When it comes to distinguishing between ulcerative colitis and Crohn’s disease, one key factor is the presence of crypt abscesses. These are typically seen in ulcerative colitis, which is the more common of the two inflammatory bowel diseases. In ulcerative colitis, inflammation starts in the rectum and spreads continuously up the colon, whereas Crohn’s disease often presents with skip lesions. Patients with ulcerative colitis may experience left-sided abdominal pain, cramping, bloody diarrhea with mucous, and unintentional weight loss. Colonoscopy typically reveals diffuse and contiguous ulceration and inflammatory infiltrates affecting the mucosa and submucosa only, with the presence of crypt abscesses being a hallmark feature. In contrast, Crohn’s disease is characterized by a transmural inflammatory phenotype, with non-caseating granulomas and stricturing of the bowel wall being common complications. Patients with Crohn’s disease may present with right-sided abdominal pain, watery diarrhea, and weight loss, and may have a more systemic inflammatory response than those with ulcerative colitis. Barium enema and colonoscopy can help to differentiate between the two conditions, with the presence of multiple linear ulcers in the bowel wall (rose-thorn appearance) and bowel wall thickening being suggestive of Crohn’s disease.

Differentiating Abdominal Conditions: Crohn’s Disease, Ulcerative Colitis, Peptic Ulcer Disease, Gallstones, and Diverticulitis

Abdominal pain can be caused by a variety of conditions, making it important to differentiate between them. Crohn’s disease is an inflammatory bowel disease that can affect the entire bowel and typically presents between the ages of 20 and 50. It is chronic and relapsing, with skip lesions of normal bowel in between affected areas. Ulcerative colitis is another inflammatory bowel disease that starts at the rectum and moves upward. It can be classified by the extent of inflammation, with symptoms including bloody diarrhea and mucous. Peptic ulcer disease causes epigastric pain and may present with heartburn symptoms, but it is not consistent with the clinical picture described in the vignette. Gallstones typically cause right upper quadrant pain and are more common in females. Diverticulitis presents with left iliac fossa abdominal pain and is more common in elderly patients. Complications of untreated diverticulitis include abscess formation, bowel obstruction, or perforation. Understanding the differences between these conditions can aid in proper diagnosis and treatment.

Management of Acute Cholangitis: Next Steps

Acute cholangitis (AC) is a serious infection of the biliary tree that requires prompt management. The patient typically presents with right upper quadrant pain, fever, and jaundice. The next steps in management depend on the patient’s clinical presentation and stability.

Intravenous (IV) antibiotics are the first-line treatment for AC. The patient’s febrile state and elevated inflammatory markers indicate the need for prompt antibiotic therapy. Piperacillin and tazobactam are a suitable choice of antibiotics.

Exploratory laparotomy is indicated in patients who are hemodynamically unstable and have signs of intra-abdominal haemorrhage. However, this is not the next best step in management for a febrile patient with AC.

Percutaneous cholecystostomy is a minimally invasive procedure used to drain the gallbladder that is typically reserved for critically unwell patients. It is not the next best step in management for a febrile patient with AC.

A computed tomography (CT) scan of the abdomen is likely to be required to identify the cause of the biliary obstruction. However, IV antibiotics should be commenced first.

Endoscopic retrograde cholangiopancreatography (ERCP) may be required to remove common bile duct stones or stent biliary strictures. However, this is not the next best step in management for a febrile patient with AC.

In summary, the next best step in management for a febrile patient with AC is prompt IV antibiotics followed by abdominal imaging to identify the cause of the biliary obstruction.

Differential Diagnosis for Retrosternal Pain: GORD, PUD, MI, Pancreatitis, and Pericarditis

When a patient presents with retrosternal pain, it is important to consider various differential diagnoses. In this case, the patient’s pain is burning in nature and occurs in the postprandial period, making gastro-oesophageal reflux disease (GORD) a likely diagnosis. Other common manifestations of GORD include hypersalivation, globus sensation, and laryngitis. However, if the patient had any ‘alarm’ symptoms, such as weight loss or difficulty swallowing, further investigation would be necessary.

Peptic ulcer disease (PUD) is another potential cause of deep epigastric pain, especially in patients with risk factors such as Helicobacter pylori infection, non-steroidal anti-inflammatory use, and alcoholism.

Myocardial infarction (MI) is less likely in this case, as the patient’s pain does not worsen with exertion and is not accompanied by other cardiac symptoms. Additionally, the patient’s ECG is normal.

Pancreatitis typically presents with abdominal pain that radiates to the back, particularly in patients with gallstones or a history of alcoholism. The patient’s non-radiating, retrosternal burning pain is not consistent with pancreatitis.

Pericarditis is characterized by pleuritic chest pain that is aggravated by inspiration and lying flat, but relieved by sitting forward. Widespread ST-segment elevation on electrocardiogram is also common. Non-steroidal anti-inflammatories are typically used as first-line treatment.

In summary, a thorough consideration of the patient’s symptoms and risk factors can help narrow down the potential causes of retrosternal pain and guide appropriate diagnostic and treatment strategies.

Gastrointestinal Stromal Tumours (GISTs) vs Other Gastric Conditions

Gastrointestinal stromal tumours (GISTs) are the most common tumours of mesenchymal origin in the gastrointestinal tract, with approximately 50-70% occurring in the stomach. They are histologically characterized by spindle cells, epithelioid-like cells, or mixed spindle-epithelioid cells. GISTs tend to occur in individuals above the age of 40 and are equally common in men and women. Biopsy specimens are stained with DOG1 for identification, and surgical resection is the preferred treatment option. Systemic chemotherapy with imatinib is an alternative for patients who cannot undergo complete surgical resection. Disease survival rates at the 5-year stage range from 30-60%.

Other gastric conditions, such as gastric carcinoma, Helicobacter pylori gastritis, gastric leiomyosarcoma, and gastric lipoma, may present with similar symptoms but have different endoscopic and histological findings. Gastric carcinomas are most often adenocarcinomas, while Helicobacter pylori gastritis is the most common cause of gastritis worldwide. Gastric leiomyosarcoma is a differential diagnosis for GISTs, but GISTs are more common. Gastric lipomas would not present with the same combination of findings seen in GISTs.

The patient in this scenario presents with symptoms that suggest a blockage in their bowel and potential signs of cancer, such as a loss of appetite and anemia. Therefore, the most important initial investigation is a colonoscopy. A colonic transit study is not appropriate as it is used for slow colonic transit and this patient has symptoms of obstruction. An abdominal X-ray can be used to investigate faecal impaction and rectal masses, but a colonoscopy should be used first-line for detailed information about colonic masses. While a CT abdomen may be needed, a colonoscopy should be performed as the initial investigation for intestinal luminal obstruction and potential malignancy. Checking thyroid function may be useful if there is suspicion of a secondary cause of constipation, but in this case, the patient’s symptoms suggest colonic obstruction and cancer, making a thyroid function test an inappropriate initial investigation.

Liver Metastases: Causes and Differential Diagnosis

Liver metastases are a common cause of nodular hepatomegaly, with the most frequent primary sites being the bowel and breast. While palpable metastases may not affect liver function, obstruction to the biliary tract or involvement of over half of the liver can lead to impaired function and the presence of ascites. Autopsy studies have shown that 30-70% of cancer patients have liver metastases, with the frequency depending on the primary site. Most liver metastases are multiple and affect both lobes.

When considering a differential diagnosis, cirrhosis can be ruled out as it is the end-stage of chronic liver disease and would typically present with elevated serum alanine aminotransferase (ALT). Hepatoma is less common than metastases and lymphoma may present with evidence of involvement in other sites, such as lymphadenopathy. Myelofibrosis, which is associated with bone marrow fibrosis and abnormal stem cell appearance in the liver and spleen, may be asymptomatic in its early stages or present with leuko-erythroblastic anemia, malaise, weight loss, and night sweats. However, it is much less common than liver metastases.

In summary, liver metastases should be considered as a potential cause of nodular hepatomegaly, particularly in patients with a history of cancer. A thorough differential diagnosis should be conducted to rule out other potential causes.

Arteries of the Stomach and Duodenum: Potential Sites of Haemorrhage

The gastrointestinal tract is supplied by a network of arteries that can be vulnerable to erosion and haemorrhage in cases of ulceration. Here are some of the key arteries of the stomach and duodenum to be aware of:

Gastroduodenal artery: This branch of the common hepatic artery travels to the first part of the duodenum, where duodenal ulcers often occur. If the ulceration erodes through the gastroduodenal artery, it can cause a catastrophic haemorrhage and present as haematemesis.

Left gastric artery: Arising from the coeliac artery, the left gastric artery supplies the distal oesophagus and the lesser curvature of the stomach. Gastric ulceration can cause erosion of this artery and lead to a massive haemorrhage.

Left gastroepiploic artery: This artery arises from the splenic artery and runs along the greater curvature of the stomach. If there is gastric ulceration, it can be eroded and lead to a massive haemorrhage.

Right gastroepiploic artery: Arising from the gastroduodenal artery, the right gastroepiploic artery runs along the greater curvature of the stomach and anastomoses with the left gastroepiploic artery.

Short gastric arteries: These branches arise from the splenic artery and supply the fundus of the stomach, passing through the gastrosplenic ligament.

Knowing the potential sites of haemorrhage in the gastrointestinal tract can help clinicians to identify and manage cases of bleeding effectively.

Gastrointestinal Conditions: Understanding Oesophageal Varices, Hiatus Hernia, Mallory-Weiss Tear, Barrett’s Oesophagus, and Oesophageal Stricture

Gastrointestinal conditions can cause discomfort and even life-threatening complications. Here are five conditions that affect the oesophagus:

Oesophageal Varices: These are enlarged veins in the lower third of the oesophagus that can rupture and cause severe bleeding. They are often caused by portal hypertension, which is associated with chronic liver disease.

Hiatus Hernia: This condition occurs when the diaphragmatic crura separate, causing the stomach to protrude above the diaphragm. There are two types: axial and non-axial. Bleeding with a hiatus hernia is usually not severe.

Mallory-Weiss Tear: This condition is characterized by tears in the oesophageal lining caused by prolonged vomiting. It presents with bright red haematemesis.

Barrett’s Oesophagus: This condition is associated with reflux, inflammation, and possible ulceration. Bleeding is not usually severe.

Oesophageal Stricture: This condition results from scarring, typically caused by reflux or scleroderma. It is a chronic process that does not usually cause severe bleeding.

Understanding these conditions can help individuals recognize symptoms and seek appropriate medical attention.

The patient is likely suffering from chronic liver disease and portal hypertension, possibly caused by a hepatitis B infection. This is common in regions such as sub-Saharan Africa and East Asia, where up to 10% of adults may be chronically infected. Acute paracetamol overdose can also cause liver failure, but it does not typically present with haematemesis. Mushroom poisoning can be deadly and cause liver damage, but it is not a cause of chronic liver disease. Hepatitis C is another cause of liver cirrhosis, but it is more common in other regions such as Egypt. Haemochromatosis is a rare autosomal recessive disease that can present with cirrhosis and other symptoms, but it is less likely in this case.