A 45-year-old man with a history of alcohol excess is diagnosed as having grade 3 oesophageal varices during an outpatient endoscopy. Of the following options, what is the most appropriate management to prevent variceal bleeding?
Correct Answer A: Endoscopic sclerotherapy now has little role in the prophylaxis of variceal haemorrhage.
Oesophageal varices:
Acute treatment of variceal haemorrhage:
Prophylaxis of variceal haemorrhage:
A 78-year-old woman is admitted with a productive cough and pyrexia to hospital. Chest x-ray shows a pneumonia and she is commenced on intravenous ceftriaxone. Four days following admission a stool sample is sent because of diarrhoea. This confirms the suspected diagnosis of Clostridium difficile diarrhoea and a 10-day course of oral metronidazole is started. After 10 days her diarrhoea is ongoing but she remains clinically stable.
What is the most appropriate treatment?
Correct Answer A: The Health Protection Agency suggests switching to oral vancomycin in this scenario.
Clostridium difficile: Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile.
Features:
Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool.
Management:
A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests show the following:
A diagnosis of ulcerative colitis is suspected.
Which part of the bowel is most likely to be affected?
Correct Answer B: Ulcerative colitis - the rectum is the most common site affected.
Ulcerative colitis:
Ulcerative colitis (UC) is a form of inflammatory bowel disease. Inflammation always starts at rectum (hence it is the most common site for UC), never spreads beyond ileocaecal valve and is continuous. The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years.
The initial presentation is usually following insidious and intermittent symptoms. Features include:
Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are common:
Pathology:
Barium enema:
A 31-year-old woman presents with symptoms consistent with coeliac disease.
Which one of the following tests should be used first-line when screening patients for coeliac disease?
Correct Answer B: Coeliac disease - tissue transglutaminase antibodies first-line test.
Tissue transglutaminase antibodies are recommended as the first-line serological test according to NICE.
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.
Which one the following disorders is most strongly associated with primary biliary cirrhosis?
Correct Answer C: All of the above conditions are associated with primary biliary cirrhosis but Sjogren's syndrome is the most common, being seen in up to 80% of patients .
Primary biliary cirrhosis:
Primary biliary cirrhosis is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman.
Associations:
Diagnosis:
Click to expand