secondary to hepatitis C have a 3-5% annual incidence of hepatocellular carcinoma.
Hepatocellular carcinoma: Hepatocellular carcinoma (HCC) is the third most common cause of cancer worldwide. Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.
The main risk factor for developing HCC is liver cirrhosis, for example secondary* to hepatitis B & C, alcohol, haemochromatosis and primary biliary cirrhosis.
Other risk factors include:
Features:
Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:
Management options:
*Wilson's disease is an exception
A 25-year-old intravenous drug user with chronic hepatitis C becomes pregnant. Approximately what is the chance of the virus being transmitted to her child?
Correct Answer A:
Hepatitis C:
Hepatitis C is likely to become a significant public health problem in the UK in the next decade. It is thought around 200,000 people are chronically infected with the virus. At risk groups include intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs).
Transmission:
Management of chronic infection:
Complications of treatment:
A 22-year-old man is investigated for weight loss and diarrhoea. A rectal biopsy is taken and reported as follows:
Deep inflammatory infiltrate from the mucosa to the lamina propria Numerous granulomata noted.
What is the most likely diagnosis?
Correct Answer A: Inflammation in ulcerative colitis is usually limited to the mucosa and submucosa.
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.
Blood:
Endoscopy:
Histology:
Small bowel enema:
A 59-year-old woman is admitted to the Emergency Department with a productive cough and pyrexia. She is usually fit and well but is undergoing investigation for dysphagia. This has been present for the past 3 months and affects both food and drink. A chest x-ray shows an air-fluid level behind a normal-sized heart.
Correct Answer C: A retrocardiac air-fluid level is sometimes seen in patients with achalasia.
Achalasia:
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
Clinical features:
Investigations:
Treatment:
A 31-year-old woman is reviewed in clinic. She has been referred by her GP with an 8 month history of abdominal discomfort associated with bloating.
Which one of the following tests is it least useful to perform before making a positive diagnosis of irritable bowel syndrome?
Correct Answer B: NICE recommends that thyroid function tests are not necessary prior to making a positive diagnosis of IBS.
Erythrocyte sedimentation rate and C-reactive protein may help exclude inflammatory bowel disease.
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 inquired about:
Suggested primary care investigations are:
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