A 59-year-old female presents with a two month history of indigestion. She is otherwise well, has not had a similar episode before and takes no regular medication. Of note there is no recent weight loss or vomiting and abdominal examination is unremarkable.
What is the most appropriate initial management?
Correct Answer C: This patient meets the criteria for urgent referral for endoscopy as she is older than 55 years, has recent onset, persistent and unexplained symptoms.
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 19-year-old man is referred to the general medical clinic. For the past six months his family have noted increasing behavioural and speech problems. He himself has noticed that he is more clumsy than normal and reports excessive salivation. His older brother died of liver disease.
Given the likely underlying condition what is the most appropriate therapy?
Correct Answer E: This man is likely to have Wilson's disease.
Wilson's disease: Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.Metabolic abnormalities include increased copper absorption from the small intestine and decreasedhepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13.
The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease.
Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:
Diagnosis:
Management:
Which one of the following statements is incorrect regarding Dubin-Johnson syndrome?
Correct Answer E: This patient likely has Dubin-Johnson Syndrome (DJS). This benign, relatively rare disorder is characterized by low-grade, predominantly conjugated hyperbilirubinemia (Table VII-69). Total bilirubin concentrations are typically between 34 and 85 μmol/L (2 and 5 mg/dL) but on occasion can be in the normal range or as high as 340–430 μmol/L (20–25 mg/dL) and can fluctuate widely in any given patient. The degree of hyperbilirubinemia may be increased by intercurrent illness, oral contraceptive use, and pregnancy. Because the hyperbilirubinemia is due to a predominant rise in conjugated bilirubin, bilirubinuria is characteristically present. Aside from elevated serum bilirubin levels, other routine laboratory tests are normal. Physical examination is usually normal except for jaundice, although an occasional patient may have hepatosplenomegaly. Patients with DJS are usually asymptomatic, although some may have vague constitutional symptoms. In women, the condition may be subclinical until the patient becomes pregnant or receives oral contraceptives, at which time chemical hyperbilirubinemia becomes frank jaundice. Even in these situations, other routine liver function tests, including serum alkaline phosphatase and transaminase activities, are normal. Benign recurrent intrahepatic cholestasis would be expected to have biochemical abnormalities other than isolated hyperbilirubinemia and is often accompanied by intense pruritus. Cholestasis of pregnancy usually occurs in the late second trimester or early third trimester and is most often accompanied by severe pruritus that precedes biochemical abnormalities by several weeks. Crigler-Najjar syndrome type 2 is characterized by marked unconjugated hyperbilirubinemia.
Inherited hyperbilirubinemia:
A 30-year-old woman presents with a three month history of indigestion. There is no history of weight less, anorexia, dysphagia, vomiting or change in bowel habit and abdominal examination is unremarkable.
Which one of the following may decrease the accuracy of a 13C-urea breath test?
Correct Answer C: Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks.
Helicobacter pylori: tests : 1- Urea breath test:
2- Rapid urease test (e.g. CLO test):
3- Serum antibody:
4- Culture of gastric biopsy:
5- Gastric biopsy:
6- Stool antigen test:
A 40-year-old man is investigated for abnormal liver function tests. It is decided to perform a liver biopsy.
Which one of the following is a contraindication to liver biopsy?
Correct Answer E: With modern techniques such as ERCP and MRI cholangiography the risks of liver biopsy when there is extrahepatic biliary obstruction are rarely justified.
Liver biopsy: Contraindications to percutaneous liver biopsy:
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