A 49-year-old female is referred to the gastroenterology out-patient clinic with a 3 month history of epigastric pain and diarrhoea. Her GP initially prescribed lansoprazole 30mg od but this didn't alleviate her symptoms. The only past medical history of note is hyperparathyroidism. Endoscopy revealed multiple duodenal ulcerations.
What is the likely diagnosis?
Correct Answer C: Zollinger-Ellison syndrome: epigastric pain and diarrhoea.
Zollinger-Ellison syndrome typically presents with multiple gastroduodenal ulcers causing abdominal pain and diarrhoea. High-dose proton pump inhibitors are needed to control the symptoms. Around a third of patients may have multiple endocrine neoplasia type I (MEN-I), explaining the hyperparathyroidism in this patient.
MEN-I:
Zollinger-Ellison syndrome: Zollinger-Ellison syndrome is condition characterized by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome.
Features:
Diagnosis:
A 35-year-old man who is usually fit and well presents with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is unremarkable.
Of the following options, what is the most suitable initial management?
Correct Answer E: This question highlights the NICE guidelines for the management of dyspepsia.
There is no evidence currently to suggest whether a one month course of a PPI or 'test and treat' strategy should be adopted first line. Many clinicians prefer to test for H pylori first as this cannot be done within 2 weeks of acid suppression therapy, as false-negative results may occur Given the options available, only the answer is in line with current NICE guidelines.
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 ('un-diagnosed 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.
A 38-year-old female with a long history of alcohol excess presents with abdominal pain, weight loss and bulky stools.
What is the most suitable investigation to confirm the diagnosis?
Correct Answer D: This patient has chronic pancreatitis. CT is the most sensitive method to detect the characteristic pancreatic calcification which is associated with the condition.
Chronic pancreatitis: Chronic pancreatitis is an inflammatory condition which can ultimately affect both the exocrine and endocrine functions of the pancreas. Around 80% of cases are due to alcohol excess with up to 20% of cases being unexplained.
Investigation:
Management:
A 54-year-old man is investigated for dyspepsia. An endoscopy shows a gastric ulcer and a CLO test done during the procedure demonstrates H. pylori infection. A course of H. pylori eradication therapy is given. Six weeks later the patients comes for review.
What is the most appropriate test to confirm eradication?
Correct Answer D: It is important to remember that H. pylori serology remains positive following eradication.
Helicobacter pylori: tests
Urea breath test:
Rapid urease test (e.g. CLO test):
Serum antibody:
Culture of gastric biopsy:
Gastric biopsy:
Stool antigen test:
A 34-year-old female with a history of alcoholic liver disease is admitted with frank haematemesis. She was discharged three months ago following treatment for bleeding oesophageal varices. Following resuscitation, what is the most appropriate treatment whilst awaiting endoscopy?
Correct Answer E: Terlipressin is the only licensed vasoactive agent for variceal haemorrhage in the UK.
Oesophageal varices
Acute treatment of variceal haemorrhage:
Prophylaxis of variceal haemorrhage:
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