A 54-year-old female is admitted one week following a cholecystectomy with profuse diarrhoea.
What is the most likely diagnosis?
Correct Answer C: Clostridium difficile is the most likely cause as the patient would have been given broad-spectrum antibiotics at the time of the operation.
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 29-year-old woman develops severe vomiting four hours after having lunch at a local restaurant.
What is the most likely causative organism?
Correct Answer E: The short incubation period and severe vomiting point to a diagnosis of Staphylococcusaureus food poisoning.
Gastroenteritis: Gastroenteritis may either occur whilst at home or whilst travelling abroad (travellers' diarrhoea) Travellers' diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool.
The most common cause is Escherichia coli.
Another pattern of illness is 'acute food poisoning'. This describes the sudden onset of nausea, vomiting anddiarrhoea after the ingestion of a toxin. Acute food poisoning is typically caused by Staphylococcus aureus, Bacillus cereus or Clostridium perfringens.
Stereotypical histories:
Incubation period:
*Vomiting subtype, the diarrhoeal illness has an incubation period of 6-14 hours.
A 39-year-old man with a history of liver cirrhosis secondary to alcohol excess is admitted with an upper gastrointestinal haemorrhage. He is treated with terlipressin and has an endoscopy with variceal band ligation 6 hours following admission.
Which further intervention has been shown to reduce mortality during the acute admission?
Correct Answer D: Antibiotic prophylaxis reduces mortality in cirrhotic patients with gastrointestinal bleeding.
Oesophageal varices:
Acute treatment of variceal haemorrhage:
Prophylaxis of variceal haemorrhage:
A 26-year-old man with a history of speech and behavioural problems presents with lethargy. On examination he is noted to have jaundiced sclera.
Correct Answer D:
Wilson's disease:
Wilson's disease is an autosomal recessive disorder characterized by excessive copper deposition in the tissues.
Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic 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:
A 54-year-old man develops central abdominal pain a few hours after having an Endoscopic Retrograde Cholangiopancreatography (ERCP) performed. Investigations reveal the following:
What is the most appropriate management?
Correct Answer E: This patient has developed acute pancreatitis following ERCP and should be treated with intravenous fluids and analgesia.
Quinolones have not been shown to be beneficial in acute pancreatitis.
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.
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