Question 116#

Which one of the following patients would it be most suitable to offer a screening test for coeliac disease to?

A. A patient who is 'tired all the time'

Correct Answer A: 

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:

• Anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
• Hyposplenism
• Osteoporosis
• Lactose intolerance
• Enteropathy-associated T-cell lymphoma of small intestine
• Subfertility, unfavourable pregnancy outcomes
• Rare: oesophageal cancer, other malignancies

Question 117#

A 31-year-old man returns for review. He was diagnosed with an anal fissure around 7 weeks ago and has tried dietary modification, laxatives and topical anaesthetic with little benefit.

What is the most appropriate next step?

A. Oral bisacodyl

Correct Answer E: Anal fissure - topical glyceryl trinitrate.

Anal fissure:
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks. Around 90% of anal fissures occur on the posterior midline.

Management of an acute anal fissure (< 6 weeks):

• Dietary advice: high-fibre diet with high fluid intake
• Bulk-forming laxatives are first line - if not tolerated then lactulose should be tried
• Lubricants such as petroleum jelly may be tried before defecation
• Topical anaesthetics -analgesia
• Topical steroids do not provide significant relief

Management of a chronic anal fissure (> 6 weeks):

• The above techniques should be continued
• Topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure
• If topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin

Question 118#

Which one of the following features is least associated with ulcerative colitis?

A. Inflammatory cell infiltrate in the lamina propria

Correct Answer C: 

IBD: histology:

This histological differences between ulcerative colitis and Crohn's are summarized below:

Ulcerative colitis:

• Inflammation in mucosa and submucosa only (unless fulminant disease)
• Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps')
• Inflammatory cell infiltrate in lamina propria
• Crypt abscesses
• Depletion of goblet cells and mucin from gland epithelium
• Granulomas are infrequent

Crohn's:

• Inflammation occurs in all layers, down to the serosa. This predisposes to strictures, fistulas and adhesions
• Oedema of mucosa and submucosa, combined with deep fissured ulcers ('rose-thorn') leads to a 'cobblestone' pattern
• Lymphoid aggregates
• Non-caseating granulomas

Question 119#

A 64-year-old woman complains of having 'excessive wind'. She is normally fit and well but for the past three months she has felt bloated and has been passing wind frequently. She also complains of vague upper abdominal pain and chronic diarrhoea. A hydrogen breath test confirms a diagnosis of small bowel bacterial overgrowth syndrome.

What is the treatment of choice?

A. Tetracycline

Correct Answer B: Tetracyclines are no longer commonly used due to widespread bacterial resistance.

Small bowel bacterial overgrowth syndrome:
Small bowel bacterial overgrowth syndrome (SBBOS) is a disorder characterized by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms.

Risk factors for SBBOS:

• Neonates with congenital gastrointestinal abnormalities
• Scleroderma
• Diabetes mellitus

It should be noted that many of the features overlap with irritable bowel syndrome:

• Chronic diarrhoea
• Bloating, flatulence
• Abdominal pain

Diagnosis:

• Hydrogen breath test

Management:

• Correction of underlying disorder
• Antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Coamoxiclav or metronidazole are also effective in the majority of patients

Question 120#

A 25-year-old man presents with bloating and alteration in his bowel habit. He has been keeping a food diary and feels his symptoms may be secondary to a food allergy. Blood tests show a normal full blood count, ESR and thyroid function tests. Anti-endomysial antibodies are negative.

What is the most suitable test to investigate possible food allergy?

A. Total IgE levels

Correct Answer D: Skin prick testing would be first-line here as it is inexpensive and a large number of allergens can be investigated. Whilst there is a role for IgE testing in food allergy it is in the form of specific IgE antibodies rather than total IgE levels.

Allergy tests: