A 39-year-old man with a history of alcohol excess presents to the Emergency Department with a 2 day history of severe epigastric pain. His amylase is found to be 1260.
What is the best marker of severity?
Correct Answer A: CRP is now a widely used marker of severity in acute pancreatitis. Other methods which have to correlate with prognosis include the Ranson criteria and APACHE II score (Acute Physiology And Chronic Health Evaluation).
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.
A 18-year-old male is admitted following after deliberately ingesting 40 grams of paracetamol. Twenty-four hours after admission he is reassessed with a view to liver transplantation.
Of the following, which one would most strongly indicate the need for a liver transplant?
Correct Answer B: The arterial pH is the single most important factor. The creatinine, encephalopathy grade and INR must all be grossly abnormal otherwise.
Paracetamol overdose: management: 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:
If the high risk (see below) consider treatment at a lower dose (75 mg/kg):
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 44-year-old man is diagnosed with a right-sided colon cancer. He has a strong family history of colorectal and ovarian cancer. Genetic tests confirm a diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) due to a defect in the MSH2 gene.
What is the function of this gene?
Correct Answer D:
Colorectal cancer: genetics:
It is currently thought there are three types of colon cancer:
Studies have shown that sporadic colon cancer may be due to a series of genetic mutations. For example, more than half of colon cancers show allelic loss of the APC gene. It is believed a further series of gene abnormalities e.g. activation of the K-ras oncogene, deletion of p53 and DCC tumour suppressor genes lead to invasive carcinoma HNPCC, an autosomal dominant condition, is the most common form of inherited colon cancer.
Around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive. Currently seven mutations have been identified, which affect genes involved in DNA mismatch repair leading to micro-satellite instability. The most common genes involved are:
The Amsterdam criteria are sometimes used to aid diagnosis:
FAP is a rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30- 40 years. Patients inevitably develop carcinoma. It is due to a mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5. Genetic testing can be done by analyzing DNA from a patients white blood cells. Patients generally have a total colectomy with ileo-anal pouch formation in their twenties.
Patients with FAP are also at risk from duodenal tumours. A variant of FAP called Gardner's syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin.
What percentage of patients with ulcerative colitis have primary sclerosing cholangitis?
Correct Answer D: 4% of patients with UC have PSC, 80% of patients with PSC have UC.
Primary sclerosing cholangitis: Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterized by inflammation and fibrosis of intra and extra-hepatic bile ducts.
Associations:
Features:
Investigation:
Complications:
A 44-year-old man with alcoholic liver disease is admitted with pyrexia. He has been unwell for the past three days and has multiple previous admissions before with variceal bleeding. Examination shows multiple stigmata of chronic liver disease, ascites and jaundice. Paracentesis is performed with the following results:
What is the most appropriate treatment?
Correct Answer C: Spontaneous bacterial peritonitis - intravenous cefotaxime.
Please see the British Society of Gastroenterology guidelines for more details.
Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
Diagnosis:
Management:
Alcoholic liver disease is a marker of poor prognosis in SBP.
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