A 31-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophageal variceal haemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 104/60 mmHg and his pulse is 84/min.
What is the most appropriate intervention?
Correct Answer C:
Oesophageal varices:
Acute treatment of variceal haemorrhage:
Prophylaxis of variceal haemorrhage:
A 25-year-old man presents with lethargy and increased skin pigmentation. Blood test reveal deranged liver function tests and impaired glucose tolerance. Given the likely diagnosis of haemochromatosis, what is the most appropriate initial investigation strategy?
Correct Answer A: The British Committee for Standards in Haematology (BCSH) guidelines recommend measuring the transferring saturation first as this is the most specific and sensitive test for iron accumulation. They also recommend that serum ferritin is measured but this marker is not usually abnormal in the early stages of iron accumulation.
Screening for haemochromatosis:
Haemochromatosis: investigation:
Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. The British Committee for Standards in Haematology (BCSH) published guidelines for the investigation and management of haemochromatosis in 2000.
There is continued debate about the best investigation to screen for haemochromatosis. The 2000 BCSH guidelines suggest:
These guidelines may change as HFE gene analysis become less expensive.
Diagnostic tests:
Typical iron study profile in patient with haemochromatosis:
Monitoring adequacy of venesection:
Joint x-rays characteristically show chondrocalcinosis.
*There are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene.
A patient with upper gastrointestinal symptoms tests positive for Helicobacter pylori following a urea breath test.
Which one of the following conditions is most strongly associated Helicobacter pylori infection?
Correct Answer D: Helicobacter pylori infection is also associated with both gastric adenocarcinoma and atrophic gastritis but the strongest association is with duodenal ulceration.
Helicobacter pylori:
Helicobacter pylori is a Gram negative bacteria associated with a variety of gastrointestinal problems, principally peptic ulcer disease.
Associations:
The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear - there is currently no role in GORD for the eradication of H pylori.
Management - eradication may be achieved with a 7 day course of:
A 24-year-old man presents with rectal bleeding and pain on defecation. This has been present for the past two weeks. He has a tendency towards constipation and notices that when he wipes himself fresh blood is often on the paper. Rectal examination is limited due to pain but no external abnormalities are seen.
What is the most likely diagnosis?
Correct Answer E: Superficial anal fissures may be difficult to see on examination.
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):
Analgesia:
Management of a chronic anal fissure (> 6 weeks):
A 54-year-old woman presents with jaundice shortly after being discharged from hospital. Liver function tests are reported as follows:
Which of the following antibiotics is she most likely to have received?
Correct Answer A: Flucloxacillin + co-amoxiclav are well recognized causes of cholestasis.
Drug-induced liver disease: Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed. There is however considerable overlap, with some drugs causing a range of changes to the liver.
The following drugs tend to cause a hepatocellular picture:
The following drugs tend to cause cholestasis (+/- hepatitis):
Liver cirrhosis:
*Rrisk may be reduced with erythromycin stearate
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