Week 11 - Case two Flashcards
there is a link between coeliac disease and which other autoimmune conditions
type 1 diabetes and thyroid disease
what are created in patients with coeliac disease
autoantibodies are created in response to eating gluten.
what do these autoantibodies target
the epithelial cells of the small intestine, leading to inflammation
what are the three antibodies related to coeliacs
Anti-tissue transglutaminase antibodies (anti-TTG)
Anti-endomysial antibodies (anti-EMA)
Anti-deamidated gliadin peptide antibodies (anti-DGP)
where does the inflammation affect
the small bowel, particularly the jejenum.
what does coeliac disease cause in the villi
causes atrophy of the intestinal villi, resulting in malabsorption
what certain human leukocyte antigen (HLA) genotypes is coeliac disease associated with
HLA-DQ2
HLA-DQ8
what are the presenting symptoms of coeliac disease
Failure to thrive in young children
Diarrhoea
Bloating
Fatigue
Weight loss
Mouth ulcers
what is dermatitis herpetiformis
is an itchy, blistering skin rash, typically on the abdomen caused by coeliac disease
when does anaemia occur
secondary to malabsorption and deficiency of iron, B12, or folate
what are the neurological symptoms that coeliac disease can present with
Peripheral neuropathy
Cerebellar ataxia
Epilepsy
what must the patient do while being investigated for coeliac disease
must continue to eat gluten.
what are the first line blood tests for coeliac disease
Total immunoglobulin A levels (to exclude IgA deficiency)
Anti-tissue transglutaminase antibodies (anti-TTG)
what is the second line option where there is doubt
Anti-endomysial antibodies (anti-EMA)
TOP TIP TO REMEMBER
Initial anti-TTG and anti-EMA antibody tests are IgA. Some patients have an IgA deficiency. When you test for these antibodies, it is important to test for total immunoglobulin A levels because if the total IgA level is low, the antibody test will be negative, even in a patient with coeliac disease. In this circumstance, you can test for the IgG version of anti-TTG or anti-EMA antibodies.
how is the diagnosis of coeliac disease confirmed
by endoscopy and jejunal biopsy
what are the typical biopsy findings
Crypt hyperplasia
Villous atrophy
what is the management of coeliac disease
A lifelong gluten-free diet should completely resolve the symptoms. Dietician input may be helpful. Relapse will occur upon consuming gluten. Coeliac antibodies may help monitor the disease.
what are the complications of coeliac disease
Nutritional deficiencies
Anaemia
Osteoporosis
Hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)
Ulcerative jejunitis
Enteropathy-associated T-cell lymphoma (EATL)
Non-Hodgkin lymphoma
Small bowel adenocarcinoma
what is IBS caused by
a disturbance of the gut-brain interaction resulting in troublesome abdominal pain and intestinal symptoms.
what are the three key features of IBS that can be remembered with the IBS mneumonic
I – Intestinal discomfort (abdominal pain relating to the bowels)
B – Bowel habit abnormalities
S – Stool abnormalities (watery, loose, hard or associated with mucus)
what are common symptoms of IBS
Abdominal pain
Diarrhoea
Constipation
Fluctuating bowel habit
Bloating
Worse after eating
Improved by opening bowels
Passing mucus
what are the differentials when considering IBS
Bowel cancer
Inflammatory bowel disease
Coeliac disease
Ovarian cancer (often presents with vague symptoms, particularly bloating in women over 50 years)
Pancreatic cancer
what are the investigations that can be used to assess for underlying differentials (normal in IBS)
Full blood count for anaemia
Inflammatory markers (e.g., ESR and CRP)
Coeliac serology (e.g., anti-TTG antibodies)
Faecal calprotectin for inflammatory bowel disease
CA125 for ovarian cancer
what does the NICE guidlines suggest a patient must have before a diagnoses of IBS
The NICE clinical knowledge summaries (updated 2022) suggest before a diagnosis, differentials need to be excluded, and the patient should have at least 6 months of abdominal pain or discomfort with at least one of:
Pain or discomfort relieved by opening the bowels
Bowel habit abnormalities (more or less frequent)
Stool abnormalities (e.g., watery, loose or hard)
for a diagnosis, a patient also requires at least two of:
Straining, an urgent need to open bowels or incomplete emptying
Bloating
Worse after eating
Passing mucus
what is first line medication for IBS dependent on symptoms
Loperamide for diarrhoea
Bulk-forming laxatives (e.g., ispaghula husk) for constipation (lactulose can cause bloating and is avoided)
Antispasmodics for cramps (e.g., mebeverine, alverine, hyoscine butylbromide or peppermint oil)
what is volvulus
a condition where the bowel twists around itself and the mesentery that it is attached to
what is the mesentery
the membraneous peritioneal tissue that creates a connection between the bowel and the posterior abdominal wall.
the bowel gets its blood supply from the mesentery
what can twisting of the bowel lead to
a closed loop bowel obstruction, where a section of bowel is isolated by obstruction on either side
what are the two main types of volvulus
Sigmoid volvulus
Caecal volvulus
which is more common and in who
sigmoid is more common and tends to affect older patient
what is the key cause of sigmoid volvulus
chronic constipation and lengthening of the mesentery attached to the sigmoid colon
the sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist.
what else is a sigmoid volvulus associated with
a high fibre diet and excessive use of laxitives
what are the risk factors for volvulus
Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions
what are the signs and symptoms of a volvulus
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
what is the sign seen on abdominal x ray in sigmoid volvulus
coffee been - where the dilated and twisted sigmoid colon looks like a giant coffee bean.
what is the investigation of choice to confirm a volvulus
contract CT scan.
what is the initial management of volvulus
The initial management is the same as with bowel obstruction (nil by mouth, NG tube and IV fluids).
what is the conservative management of voluvus
Conservative management with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis). A flexible sigmoidoscope is inserted carefully, with the patient in the left lateral position, resulting in a correction of the volvulus. A flatus tube / rectal tube is left in place temporarily to help decompress the bowel and is later removed. There is a risk of recurrence (around 60%).
what does surgical management for a volvulus involve
Laparotomy (open abdominal surgery)
Hartmann’s procedure for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy)
Ileocaecal resection or right hemicolectomy for caecal volvulus
when is an urgent referral for ovarian cancer made
Urgently refer (appointment within two weeks) if physical examination identifies any of the following:
ascites
pelvic or abdominal mass (which is not obviously uterine fibroids)
what is the urgent investigation for ovarian cancer
Arrange CA125 and/or ultrasound tests in women (especially if 50 or over) who persistently or frequently (particularly more than 12 times per month) experience the following:
persistent abdominal distension (bloating)
early satiety and/or loss of appetite
pelvic or abdominal pain
increased urinary urgency and/or frequency
new onset symptoms suggestive of IBS (as IBS rarely presents for the first time in women of this age)
Consider CA125 and/or ultrasound tests if a woman reports any of the following:
unexplained weight loss
fatigue
changes in bowel habit (though colorectal cancer is a more common malignant cause)
what is faecal calprotectin used for
Faecal calprotectin is a biomarker of bowel inflammation and is now the principle way to distinguish between irritable bowel syndrome (normal faecal calprotectin) and inflammatory bowel disease (elevated faecal calprotectin even if CRP is normal)
what thyroid problems can cause diarrhoea
hyperthyroidism
An 82-year-old female presents with a 1-day history of generalised abdominal pain and distention. She has vomited 5 times today and her bowels have not opened for 2 days. Prior to this, she has no recent bowel habit or appetite change or weight loss. She has had no previous surgery. When you examine her, there is a small tender mass below and lateral to the left pubic tubercle. What is the most likely diagnosis?
An obstructing femoral hernia
A previously fit and well 25-year-old female presents with a 3-day history of right iliac fossa pain which is getting progressively worse. On examination, there is guarding and rebound tenderness in the right lower quadrant. Her observations are: Heart rate=105 bpm, Blood pressure 110/95 mmHg, Respiratory rate 20/min with saturations of 99% on room air. Bloods results so far include: Hb 11.8g/L (normal range is 11.5-16.0), WCC18.1x109/L (4-11) and CRP 120mg/L (<3). What is the next most appropriate investigation?
Should not have been checked.
Serum beta human chorionic gonadotropin
A 60-year-old male with a background of ischaemic heart disease and a BMI of 50 kg/m2 presents to A&E with a sudden onset of constant central abdominal pain that radiates into his back. He looks pale and clammy. His observations are: Heart rate=110 bpm, Blood pressure 105/92 mmHg, Respiratory rate 20/min with saturations of 99% on room air. What is the most likely diagnosis?
A ruptured abdominal aortic aneurysm
A 34-year-old female presents with intermittent colicky abdominal pain and diarrhoea. She also mentions she sees a small amount of blood in her stools and has been feeling more tired recently. What is the most likely diagnosis?
Crohn’s disease
A 64-year-old male with a background of poorly controlled Crohn’s disease presents with severe abdominal pain and distension. He looks pale and clammy and has been having bloody diarrhoea for the last 5 days. His observations are: Heart rate=115 bpm, Blood pressure 110/92 mmHg, Respiratory rate 21/min with saturations of 98% on room air. His erect CXR looks normal, but on his AXR, the left colon is featureless with a diameter of 7cm. What is the most likely diagnosis?
Toxic megacolon
