Which one of the following is not associated with villous atrophy on jejunal biopsy?
Correct Answer D: Causes of villous atrophy (other than coeliacs): tropical sprue, Whipple's, lymphoma, hypogammaglobulinaemia.
Jejunal villous atrophy:
Whilst coeliac disease is the classic cause of jejunal villous atrophy there are a number of other causes you need to be aware of Causes:
A 34-year-old male is admitted with central abdominal pain radiating through to the back and vomiting. The following results are obtained:
Which one of the following medications is most likely to be responsible?
Correct Answer B: Sodium valproate induced pancreatitis is more common in young adults and tends to occur within the first few months of treatment. Asymptomatic elevation of the amylase level is seen in up to 10% of patients.
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 59-year-old woman presents with dysphagia. There is no history of heartburn, weight loss or change in bowel habit. During endoscopy there is some difficulty passing through the lower oesophageal sphincter but no other abnormality is noted.
Which one of the following tests is most likely to reveal the diagnosis?
Correct Answer B: The gold standard test for achalasia is oesophageal manometry.
Achalasia: Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
Clinical features:
Investigations:
Treatment:
Which of the following is not a recognized complication of coeliac disease?
Correct Answer A: Hypo-, not hypersplenism is seen in coeliac disease.
Coeliac disease: 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).
It is strongly associated with HLA-DQ2 (95% of patients) and HLA-B8 (80%) as well as HLA-DR3 and HLA-DR7 In 2009 NICE issued guidelines on the investigation of coeliac disease. They suggest that the following patients should be screened for coeliac disease:
Complications:
A 43-year-old man with type 2 diabetes mellitus presents with lethargy. His current medications include metformin and gliclazide, although the gliclazide may soon be stopped due to his obesity. A number of blood tests are ordered which reveal the following:
On discussing these results he states that he does not drink alcohol.
What is the most likely cause of these abnormal results?
Correct Answer E: Obese T2DM with abnormal LFTs - ? non-alcoholic fatty liver disease.
By far the most likely diagnosis in an obese type 2 diabetic is non-alcoholic fatty liver disease. This patient will require a liver screen, ultrasound and liver biopsy to confirm the diagnosis. A normal ferritin makes a diagnosis of haemochromatosis unlikely, although it should always be considered in patients with both abnormal LFTs and diabetes.
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 labelled as cryptogenic cirrhosis.
Associated factors:
Features:
Management:
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