Diagnostic Tests for Achalasia: Oesophageal Manometry Study and Other Modalities

Achalasia is a motility disorder of the oesophagus that causes progressive dysphagia for liquids and solids, accompanied by severe chest pain. While it is usually idiopathic, it can also be secondary to Chagas’ disease or oesophageal cancer. The diagnosis of achalasia is confirmed through oesophageal manometry, which reveals an abnormally high lower oesophageal sphincter tone that fails to relax on swallowing.

Other diagnostic modalities include a barium swallow study, which may show a classic bird’s beak appearance, but is not confirmatory. A CT scan of the thorax may show a dilated oesophagus with food debris, but is also not enough for diagnosis. Upper GI endoscopy with biopsy is needed to rule out mechanical obstruction or pseudo-achalasia.

Treatment for achalasia is mainly surgical, but botulinum toxin injection or pharmacotherapy may be tried in those unwilling to undergo surgery. Drugs used include calcium channel blockers, long-acting nitrates, and sildenafil. Oesophageal pH monitoring is useful in suspected gastro-oesophageal reflux disease (GORD), but is not diagnostic for achalasia.

In summary, oesophageal manometry is the best confirmatory test for suspected cases of achalasia, and other diagnostic modalities are used to rule out other conditions. Treatment options include surgery, botulinum toxin injection, and pharmacotherapy.

Differential diagnosis of jaundice: considering cholangiocarcinoma, malaria, haemolytic anaemia, acute cholecystitis, and pancreatitis

Jaundice is a common clinical manifestation of various diseases, including liver, biliary, and haematological disorders. When evaluating a patient with jaundice, it is important to consider the differential diagnosis based on the clinical features and risk factors. One rare but important cause of jaundice is cholangiocarcinoma, a cancer of the bile ducts that typically presents with painless progressive jaundice, hepatomegaly, and risk factors such as male gender, age over 50, and certain liver diseases. However, other conditions such as malaria and haemolytic anaemia can also cause pre-hepatic jaundice, which is characterized by elevated bilirubin levels but normal urine and stool colours. Acute cholecystitis, on the other hand, typically presents with severe abdominal pain, fever, and signs of inflammation, while pancreatitis is characterized by epigastric pain, fever, and elevated pancreatic enzymes. Therefore, a thorough history, physical examination, and laboratory tests are necessary to differentiate these conditions and guide appropriate management.

Portal Hypertension and Varices in Alcoholic Cirrhosis

The portal vein is responsible for carrying blood from the gut and spleen to the liver. In cases of alcoholic cirrhosis, this flow can become obstructed, leading to increased pressure and the need for blood to find alternative routes. This often results in the development of porto-systemic collaterals, with the gastro-oesophageal junction being the most common site. As a result, patients with alcoholic cirrhosis often present with varices, which are superficial and prone to rupture, causing acute and massive haematemesis.

To prevent rebleeding and reduce portal pressures, beta blockers such as propranolol have been found to be the most effective treatment for portal hypertension. Propranolol is licensed for this purpose and can help manage the complications associated with varices in alcoholic cirrhosis.

Differentiating Primary Sclerosing Cholangitis from Other Liver Conditions

Primary sclerosing cholangitis (PSC) is a condition that affects around 4% of patients with a history of inflammatory bowel disease. It is characterized by an obstructive liver function test (LFT) picture and autoantibody results consistent with PSC. While endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for diagnosis, magnetic resonance cholangiopancreatography (MRCP) is now equally useful. Imaging typically shows a beaded appearance of biliary ducts, and liver biopsy may be useful in determining prognosis. Median survival from diagnosis to death or liver transplantation is around 10-15 years, with a disease recurrence rate of at least 30% in transplanted patients.

Cholelithiasis, on the other hand, typically presents with colicky abdominal pain and does not usually cause jaundice unless there is obstruction of the biliary system. Hepatocellular carcinoma risk is increased in patients with inflammatory bowel disease, but the clinical picture above is more in keeping with PSC. Primary biliary cholangitis would show positive anti-mitochondrial antibodies and mainly affect intrahepatic ducts, while ascending cholangitis would usually present with features of Charcot’s triad (jaundice, abdominal pain, and fever).

Treatment Options for Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that affects the rectum and may spread to the colon. The main symptom is bloody diarrhea, and the disease follows a relapsing and remitting course. The goal of UC management is to treat acute relapses, prevent relapses, and detect cancers early.

Mesalazine is an effective first-line treatment for mild to moderate UC, which involves enemas and oral medication. For moderately active cases, oral aminosalicylates, topical aminosalicylates, and corticosteroids are used. Azathioprine is an immunomodulator that is rarely used to induce remission but is used to keep patients in remission. Hydrocortisone is a systemic steroid used for severe cases. Infliximab is an anti-tumor necrosis factor biologic used for moderate to severe cases that are refractory to standard treatment. Methotrexate is an alternative immunomodulator for patients who cannot tolerate azathioprine. It is important to discuss adequate contraception with patients on methotrexate due to its teratogenicity.

Understanding Treatment Options for Ulcerative Colitis

Understanding Gastrointestinal Conditions: A Comparison of Ulcerative Colitis, Colon Carcinoma, Acute Diverticulitis, Crohn’s Disease, and Irritable Bowel Syndrome

Gastrointestinal conditions can be challenging to differentiate due to their overlapping symptoms. This article aims to provide a comparison of five common gastrointestinal conditions: ulcerative colitis, colon carcinoma, acute diverticulitis, Crohn’s disease, and irritable bowel syndrome.

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that presents with bloody diarrhea as its main feature. Hip pain is also a common extra-intestinal manifestation in this condition.

Colon carcinoma, on the other hand, has an insidious onset and is characterized by weight loss, iron-deficiency anemia, and altered bowel habits. It is usually detected through screening tests such as FOBT, FIT, or flexible sigmoidoscopy.

Acute diverticulitis is a condition that affects older people and is caused by chronic pressure from constipation due to low dietary fiber consumption. It presents with abdominal pain and blood in the stool, but mucous is not a common feature.

Crohn’s disease is another type of IBD that presents with abdominal pain and diarrhea. However, bloody diarrhea is not common. Patients may also experience weight loss, fatigue, and extra-intestinal manifestations such as oral ulcers and perianal involvement.

Irritable bowel syndrome (IBS) is a gastrointestinal condition characterized by episodes of diarrhea and constipation, as well as flatulence and bloating. Abdominal pain is relieved upon opening the bowels and passing loose stools. IBS is different from IBD and is often associated with psychological factors such as depression and anxiety disorders.

In conclusion, understanding the differences between these gastrointestinal conditions is crucial for accurate diagnosis and appropriate management.

Autoimmune Liver Diseases: Differentiating PBC, PSC, and AIH

Autoimmune liver diseases, including primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH), can present with non-specific symptoms and insidious onset. However, certain demographic and serological markers can help differentiate between them.

PBC is characterized by chronic granulomatous inflammation of small intrahepatic bile ducts, leading to progressive cholestasis, cirrhosis, and portal hypertension. It is often diagnosed incidentally or presents with lethargy and pruritus. AMA M2 subtype positivity is highly specific for PBC, and treatment involves cholestyramine for itching and ursodeoxycholic acid. Liver transplantation is the only curative treatment.

PSC is a disorder of unknown etiology characterized by non-malignant, non-bacterial inflammation, fibrosis, and strictures of the intra- and extrahepatic biliary tree. It is more common in men and frequently found in patients with ulcerative colitis. AMA is negative, and diagnosis is based on MRCP or ERCP showing a characteristic beaded appearance of the biliary tree.

AIH is a disorder of unknown cause characterized by autoantibodies directed against hepatocyte surface antigens. It can present acutely with signs of fulminant autoimmune disease or insidiously. There are three subtypes with slightly different demographic distributions and prognoses, and serological markers such as ASMA, anti-LKM, and anti-soluble liver antigen antibodies can help differentiate them.

A hepatitis screen is negative in this case, ruling out hepatitis C. A pancreatic head tumor would present with markedly elevated bilirubin and a normal autoimmune screen.

Pancreatic carcinoma is characterized by painless jaundice and weight loss, particularly in the head of the pancreas where a growing mass can compress or infiltrate the common bile duct. This can cause pale stools and dark urine, as well as malaise and anorexia. Acute cholecystitis, on the other hand, presents with sudden right upper quadrant pain and fevers, with tenderness and a positive Murphy’s sign. Chronic pancreatitis often causes weight loss, steatorrhea, and diabetes symptoms, as well as chronic or acute-on-chronic epigastric pain. Gallstone obstruction results in acute colicky RUQ pain, with or without jaundice depending on the location of the stone. Hepatitis A typically presents with a flu-like illness followed by jaundice, fevers, and RUQ pain, with risk factors for acquiring the condition and no pale stools or dark urine.

Differential diagnosis for a young patient with bloody diarrhoea and left lower quadrant pain

Explanation:

A young patient presents with frequent episodes of bloody diarrhoea, tenesmus, and left lower quadrant tenderness. The differential diagnosis includes several conditions that affect the large bowel, such as inflammatory bowel disease (ulcerative colitis or Crohn’s disease), Clostridium difficile infection, colorectal cancer, diverticulitis, and irritable bowel syndrome.

To confirm the diagnosis and distinguish between ulcerative colitis and Crohn’s disease, sigmoidoscopy or colonoscopy with biopsies will be needed. C. difficile infection is unlikely in this case, as the patient does not have risk factors such as recent antibiotic use, older age, recent hospital stay, or proton pump inhibitor use.

Colorectal cancer is also unlikely given the patient’s age, but inflammatory bowel disease, especially ulcerative colitis, increases the risk for colorectal cancer later in life. Therefore, it is important to ask about a family history of cancer and perform appropriate investigations.

Diverticulitis is another possible cause of left lower quadrant pain, but it is uncommon in young people, and symptomatic diverticula are rare below the age of 40. Most people have diverticula by the age of 50, but they are often asymptomatic unless they become inflamed, causing fever and tachycardia.

Finally, irritable bowel syndrome may cause bleeding from trauma to the perianal area, but the bleeding is usually small in volume and not mixed in with the stool. Therefore, this condition is less likely to explain the patient’s symptoms of bloody diarrhoea and left lower quadrant pain.

The Diaphragm and its Openings: A Vertebral Level Guide

The diaphragm is a dome-shaped muscle that separates the thoracic and abdominal cavities. It plays a crucial role in breathing and also contains several openings for important structures to pass through. Here is a guide to the vertebral levels of the diaphragm openings:

T10 – Oesophageal Hiatus: This opening allows the oesophagus to pass through and is located at the T10 vertebral level. A helpful mnemonic is that ‘oesophagus’ contains 10 letters.

T7 – No Openings: There are no openings of the diaphragm at this level.

T8 – Caval Opening: The caval opening is located at the T8 vertebral level and allows the inferior vena cava to pass through. A useful way to remember this is that ‘vena cava’ has 8 letters.

T11 – Oesophagus and Stomach: The oesophagus meets the cardia of the stomach at approximately this level.

T12 – Aortic Hiatus: The aortic hiatus is located at the T12 vertebral level and allows the descending aorta to pass through. A helpful mnemonic is that ‘aortic hiatus’ contains 12 letters.

Knowing the vertebral levels of the diaphragm’s openings can be useful for understanding the anatomy of the thoracic and abdominal cavities.