A 30-year-old woman presents with abdominal pain that is associated with alternating diarrhoea and constipation.
Which one of the following symptoms is least consistent with a diagnosis of irritable bowel syndrome?
Correct Answer B: Pain which wakes a patient at night is not a feature that would be expected in irritable bowel syndrome.
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 inquired about:
Suggested primary care investigations are:
A 30-year-old woman is investigated for chronic diarrhoea, bloating and tiredness. A diagnosis of coeliac disease is suspected.
Which one of the following factors would increase the likelihood of a false negative serology test?
Correct Answer E: Selective IgA deficiency is more common in patients with coeliac disease. For this reason IgA levels should be checked when serological tests are ordered. If the patient has selective IgA deficiency tissue transglutaminase IgG can be measured.
Patients normally need to be following a gluten-free diet for at least 6 months before the serology becomes negatives.
Coeliac disease: investigation:
Coeliac disease is caused by sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption. Conditions associated with coeliac disease include dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1 diabetes mellitus and autoimmune hepatitis).
Diagnosis is made by a combination of immunology and jejunal biopsy. Villous atrophy and immunology normally reverses on a gluten-free diet.
NICE issued guidelines on the investigation of coeliac disease in 2009. If patients are already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.
Immunology:
Jejunal biopsy:
Rectal gluten challenge has been described but is not widely used.
A 70-year-old man who is known to have atrial fibrillation presents with abdominal pain and rectal bleeding. A diagnosis of ischaemic colitis is suspected.
Which part of the colon is most likely to be affected?
Correct Answer C:
Mesenteric ischaemia: Mesenteric ischaemia is primarily caused by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
Predisposing factors:
Features:
Management:
A 23-year-old female with a history of diarrhoea and weight loss has a colonoscopy to investigate her symptoms. A biopsy is taken and reported as follows:
What is the most likely diagnosis?
Correct Answer D: Diarrhoea - biospy shows pigment laden macrophages = laxative abuse.
Melanosis coli: Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages.
It is associated with laxative abuse, especially anthraquinone compounds such as senna.
A patient who was an intravenous drug user in the 1990s asks for a hepatitis C test.
What is the most appropriate action?
Correct Answer C: HCV RNA tests are normally only ordered following a positive antibody test.
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:
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