Management

Question 1

Mesenteric Ischaemia

Answer 1

• Supportive care

- Laparotomy and bowel resection

Question 2

Renal Stones (acute management)

Answer 2

Medication
The British Association of Urological Surgeons (BAUS) recommend diclofenac (intramuscular/oral) as the analgesia of choice for renal colic*
BAUS also endorse the widespread use of alpha-adrenergic blockers to aid ureteric stone passage

Imaging
BAUS guidelines recommend ultrasound as the initial imaging modality of choice. The sensitivity of ultrasound for stones is around 45% and specificity is around 90%. Complications such as hydronephrosis can also be quickly identified
following an ultrasound, BAUS recommend a non-contrast CT (NCCT) to confirm the diagnosis. 99% of stones are identifiable on NCCT. Some GPs now have direct access to NCCT

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.

Question 3

Renal Stones (prevention)

Answer 3

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
high fluid intake
low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet)
thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stones
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion

Uric acid stones
allopurinol
urinary alkalinization e.g. oral bicarbonate

Question 4

Ascending Cholangitis

Answer 4

• Intravenous antibiotics

- Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

Question 5

Addison’s Disease

Answer 5

Patients who have Addison’s disease are usually given both glucocorticoid and mineralocorticoid replacement therapy.

This usually means that patients take a combination of:
hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the morning dose
fludrocortisone

Patient education is important:
emphasise the importance of not missing glucocorticoid doses
consider MedicAlert bracelets and steroid cards
discuss how to adjust the glucocorticoid dose during an intercurrent illness (see below)

Management of intercurrent illness
in simple terms the glucocorticoid dose should be doubled

Question 6

Primary Hyperaldosteronism

Answer 6

Investigations:

• High serum aldosterone
• Low serum renin
• High-resolution CT abdomen
• Adrenal vein sampling

Management:

• Adrenal adenoma: surgery
• Bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

Question 7

Normal Pressure Hydrocephalus

Answer 7

Imaging:
- Hydrocephalus with an enlarged fourth ventricle

Management:
- Ventriculoperitoneal shunting

Question 8

Peutz-Jeghers Syndrome

Answer 8

Conservative unless complications develop

Question 9

Ulcerative Colitis

Answer 9

The severity of UC is usually classified as being mild, moderate or severe:

• mild: < 4 stools/day, only a small amount of blood
• moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
• severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Inducing Remission

• treatment depends on the extent and severity of disease
• rectal (topical) aminosalicylates or steroids: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
• oral aminosalicylates
• oral prednisolone is usually used second-line for patients who fail to respond to aminosalicylates. NICE recommend waiting around 4 weeks before deciding if first-line treatment has failed
• severe colitis should be treated in hospital. Intravenous steroids are usually given first-line

Maintaining Remission

• oral aminosalicylates e.g. mesalazine
• azathioprine and mercaptopurine
• methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)
• there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

Question 10

Crohn’s Disease

Answer 10

General Points:

• patients should be strongly advised to stop smoking
• some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy

Inducing Remission

• glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
• enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
• 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
• azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
• infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
• metronidazole is often used for isolated peri-anal disease

Maintaining Remission:

• as above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
• azathioprine or mercaptopurine is used first-line to maintain remission
• methotrexate is used second-line
• 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery

Surgery:
- around 80% of patients with Crohn’s disease will eventually have surgery

Question 11

Erythema Nodosum

Answer 11

Usually resolves by itself within 6 weeks. Lesions heal without scarring.