Answer: Fitz Hugh Curtis syndrome

Fitz-Hugh-Curtis syndrome is a rare disorder that occurs almost exclusively in women. It is characterized by inflammation of the membrane lining the stomach (peritoneum) and the tissues surrounding the liver (perihepatitis). The muscle that separates the stomach and the chest (diaphragm), which plays an essential role in breathing, may also be affected. Common symptoms include severe pain in the upper right area (quadrant) of the abdomen, fever, chills, headaches, and a general feeling of poor health (malaise). Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease (PID), a general term for infection of the upper genital tract in women. Infection is most often caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Fitz-Hugh-Curtis syndrome is characterized by the onset of sudden, severe pain in the upper right area of the abdomen. Pain may spread to additional areas including the right shoulder and the inside of the right arm. Movement often increases pain. The upper right area may be extremely tender.

Additional symptoms may occur in some cases including fever, chills, night sweats, vomiting and nausea. Some affected individuals may develop headaches, hiccupping, and a general feeling of poor health (malaise).

Some affected individuals may have symptoms associated with pelvic inflammatory disease including fever, vaginal discharge, and lower abdominal pain. Lower abdominal pain may precede, follow, or occur simultaneously with upper abdominal pain.

Most cases of Fitz-Hugh-Curtis syndrome are caused by infection with the bacterium Chlamydia trachomatis, which causes Chlamydia or the organism Neisseria gonorrhoeae, which causes gonorrhoea. Chlamydia and gonorrhoea are common sexually transmitted diseases (STDs). Researchers believe that more cases of Fitz-Hugh-Curtis syndrome are caused by infection with Chlamydia trachomatis than with Neisseria gonorrhoeae.

The exact process by which such infections cause Fitz-Hugh-Curtis syndrome (pathogenesis) is not completely understood. Some researchers believe that it occurs because of infection of the liver and surrounding tissue, which may result from bacteria traveling from the pelvis directly to the liver or via the bloodstream or lymphatic system. Fitz-Hugh-Curtis syndrome is characterized by the developed of string-like, fibrous scar tissue (adhesions) between the liver and the abdominal wall or the diaphragm.

Laparoscopy is the gold standard for diagnosing FHCS and PID. In the setting of PID, laparoscopy can show oedema with exudates on tubal surfaces, ectopic pregnancy, or tubo-ovarian abscess. FHCS can be diagnosed directly via visualization of adhesions between the diaphragm and liver or liver and the anterior abdominal wall.

Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and are characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapse

Only ,30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:
Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both

Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction

Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction

Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

Quadrantanopia refers to an anopia affecting a quarter of the field of vision. While quadrantanopia can be caused by lesions in the temporal and parietal lobes, it is most commonly associated with lesions in the occipital lobe.
A lesion affecting one side of the temporal lobe may cause damage to the inferior optic radiations (known as the temporal pathway or Meyer’s loop) which can lead to superior quadrantanopia on the contralateral side of both eyes (colloquially referred to as pie in the sky).

Therefore, a left temporal lobe infarct will affect the right superior quadrantanopia.

This patient is a case of fistula-in-ano.

A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening. Fistulae usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome.

Fistula-in-ano is classified into two groups based on its anatomical location.
1. Low fistula: relatively close to the skin and passes through a few or no sphincter muscle fibres, crosses <30% external sphincter
2. High fistula: passes through a large amount of muscle

Assessment of fistula-in-ano includes:
1. Examination of the perineum
2. Digital rectal examination (DRE)
Low, uncomplicated fistulas may not require any further assessment. Other groups will usually require more detailed investigation.
3. Endo-anal USS
4. Ano-rectal MRI scan

Treatment options include:
1. Seton suture
2. Fistulotomy: Low fistulas that are simple should be treated by fistulotomy once the acute sepsis has been controlled. Fistulotomy (where safe) provides the highest healing rates.
3. Anal fistula plugs and fibrin glue
4. Ano-rectal advancement flaps: primarily for high fistulae

Hernia containing Meckel’s diverticulum is termed as Littre’s hernia.

Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. A Littre’s hernia is an abdominal wall hernia that involves the Meckel’s diverticulum which is a congenital outpouching or bulge in the lower part of the small intestine and is a leftover of the umbilical cord.

Management of Littre’s hernia includes resection of the diverticulum followed by herniorrhaphy.

Answer: Perthes disease

Perthes’ disease is a condition affecting the hip joint in children. It is rare (1 in 9,000 children are affected) and we do not clearly understand why it occurs.

Part or all of the femoral head (top of the thigh bone: the ball part of the ball-and-socket hip joint) loses its blood supply and may become misshapen. This may lead to arthritis of the hip in later years.

The earliest sign of Legg-Calvé-Perthes disease (LCPD) is an intermittent limp (abductor lurch), especially after exertion, with mild or intermittent pain in the anterior part of the thigh. LCPD is the most common cause of a limp in the 4- to 10-year-old age group, and the classic presentation has been described as a painless limp.
The patient may present with limited range of motion of the affected extremity. The most common symptom is persistent pain.

Hip pain may develop and is a result of necrosis of the involved bone. This pain may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip may develop adduction flexion contracture. The patient may have an antalgic gait with limited hip motion.
Early radiographic changes may reveal only a nonspecific effusion of the joint associated with slight widening of the joint space, metaphyseal demineralization (decreased bone density around the joint), and periarticular swelling (bulging capsule). This is the acute phase, and it may last 1-2 weeks. Decreasing bone density in and around the joint is noted after a few weeks. Eventually, the disease may progress to collapse of the femoral head, increase in the width of the neck, and demineralization of the femoral head. The final shape of this area depends on the extent of necrosis and the degree of collapse.

The patient has a Weber type A fracture, based on the Danis-Weber classification system for lateral malleolar fractures. It is a stable ankle injury and can, therefore, be managed conservatively. Whilst this patient could also be treated in a below-knee plaster, most clinicians, nowadays, treat this injury in an ankle boot. Patients are also advised to mobilise with the ankle boot as pain allows and can wean themselves off as the symptoms improve.

The Danis-Weber classification system is based on the level of the fibula fracture in relation to the syndesmosis (the connection between the distal ends of the tibia and fibula). The more proximal, the greater the risk of syndesmotic injury and, therefore, fracture instability.

1. Weber type A: fracture below the level of the syndesmosis
2. Weber type B: fracture at the level of the syndesmosis/level of the tibial plafond
3. Weber type C: fracture above the level of the syndesmosis. This includes Maisonneuve fracture (proximal fibula fracture) which can be associated with ankle instability.

Ankle fractures are common. They affect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women have a higher rate post-menopausal (fragility-type fractures). Patients present, following a traumatic event, with a painful, swollen ankle, and reluctance/inability to bear weight.

Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious, then plain radiographs are appropriate. Antero-posterior, lateral, and mortise views are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space, and lateral talar shift all indicate a syndesmotic injury.

When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Unimalleolar Weber type A fractures, by definition, are stable and therefore, can be mobilised fully in an ankle boot.

All of the listed options are true regarding radioiodine therapy, except for the first option. Treatment with radioiodine does not increase the risk of parathyroid carcinoma.

Recurrence of Graves’ disease is treated similar to normal Graves’ disease. However, some patients may need definitive treatment with radioiodine or thyroidectomy. These patients are usually hypothyroid post treatment and are treated with L-thyroxine until their TSH values are within normal parameters.

A thyroglossal duct cyst (TGDC) is the most common mass found in the midline of the neck. The mass is usually located at or below the level of the hyoid bone, although a TGDC can be located anywhere from the foramen cecum to the level of the thyroid gland.
Most patients with a TGDC present with asymptomatic masses in the midline of the neck.
Recurrent inflammation associated with infection of a TGDC is not uncommon. When an infection is present, the cyst often enlarges and an abscess may form. Spontaneous rupture with secondary sinus tract formation can also occur.

The surgical treatment of choice for thyroglossal cysts is the Sistrunk operation, in which an en block resection of the sinus tract and above (including the midportion of the hyoid bone) is performed. Recurrence is approximately 3-5% and is increased by incomplete excision and a history of recurrent infections.

Pancreatitis is inflammation of the pancreas with variable involvement of regional tissues or remote organ systems. Acute pancreatitis (AP) is characterized by severe pain in the upper abdomen and elevation of pancreatic enzymes in the blood. In the majority of patients,
Biliary pancreatitis should always be treated eventually with a cholecystectomy after the process has subsided.
Feeding should be introduced enterally as the patient’s anorexia and pain resolves.
The use of nasogastric aspiration offers no clear advantage in patients with mild AP, but is beneficial in patients with profound pain, severe disease, paralytic ileus, and intractable vomiting.
AP is a mild, self-limiting disease that resolves spontaneously without complications. Patients can be initiated on a low-fat diet initially and need not invariably start their dietary advancement using a clear liquid diet. Systematic reviews and meta-analyses have shown that administration of enteral nutrition may reduce mortality and infectious complications compared with parenteral nutrition. Although the ideal timing to initiate enteral feeding remains undetermined, administration within 48 hours appears to be safe and tolerated.

Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. EDH results from a traumatic head injury, usually with an associated skull fracture and arterial laceration. The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of the haemorrhage in the formation of an epidural hematoma. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient’s preoperative neurologic condition.

Answer: Chondromalacia patellae

Chondromalacia patellae, also known as “runner’s knee,” is a condition where the cartilage on the under surface of the patella (kneecap) deteriorates and softens. This condition is common among young, athletic individuals, but may also occur in older adults who have arthritis of the knee. Chondromalacia is understood as patellar pain in the anterior side of the knee which worsens on sitting for prolonged periods, or going down stairs/slopes, with joint clicking and episodes of pseudo-locking and failure.

Chondromalacia is often seen as an overuse injury in sports, and sometimes taking a few days off from training can produce good results. In other cases, improper knee alignment is the cause and simply resting doesn’t provide relief. The symptoms of runner’s knee are knee pain and grinding sensations, but many people who have it never seek medical treatment.
Chondromalacia patella often occurs when the under surface of the kneecap comes in contact with the thigh bone causing swelling and pain. Abnormal knee cap positioning, tightness or weakness of the muscles associated with the knee, too much activity involving the knee, and flat feet may increase the likelihood of chondromalacia patella.

What are the symptoms of chondromalacia patella?
Dull, aching pain that is felt:

Behind the kneecap
Below the kneecap
On the sides of the kneecap
A feeling of grinding when the knee is flexed may occur. This can happen:

Doing knee bends
Going down stairs
Running down hill
Standing up after sitting for awhile

Based on the aforementioned findings in this case, the most likely diagnosis is medullary carcinoma of the thyroid associated with multiple endocrine neoplasia (MEN).

Medullary thyroid cancer is a tumour of the parafollicular cells (C cells) of the thyroid and is neural crest in origin. It may be familial and occur as part of the MEN 2A disease spectrum. Less than 10% of thyroid cancers are of this type with patients typically presenting as children or young adults. Diarrhoea occurs in 30% of the cases. In association with MEN syndromes, medullary thyroid cancers are always bilateral and multicentric. Spread may either be lymphatic or haematogenous, and as these tumours are not derived primarily from thyroid cells, they are not responsive to radioiodine.

Toxic nodular goitre is very rare. In sporadic medullary carcinoma of the thyroid, patients typically present with a unilateral solitary nodule and it tends to spread early to the lymph nodes in neck.

Acute subdural hematoma is usually caused by external trauma that creates tension in the wall of a bridging vein as it passes between the arachnoid and dural layers of the brain’s lining—i.e., the subdural space. The circumferential arrangement of collagen surrounding the vein makes it susceptible to such tearing.

Acute bleeds often develop after high-speed acceleration or deceleration injuries. They are most severe if associated with cerebral contusions. Though much faster than chronic subdural bleeds, acute subdural bleeding is usually venous and therefore slower than the arterial bleeding of an epidural haemorrhage. Acute subdural hematomas due to trauma are the most lethal of all head injuries and have a high mortality rate if they are not rapidly treated with surgical decompression. The mortality rate is higher than that of epidural hematomas and diffuse brain injuries because the force required to cause subdural hematomas tends to cause other severe injuries as well.

Generally, acute subdural hematomas are less than 72 hours old and are hyperdense compared with the brain on computed tomography scans. The subacute phase begins 3-7 days after acute injury. Chronic subdural hematomas develop over the course of weeks and are hypodense compared with the brain. However, subdural hematomas may be mixed in nature, such as when acute bleeding has occurred into a chronic subdural hematoma.
Lateralizing findings include ipsilateral pupillary dilatation with impaired reaction and motor deficit. Usually the pupillary dilatation will be ipsilateral and motor deficit (hemiparesis or hemiplegia) will be contralateral to the site of subdural hematoma.

An anal fistula is an abnormal tract between the anal canal and the skin around the anus.
Anal fistulas can be classified according to their relationship with the external sphincter. A fistula may be complex, with several openings onto the perianal skin. Intersphincteric fistulas are the most common type and cross only the internal anal sphincter. Trans-sphincteric fistulas pass through both the internal and external sphincters.

The aim is to drain the infected material and encourage healing.
For simple intersphincteric and low trans-sphincteric anal fistulas, the most common treatment is a fistulotomy or laying open of the fistula tract.
For high and complex (deeper) fistulas that involve more muscle, with a high risk of faecal incontinence or recurrence, surgery aims to treat the fistula and preserve sphincter-muscle function. Techniques include a 1‑stage or 2‑stage seton (suture material or rubber sling) either alone or in combination with fistulotomy, ligation of an intersphincteric fistula tract, creating a mucosal advancement flap, injecting glue or paste, or inserting a fistula plug .

Sentinel lymph node biopsy has become the gold standard for axillary staging for patients with clinically and radiologically node negative axilla. The recommended technique is the dual technique of blue dye/radioisotope and this is associated with high sentinel node identification rates (> 95 %). However, in centres where radioisotope is not available, blue dye guided four node sampling appears to be a reasonable alternative. Sentinel node biopsy was shown to be an accurate technique for axillary node staging in the ALMANAC Trial with less associated morbidity and strong health economic arguments for its use.

The tumour in this patient is small so a wide local excision should be done.
Lumpectomy or breast wide local excision is a surgical removal of a discrete portion or lump of breast tissue, usually in the treatment of a malignant tumour or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumours.

Anal fissure is a tear in the anoderm distal to the dentate line. It is the most common cause of severe anal pain. It is equally one of the most common reasons for bleeding per anus in infants and young children. The pain of an anal ulcer is intolerable and always disproportionate to the severity of the physical lesion. It may be so severe that patients may avoid defecation for days together until it becomes inevitable. This leads to hardening of the stools, which further tear the anoderm during defecation, setting a vicious cycle. The fissures can be classified into 1] Acute or superficial and 2] Chronic fissure in ano.

Initial therapy for an anal fissure is medical, and more than 80% of acute anal fissures resolve without further therapy.
The goals of treatment are to relieve the constipation and to break the cycle of hard bowel movement, associated pain, and worsening constipation. Softer bowel movements are easier and less painful for the patient to pass.

First-line medical therapy consists of therapy with stool-bulking agents, such as fibre supplementation and stool softeners. Laxatives are used as needed to maintain regular bowel movements. Mineral oil may be added to facilitate passage of stool without as much stretching or abrasion of the anal mucosa, but it is not recommended for indefinite use. Sitz baths after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm.
Recurrence rates are in the range of 30-70% if the high-fibre diet is abandoned after the fissure is healed. This range can be reduced to 15-20% if patients remain on a high-fibre diet.

Second-line medical therapy consists of intra-anal application of 0.4% nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to the internal sphincter.
Some physicians use NTG ointment as initial therapy in conjunction with fibre and stool softeners, and others prefer to add it to the medical regimen if fibre and stool softeners alone fail to heal the fissure. NTG ointment is thought to relax the internal sphincter and to help relieve some of the pain associated with sphincter spasm; it also is thought to increase blood flow to the anal mucosa.
Unfortunately, many people cannot tolerate the adverse effects of NTG, and as a result, its use is often limited. The main adverse effects are headache and dizziness; therefore, patients should be instructed to use NTG ointment for the first time in the presence of others or directly before bedtime.
Analogous to the use of NTG intra-anal ointment, nifedipine ointment is also available for use in clinical trials. It is thought to have similar efficacy to NTG ointment but with fewer adverse effects.

Botulinum toxin has been used to treat acute and chronic anal fissures. It is injected directly into the internal anal sphincter, in effect performing a chemical sphincterotomy. The effect lasts about 3 months, until nerve endings regenerate. This 3-month period may allow acute fissures (and sometimes chronic fissures) to heal and symptoms to resolve. If botulinum toxin injection provides initial relief of symptoms but there is a recurrence after 3 months, the patient may benefit from surgical sphincterotomy.

Surgical therapy is usually reserved for acute anal fissures that remain symptomatic after 3-4 weeks of medical therapy and for chronic anal fissures.
Sphincter dilatation
Lateral internal sphincterotomy

Tuberous sclerosis is a genetic disorder characterized by the growth of numerous noncancerous (benign) tumours in many parts of the body. These tumours can occur in the skin, brain, kidneys, and other organs, in some cases leading to significant health problems. Tuberous sclerosis also causes developmental problems, and the signs and symptoms of the condition vary from person to person.

Virtually all affected people have skin abnormalities, including patches of unusually light-coloured skin, areas of raised and thickened skin, and growths under the nails. Tumours on the face called facial angiofibromas are also common beginning in childhood.

Tuberous sclerosis often affects the brain, causing seizures, behavioural problems such as hyperactivity and aggression, and intellectual disability or learning problems. Some affected children have the characteristic features of autism, a developmental disorder that affects communication and social interaction. Benign brain tumours can also develop and these tumours can cause serious or life-threatening complications.

Kidney tumours are common in people with tuberous sclerosis; these growths can cause severe problems with kidney function and may be life-threatening in some cases. Additionally, tumours can develop in the heart, lungs, and the retina.

Multiple endocrine neoplasia type 2 (MEN2) is a hereditary condition associated with 3 primary types of tumours: medullary thyroid cancer, parathyroid tumours, and pheochromocytoma. MEN2 is classified into subtypes based on clinical features. Virtually all patients with classical MEN2A develop medullary thyroid carcinoma (MTC), which is often the first manifestation of the disease and usually occurs early in life. Pheochromocytomas (PHEOs) tend to be diagnosed several years later or simultaneously with the MTC.

Answer: Measurement of faecal calprotectin

Based on Rome criteria, this patient has Irritable Bowel Syndrome (IBS). Irritable bowel syndrome (IBS) is a group of symptoms—including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage. These symptoms occur over a long time, often years. It has been classified into four main types depending on whether diarrhoea is common or constipation is common, or both are common, or neither occurs very often (IBS-D, IBS-C, IBS-M, or IBS-U respectively). IBS negatively affects quality of life and may result in missed school or work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

The recommendations for physicians are to minimize the use of medical investigations. Rome criteria are usually used. They allow the diagnosis to be based only on symptoms, but no criteria based solely on symptoms is sufficiently accurate to diagnose IBS. Worrisome features include onset at greater than 50 years of age, weight loss, blood in the stool, iron-deficiency anaemia, or a family history of colon cancer, celiac disease, or inflammatory bowel disease. The criteria for selecting tests and investigations also depends on the level of available medical resources.

Rome criteria
The Rome IV criteria includes recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria:

Related to defecation
Associated with a change in frequency of stool
Associated with a change in form (appearance) of stool.
Physicians may choose to use one of these guidelines or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against misdiagnosis of other diseases as IBS. Such red flag symptoms may include weight loss, gastrointestinal bleeding, anaemia, or nocturnal symptoms. However, red flag conditions may not always contribute to accuracy in diagnosis; for instance, as many as 31% of people with IBS have blood in their stool, many possibly from hemorrhoidal bleeding.

The diagnostic algorithm identifies a name that can be applied to the person’s condition based on the combination of symptoms of diarrhoea, abdominal pain, and constipation. For example, the statement 50% of returning travellers had developed functional diarrhoea while 25% had developed IBS would mean half the travellers had diarrhoea while a quarter had diarrhoea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested all people with IBS have the same underlying disease but with different symptoms

The main diseases that cause an increased excretion of faecal calprotectin are inflammatory bowel diseases, coeliac disease, infectious colitis, necrotizing enterocolitis, intestinal cystic fibrosis and colorectal cancer.

Although a relatively new test, faecal calprotectin is regularly used as indicator for inflammatory bowel diseases (IBD) during treatment and as diagnostic marker. IBD are a group of conditions that cause a pathological inflammation of the bowel wall. Crohn’s disease and ulcerative colitis are the principal types of inflammatory bowel disease. Inflammatory processes result in an influx of neutrophils into the bowel lumen. Since calprotectin comprises as much as 60% of the soluble protein content of the cytosol of neutrophils, it can serve as a marker for the level of intestinal inflammation. Measurement of faecal calprotectin has been shown to be strongly correlated with 111-indium-labelled leucocytes – considered the gold standard measurement of intestinal inflammation. Levels of faecal calprotectin are usually normal in patients with irritable bowel syndrome (IBS). In untreated coeliac disease, concentration levels of faecal calprotectin correlate with the degree of intestinal mucosal lesion and normalize with a gluten-free diet.

Faecal calprotectin is measured using immunochemical techniques such as ELISA or immunochromatographic assays. The antibodies used in these assays target specific epitopes of the calprotectin molecule.

Gallbladder ultrasonography should be considered if the patient has recurrent dyspepsia or characteristic postprandial pain.

Abdominal computed tomography (CT) scanning is appropriate to screen for tumours, obstruction, and pancreatic disease if these are diagnostic possibilities.

CT and magnetic resonance (MR) enterography or wireless capsule endoscopy are employed if red flags exist to suggest enteritis (small bowel inflammation) or a tumour.

Colonoscopy is appropriate if alarm symptoms are present and in patients who otherwise qualify for screening colonoscopy.