A 54-year-old female with a history of scleroderma presents with chronic diarrhoea and bloating. Blood tests show a mild macrocytic anaemia. A diagnosis of small bowel bacterial overgrowth is suspected.
Which one of the following tests is most likely to confirm the diagnosis?
Correct Answer B: Whilst small bowel aspiration and culture is the gold standard investigation in this situation, its use is often limited due to resource limitations. Please see the British Society of Gastroenterology guidelines.
guidelines The hydrogen breath test is another option. It has low sensitivity but high specificity.
Bacterial overgrowth: investigation:
The gold standard investigation of bacterial overgrowth is small bowel aspiration and culture.
Other possible investigations include:
In practice many clinicians give an empirical course of antibiotics as a trial
A 52-year-old woman is diagnosed with non-alcoholic steatohepatitis following a liver biopsy.
What is the single most important step to help prevent the progression of her disease?
Correct Answer E:
Non-alcoholic fatty liver disease: Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world. It is largely caused by obesity and describes a spectrum of disease ranging from:
NAFLD is thought to represent the hepatic manifestation of the metabolic syndrome and hence insulin resistance is thought to be the key mechanism leading to steatosis.
Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse. It is relatively common and though to affect around 3-4% of the general population. The progression of disease in patients with NASH may be responsible for a proportion of patients previously labeled as cryptogenic cirrhosis.
Associated factors:
Features:
Management:
A 31-year-old female is admitted to the Emergency Department following a paracetamol overdose. The paracetamol level comes back as elevated but the doctor is unsure which treatment line to use.
Which one of the following features in the medical history would classify the patient as high risk?
Correct Answer B: Paracetamol overdose - high risk if chronic alcohol, HIV, anorexia or P450 inducers.
Paracetamol overdose: risk factors: The following groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose:
A 26-year-old woman who is known to have type 1 diabetes mellitus presents with a three-month history of diarrhoea, fatigue and weight loss. She has tried excluding gluten from her diet for the past 4 weeks and feels much better. She requests to be tested so that a diagnosis of coeliac disease is confirmed.
What is the most appropriate next step?
Correct Answer E: Serological tests and jejunal biopsy may be negative if the patient is following a gluten-free diet. The patient should eat some gluten in more than one meal every day for at least 6 weeks before further testing.
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.
What is the most common cause of hepatocellular carcinoma in the United Kingdom?
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:
Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:
Management options:
*Wilson's disease is an exception.
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