A 56-year-old man visits the general medical clinic complaining of bloating, acid reflux, and pain during meals. Upon endoscopy, he is diagnosed with a peptic ulcer and further testing reveals the presence of Helicobacter pylori. The patient has a history of depression but is not currently taking any medications. He denies using NSAIDs and has a childhood allergy to penicillin that caused a systemic rash. What is the recommended treatment plan for this patient?
A 32-year-old woman, who is 16 weeks pregnant, has been referred for an opinion by the obstetricians due to recurrent vomiting. Despite treatment with anti-emetics, she has not been able to stop vomiting since the beginning of her pregnancy. As a result, she has lost 5 kg of weight. Nasogastric and nasojejunal feeding were unsuccessful due to recurrent regurgitation of the tubes. Therefore, she has been started on total parenteral nutrition (TPN) and requires supplemental intravenous fluids due to recurrent vomiting. Her blood tests were checked 72 hours after initiating TPN and the results are as follows:
What is the most likely explanation for these results?
An 80-year-old woman presents with melaena, passing dark, black tarry stools for the last 36 hours. She has a medical history of chronic renal failure, angina, and is taking aspirin, isosorbide mononitrate, ramipril, calcium carbonate, alfacalcidol, and erythropoietin. On examination, she is sweaty and clammy with a pulse rate of 102 beats per minute and blood pressure of 102/43 mmHg. Her blood tests show low haemoglobin, high urea and creatinine, and a normal INR. Upper GI endoscopy reveals a gastric ulcer with a visible, non-bleeding vessel and no blood in the stomach. What is the most significant risk factor for mortality based on her clinical history?
A 65-year-old man presents to gastroenterology outpatients to discuss his gastroscopy results. He underwent endoscopy due to a six-week history of dyspeptic symptoms and weight loss, and has a past medical history of osteoarthritis treated with ibuprofen. The gastroscopy report reveals a 3 cm ulcer with flat edges in the gastric antrum, which tested positive for rapid urease (Campylobacter-like organism). He is curious about the impact of Helicobacter pylori eradication therapy and acid suppression on his peptic ulcer disease.
What advice should he be given regarding the effects of Helicobacter pylori eradication therapy and acid suppression on his peptic ulcer disease?
A 40-year-old woman with a history of Crohn’s disease presented to the gastroenterology clinic with complaints of tiredness, loose stools, persistent abdominal pains, bloating, and weight loss of approximately 4kg over the past 8 months. Despite a trial of mebeverine and loperamide, her symptoms persisted. On examination, she appeared pale but otherwise well. Investigations revealed low Hb, high MCV, high platelets, low B12, and high folate levels. Gastroscopy and colonoscopy were normal, but capsule endoscopy showed jejunal strictures and fistulae. The Schilling test showed 1% B12 isotope excretion before and after administration of intrinsic factor. What is the most likely diagnosis?
A 55-year-old man presents with recurrent episodes of dysphagia to solids and fluids, resolving completely after 2 weeks. This is his fourth episode in 6 months. He reports weight loss of over two stones since the problem started and is fearful of further oral intake in case he vomits up any food he tries to ingest. He denies haematemesis or melaena.
His past medical history includes angina, for which he currently takes minimal doses of GTN. He stopped taking isosorbide mononitrate prescribed to him by his cardiologist as it caused unbearable headaches. His mother died of pancreatic cancer and his uncle recently had an anterior resection for sigmoid colonic carcinoma.
His GP initially improved his swallowing symptoms with nifedipine but they now have no effect. An OGD was unable to pass an obstruction at the proximal oesophagus. A barium swallow demonstrated a ‘corkscrew appearance’. What is the most appropriate next step in management?
A 25-year-old man presents with increasing right upper quadrant pain two weeks after an emergency open appendicectomy. The pain has been constant for 5 days and is not radiating. He feels unwell, has been sweating profusely, and has vomited twice. On examination, he appears mildly jaundiced with tenderness and guarding in the right upper quadrant. His observations show a high heart rate and low blood pressure. Blood tests show elevated levels of bilirubin, ALP, and ALT. What is the most likely diagnosis?
A 50-year-old man with a history of alcohol abuse is brought in by ambulance after experiencing coffee ground vomiting. He is currently confused and unable to provide a medical history. However, notes from a previous admission indicate that he has diabetes and takes metformin. Upon examination, he appears thin, has spider naevi across his chest, and has abdominal distension. Rectal examination confirms the presence of melaena. His vital signs are as follows: temperature of 36.2°C, respiratory rate of 25 breaths per minute, oxygen saturation of 95% on room air, heart rate of 125 beats per minute, and blood pressure of 80/40 mmHg.
The following laboratory results were obtained:
– Hemoglobin: 105 g/L
– Platelets: 40 x 10^9/L
– White blood cells: 13.2 x 10^9/L
– Neutrophils: 10.0 x 10^9/L
– Lymphocytes: 1.0 x 10^9/L
– Eosinophils: 0.3 x 10^9/L
– Sodium: 130 mmol/L
– Potassium: 3.8 mmol/L
– Bilirubin: 30 µmol/L
– Alkaline phosphatase: 200 U/L
– Alanine transaminase: 98 U/L
– Creatinine: 86 µmol/L
– Albumin: 32 g/L
– INR: 1.8
– APTT: 50 seconds
– Fibrinogen: 1.4 g/L
What urgent medical treatment should be initiated before endoscopy?
A 63-year-old man presents to the emergency department with confusion and fever. According to his wife, he has been coughing up green sputum for the past few days. He had visited his GP, who prescribed him with oral co-amoxiclav and doxycycline. He has no medical history and has been taking paracetamol for his fever. Upon arrival, his temperature was 38.8ºC, heart rate was 125 bpm, blood pressure was 60/40 mmHg, and he was started on oxygen due to peripheral saturations reading 88% on air. A physical examination revealed bilateral coarse crackles on auscultation of his chest, and he was peripherally cool but responsive to voice. He was immediately given a bolus of fluids and commenced on broad-spectrum antibiotics for sepsis. A portable chest x-ray showed bilateral patchy opacifications. His blood results showed deranged LFTs, with a creatinine level of 320 µmol/L (55 – 120), and a CRP level of 222 mg/L (< 5). Despite several fluid boluses, his systolic blood pressure is 65 mmHg, and he is admitted to ITU for inotropes. What is the most likely cause of his deranged LFTs?
A 35-year-old man presents to the clinic with chronic diarrhoea. He had a significant portion of his small bowel removed due to Crohn’s disease 3 years ago and has been experiencing ongoing symptoms since then. On examination, he has a BMI of 18 and multiple scars on his abdomen. He also has dermatitis, glossitis, and angular stomatitis. The following investigations were conducted:
Haemoglobin (Hb): 110 g/l (normal range: 130-170 g/l)
Mean corpuscular volume (MCV): 105 fl (normal range: 80-100 fl)
White cell count (WCC): 6.2 × 109/l (normal range: 4.0-11.0 × 109/l)
Platelets (PLT): 240 × 109/l (normal range: 150-400 × 109/l)
Erythrocyte sedimentation rate (ESR): 15 mm/hour (normal range: <10mm/hour)
Sodium (Na+): 138 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 4.0 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Cr): 95 μmol/l (normal range: 50-120 µmol/l)
Albumin: 28 g/l (normal range: 35-55 g/l)
Alanine aminotransferase (ALT): 50 IU/l (normal range: 5-30 IU/l)
What is the most likely diagnosis for this patient?