Diagnosing Pancreatic Adenocarcinoma: Understanding the Symptoms and Differential Diagnosis

Pancreatic adenocarcinoma is a serious condition that requires prompt diagnosis and treatment. One of the key symptoms of this condition is painless jaundice, which is often accompanied by weight loss. This is due to the obstructive jaundice that occurs when the tumor is located at the head of the pancreas. Other symptoms may include pale stools and dark urine.

It is important to note that patients may present with these symptoms before experiencing abdominal pain. This is why it is crucial to refer any patient aged 40 years and over with jaundice for suspected pancreatic cancer, according to National Institute for Health and Care Excellence (NICE) guidance.

When considering a differential diagnosis, gallstone obstruction and cholecystitis can be ruled out due to the absence of severe abdominal pain. Chronic pancreatitis is also unlikely due to the lack of abdominal pain and the rarity of jaundice as a symptom. Hepatitis A may present with similar symptoms, but abdominal pain occurs in only 40% of patients.

In conclusion, understanding the symptoms and differential diagnosis of pancreatic adenocarcinoma is crucial for prompt diagnosis and treatment. Any patient with jaundice should be referred for suspected pancreatic cancer, regardless of other symptoms.

Gastro-oesophageal Reflux and its Potential Consequences

The patient’s medical history indicates a prolonged period of gastro-oesophageal reflux, which can lead to the development of Barrett’s oesophagus. This condition occurs when the normal squamous epithelium of the oesophageal lining is replaced by columnar epithelium, which is a precursor to cancer. To monitor for the presence of metaplasia, surveillance endoscopies are recommended every two to five years, depending on the length of the Barrett’s segment. If dysplasia is detected, more frequent surveillance or treatment may be necessary.

The onset of dysphagia for solids and weight loss is concerning, as it may indicate the presence of oesophageal carcinoma.

Safe and Unsafe Grains for a Gluten-Free Diet

Following a gluten-free diet can be challenging, especially when it comes to grains. If you have celiac disease or gluten intolerance, it’s important to avoid wheat, rye, and barley as they contain gluten. However, there are still plenty of safe grains to choose from. Maize, rice, millet, and potatoes are all gluten-free and can be enjoyed without worry. By making simple substitutions and being mindful of ingredients, you can still enjoy a varied and delicious diet while avoiding gluten.

Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.

An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.

The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.

The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.

Detecting Ovarian Cancer: A Challenging Diagnosis

Detecting ovarian cancer can be a challenging diagnosis as the symptoms are often vague, especially in the early stages of the disease. However, there are certain risk factors and cardinal symptoms that can help in identifying the disease. Women with a family history of breast cancer, carriers of the BRCA1 and BRCA2 gene, and Polish women are at an increased risk of ovarian cancer. Patients presenting with persistent bloating, abdominal or pelvic pain, and difficulty in eating or fullness after eating small quantities of food should be evaluated for ovarian cancer.

NICE recommends that women over the age of 50 who have one or more symptoms associated with ovarian cancer occurring more than 12 times a month or for more than a month should be offered CA125 testing. If the CA125 is 35 IU/mL or greater, an urgent ultrasound scan of the pelvis should be arranged. Therefore, performing a pelvic examination and arranging testing for CA125 is the most appropriate way forward for patients with symptoms suggestive of ovarian cancer. Early detection and prompt treatment can improve the prognosis of ovarian cancer.

Monash University in Australia has recently introduced a low-FODMAP diet for managing irritable bowel syndrome (IBS). FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine, leading to water intake and diarrhea or fermentation by bacteria causing bloating in the large bowel. A low-FODMAP diet has been found to reduce IBS symptoms such as bloating, abdominal pain, and irregular bowel habits. However, it is a challenging diet to follow as it excludes many foods containing Oligo-, Di-, Mono-saccharides and Polyols, including wheat, dairy, pulses, excess fructose, and some vegetables. Therefore, it is recommended to seek the advice of a dietician.

The LOFFLEX diet, which stands for low fat/fibre exclusion diet, has been developed for individuals with Crohn’s disease. It is often used after the elemental diet to maintain remission by avoiding high-fiber and high-fat foods that can trigger Crohn’s. The ketogenic diet has been shown to improve seizure control in people with epilepsy, particularly in children who are under the supervision of a pediatric dietician and have drug-resistant epilepsy. The specific carbohydrate and paleo diets are popular new diet trends that GPs may encounter, both of which significantly limit carbohydrate intake in the diet.

Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.

Diagnostic Tests for Coeliac Disease

Coeliac disease is an autoimmune disorder of the small bowel induced by gluten. The gold standard for diagnosis is the detection of subtotal villous atrophy on a small-bowel biopsy. However, the detection of tissue transglutaminase IgA antibodies is a widely used screening test with high specificity and sensitivity. Total immunoglobulin A (IgA) should also be measured in case of IgA deficiency. Antibodies become undetectable after 6-12 months of a gluten-free diet, making them useful for monitoring the disease. The xylose absorption test is not appropriate for this patient, while the detection of anti-gliadin antibodies and anti-endomysial antibodies can aid diagnosis but are not preferred methods. Serology for anti-tissue transglutaminase antibodies is the first-line screening test and aids referral to gastroenterology.

Understanding Coeliac Disease and the Importance of a Gluten-Free Diet

Coeliac disease affects 1 in 100 people, with a higher prevalence of 1 in 10 for those with a first-degree relative who has the condition. Patients with Coeliac disease must adhere to a strict gluten-free diet to avoid an increased risk of other diseases, such as small bowel lymphoma. Non-compliance with the diet is common, which can lead to symptoms and an increased risk of morbidity.

It is important to understand the general principles of a gluten-free diet, including the risk of contamination from cross-contamination and food additives. Some items that may contain gluten, such as baking powder, stock cubes, and soy sauce, may not be obvious and should be avoided. On the other hand, there are many safe, naturally gluten-free cereals, such as rice flour, tapioca flour, and cornmeal.

Checking a patient’s diet, compliance, and understanding is as important as checking inhaler technique in an asthmatic. While a detailed knowledge of a gluten-free diet is not expected, a broad understanding of the general principles is necessary to provide proper care for patients with Coeliac disease.

Managing Coeliac Disease with a Gluten-Free Diet

Coeliac disease is a condition that requires the management of a gluten-free diet. Gluten-containing cereals such as wheat, barley, rye, and oats must be avoided. However, some patients with coeliac disease can tolerate oats. Gluten-free foods include rice, potatoes, and corn. Compliance with a gluten-free diet can be checked by testing for tissue transglutaminase antibodies.

Patients with coeliac disease often have functional hyposplenism, which is why they are offered the pneumococcal vaccine. Coeliac UK recommends that patients with coeliac disease receive the pneumococcal vaccine and have a booster every five years. influenza vaccine is given on an individual basis according to current guidelines.

Overall, managing coeliac disease requires strict adherence to a gluten-free diet and regular immunisation to prevent infections.

Indications for Surgical Repair of Hiatus Hernia

Indications for surgical repair of hiatus hernia include recurrent respiratory tract infection due to reflux. It is also considered in patients who have a para-oesophageal hernia because of the risk of strangulation.

Given this patient’s young age and the fact that he has attended twice in six months with symptoms of respiratory tract infection, surgical referral for laparoscopic fundoplication is advised. This procedure can help alleviate symptoms of reflux and prevent further respiratory tract infections. It is important to consider surgical intervention in cases where conservative management has failed or when there is a risk of complications such as strangulation. Proper evaluation and management of hiatus hernia can improve the quality of life for patients and prevent potential complications.

Differential Diagnosis of Acute Upper Abdominal Pain

Acute upper abdominal pain can have various causes, and it is important to differentiate between them to provide appropriate treatment. Here are some possible diagnoses based on the given symptoms:

1. Acute pancreatitis: This condition is often caused by gallstones or alcohol consumption and presents with severe upper abdominal pain. Blood tests show elevated amylase levels, and immediate hospital admission is necessary.

2. Budd-Chiari syndrome: This rare condition involves the blockage of the hepatic vein and can cause right upper abdominal pain, hepatomegaly, and ascites.

3. Acute cholecystitis: This condition is characterized by localized pain in the upper right abdomen and a positive Murphy’s sign (pain worsened by deep breathing).

4. Perforated duodenal ulcer: This condition can cause sudden upper abdominal pain, but it is usually associated with a history of dyspepsia or NSAID use.

5. Renal colic: This condition causes severe pain in the loin-to-groin area and is often accompanied by urinary symptoms and hematuria.

In conclusion, a thorough evaluation of the patient’s symptoms and medical history is necessary to determine the underlying cause of acute upper abdominal pain.

Paraneoplastic Syndromes Associated with Lung Cancer

Lung cancer can be associated with various paraneoplastic syndromes, which are caused by substances produced by the tumor that affect other parts of the body. One such syndrome is hypercalcemia, which can cause confusion, lethargy, aches and pains, thirst, and constipation. Squamous cell lung carcinoma is particularly associated with ectopic parathyroid hormone production, leading to increased calcium levels.

Other paraneoplastic syndromes associated with lung cancer include Cushing’s syndrome, which can occur with small cell lung cancer due to ectopic ACTH production; Horner’s syndrome, which can occur with apical lung tumors that invade sympathetic nerve fibers, causing ptosis, miosis, and anhydrosis; and Lambert-Eaton syndrome, an autoimmune process associated with small cell lung cancer that causes muscle weakness and hyporeflexia.

Another condition associated with lung cancer is SIADH, which causes hyponatremia and can lead to confusion, seizures, cardiac failure, edema, and muscle weakness. Causes of SIADH include small cell lung cancer, as well as other malignancies, stroke, subarachnoid hemorrhage, vasculitis, TB, and certain drugs like opiates. Understanding these paraneoplastic syndromes can help clinicians identify and manage symptoms in patients with lung cancer.

Differential Diagnosis of Abdominal Pain: A Case Study

The patient presents with abdominal pain, and a differential diagnosis must be considered. The symptoms suggest carcinoma of the body or tail of the pancreas, as obstructive jaundice is not present. The pain is located in the epigastric region and radiates to the back, indicating retroperitoneal invasion of the splanchnic nerve plexus by the tumour.

Cholangiocarcinoma, a malignancy of the biliary duct system, is unlikely as jaundice is not present. Pain in the right upper quadrant may occur in advanced disease. Early gastric carcinoma often presents with symptoms of uncomplicated dyspepsia, while advanced disease presents with weight loss, vomiting, anorexia, upper abdominal pain, and anaemia.

Peptic ulcer disease is a possibility, with epigastric pain being the most common symptom. Duodenal ulcer pain often awakens the patient at night, and pain with radiation to the back can occur with posterior penetrating gastric ulcer complicated by pancreatitis. However, the presence of weight loss makes pancreatic carcinoma more likely.

Zollinger-Ellison syndrome, caused by a non-beta-islet-cell, gastrin-secreting tumour of the pancreas, is also a possibility. Epigastric pain due to ulceration is a common symptom, particularly in sporadic cases and in men. Diarrhoea is the most common symptom in patients with multiple endocrine neoplasia type 1, as well as in female patients.

In conclusion, the differential diagnosis of abdominal pain in this case includes carcinoma of the pancreas, peptic ulcer disease, and Zollinger-Ellison syndrome. Further diagnostic tests are necessary to confirm the diagnosis and determine the appropriate treatment plan.

Coeliac disease is associated with hypo-, rather than hypersplenism.

Understanding Coeliac Disease

Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.

To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.

Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.

The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.

Urgent Referral for Patient with Change in Bowel Habit

This patient requires urgent referral as he is over 60 years old and has experienced a change in bowel habit. According to NICE guidelines, the only test that may be helpful in this case is a full blood count, which can be performed alongside the referral. This will ensure that the result is available for the specialist in clinic.

NICE guidelines recommend testing for occult blood in faeces to assess for colorectal cancer in adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss, or are aged 60 and over and have anaemia even in the absence of iron deficiency. However, in this case, there has been no history of weight loss or abdominal pain, and the patient is not known to be anaemic. Therefore, other tests or investigations are not recommended as they will only serve to delay the process.

Understanding Hepatitis B Test Results

Hepatitis B is a viral infection that affects the liver. Understanding the results of hepatitis B tests is important for proper diagnosis and treatment. Here, we will discuss the different test results and what they mean.

Persistent Carrier with High Infectivity:
If a patient is positive for surface antigen, e-antigen, and core antibody, and negative for surface antibodies and e-antibodies, it suggests chronic carrier status. The presence of e-antigen confers high infectivity, indicating active viral replication. Core antibodies are a marker of past infection and will not be found in vaccinated individuals who have never been infected.

Persistent Carrier with Low Infectivity:
If a patient is positive for surface antigen and core antibody, but negative for e-antigen and e-antibodies, it suggests a moderately high viral load and elevated ALT levels. This is caused by a hepatitis B virus that has certain mutations (pre-core mutation) that allow the virus to replicate even when the e-antigen is absent.

Previous Vaccination against Hepatitis B:
If a patient has surface antibodies but not core antibodies, it indicates previous vaccination against hepatitis B.

Spontaneously Cleared Infection:
If a patient has lost surface antigen and developed surface antibodies, it marks seroconversion and indicates immunity. If IgM antibodies to core antigen (anti-HBc IgM) are present, it indicates recent infection.

In conclusion, understanding hepatitis B test results is crucial for proper diagnosis and treatment. Consultation with a healthcare provider is recommended for interpretation of test results and appropriate management.

Urgent Referral for Upper GI Cancer in H. pylori Positive Patient

This patient is showing red flag symptoms and signs that suggest upper GI cancer, including weight loss and poor appetite. Despite being Helicobacter pylori positive, urgent referral for upper GI endoscopy or to a specialist in upper GI cancer should not be delayed. An ultrasound scan is unlikely to be helpful, and prescribing a PPI should be avoided as it can mask underlying disease. It is important to prioritize urgent referral over prescribing eradication therapy for H. pylori, as the latter may delay the diagnosis of underlying pathology. By promptly referring the patient for further evaluation, healthcare providers can ensure timely diagnosis and treatment of potential upper GI cancer.

Understanding Bacterial Food Poisoning: Causes and Symptoms

Bacterial food poisoning is a common problem that can result from consuming contaminated food or water. Among the different types of bacteria that can cause food poisoning, Staphylococcus aureus, Bacillus cereus, Yersinia, Campylobacter, and Salmonella are the most common. Each of these bacteria has its own unique characteristics and symptoms.

Staphylococcus aureus is known to multiply rapidly in foods that are rich in carbohydrates and salt, such as dairy products, ice cream, cold meats, or mayonnaise. It produces a heat-stable endotoxin that causes nausea, vomiting, and diarrhea within 1-6 hours of ingestion.

Bacillus cereus infection is associated with slow-cooked food and reheated rice. The bacterium produces an emetic toxin that leads to vomiting within 1-5 hours. It can be difficult to distinguish from other short-term bacterial foodborne intoxications such as by Staphylococcus aureus.

Yersinia infection results in diarrhea some 3-10 days after contact and presents with bloody diarrhea, abdominal pain, and fever. The organism is acquired usually by insufficiently cooked pork or contaminated water, meat, or milk.

Campylobacter infection has an incubation period of 2-5 days and results in flu-like symptoms, abdominal pain, and diarrhea. It is the most common bacterium that causes food poisoning in the UK.

Salmonella infection normally leads to a picture of acute gastroenteritis with fever, abdominal cramps, and diarrhea between 12-36 hours after the ingestion of infected food. Infection occurs from a wide variety of infected foods that usually look and smell normal.

It is important for registered medical practitioners to notify the “proper officer” at their local council or local health protection team of suspected cases of food poisoning. By understanding the causes and symptoms of bacterial food poisoning, individuals can take steps to prevent infection and seek prompt medical attention if necessary.

Drugs that can cause gynaecomastia

Research has shown that the risk of developing gynaecomastia is almost insignificant when using other drugs as part of the treatment of Zollinger-Ellison syndrome. However, there are other drugs that can cause gynaecomastia, including spironolactone, digoxin, methyldopa, gonadotrophins, and cyproterone acetate.

Zollinger-Ellison syndrome is a condition where a gastrin-secreting pancreatic adenoma is associated with peptic ulcer, and 50-60% of cases are malignant. It is suspected in patients with multiple peptic ulcers that are resistant to drugs and occurs in approximately 0.1% of patients with duodenal ulcer disease.

A case study into male gynaecomastia has shown that spironolactone induced gynaecomastia by blocking androgen production, blocking androgens from binding to their receptors, and increasing both total and free oestrogen levels. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare professional.

Understanding the Risk Factors for Colonic Adenocarcinoma in Ulcerative Colitis Patients

Colonic adenocarcinoma is a serious complication that can develop in 3-5% of patients with ulcerative colitis (UC). The cancer tends to be multicentric and atypical in appearance, and it can rapidly metastasize. To prevent this, it is important to understand the risk factors associated with the onset of the disease in childhood.

One of the main risk factors for colon cancer in colitis is the early age of onset, which is before the age of 15 years. Other risk factors include extensive disease (pancolitis), duration (more than ten years), and unremitting disease. Colonoscopic surveillance is recommended for all patients, starting about ten years after the onset of symptoms.

It is important to note that annual relapses are not a risk factor for colonic carcinoma since there is remittance in between episodes. Chronic active inflammation and unremitting disease are the main risk factors.

Left-sided colitis is also a risk factor, but extensive disease and pancolitis carry a higher risk of developing colon cancer. Poor compliance with therapy is not a risk factor in itself, but unremitting disease is a risk factor for colon cancer in UC.

Finally, patients with proctitis alone do not need colonoscopy surveillance, as they are not at increased risk of developing colon cancer compared to the general population. Understanding these risk factors can help prevent the onset of colonic adenocarcinoma in UC patients.

Treatment of GORD with PPIs and Antacids

When managing GORD patients, mild symptoms occurring less than once a week can be treated with antacids as needed. However, for patients with more frequent symptoms, especially those experiencing daily discomfort, a proton pump inhibitor (PPI) is recommended. Referral for endoscopy is usually unnecessary unless there are alarm features such as unintentional weight loss, dysphagia, GI bleeding, persistent vomiting, or signs of anemia.

Initial treatment for GORD involves a high dose PPI for eight weeks (for endoscopically proven oesophagitis) or four weeks for uninvestigated reflux. The PPI should be taken once daily 30-60 minutes before the first meal of the day. Lansoprazole is an example of a suitable PPI that doesn’t interact with other medications. If there is a partial response, the dose can be increased to twice daily, and the timing of the dose can be adjusted if nocturnal symptoms are troublesome.

If there is no response to PPI treatment, reconsideration of the diagnosis and specialist referral may be necessary. An H2 receptor antagonist can be added to a PPI for patients who have a partial response to PPI treatment. It is important to note that there have been concerns about an interaction between clopidogrel and some PPIs (such as omeprazole) due to a shared metabolic pathway. However, the BNF doesn’t suggest any issue with patients taking Lansoprasole with clopidogrel.

Overall, the treatment of GORD involves a stepwise approach, starting with antacids and progressing to PPIs and other medications as needed. Regular monitoring and adjustment of treatment can help manage symptoms and improve patient outcomes.

Intussusception: A Common Cause of Intestinal Obstruction in Infants

Intussusception is a condition where a section of the bowel folds into itself, causing an obstruction. It is most commonly seen in infants over one month old, with the typical age of presentation being between two months to two years. The most common site of intussusception is the ileum passing into the caecum/colon through the ileocaecal valve.

Symptoms of intussusception include severe colic, pallor, and drawing of legs upwards during episodes of pain. A sausage-shaped mass may be palpable in the abdomen, and parents may notice the passage of a redcurrant jelly stool (blood-stained mucous). In severe cases, children may present with abdominal distention and shock.

The cause of intussusception is not always clear, but viral infections causing enlargement of Peyer’s patches have been implicated in forming a lead point for the development of intussusception. In children over the age of two, a specific lead point (such as a Meckel’s diverticulum or polyp) is more likely.

Men and women who are undergoing methotrexate treatment must use reliable contraception throughout the duration of the treatment and for a minimum of 6 months after it has ended.

Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

NICE Guidelines for Urgent Referral and Faecal Occult Blood Testing in Patients with Change in Bowel Habit

In accordance with NICE guidelines, patients aged 60 years and older with a change in bowel habit towards looser and more frequent stools (without rectal bleeding) should be urgently referred. This applies to our 68-year-old male patient. While faecal occult blood testing is not necessary in this case, NICE offers guidance on whom to test for colorectal cancer using this method.

According to the guidelines, faecal occult blood testing should be offered to adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss. Additionally, those aged under 60 with changes in bowel habit or iron-deficiency anaemia should also be tested. For patients aged 60 and over, testing should be offered if they have anaemia even in the absence of iron deficiency.

It is important to follow these guidelines to ensure timely and appropriate management of patients with potential colorectal cancer.

This woman has exhibited a concerning symptom of experiencing loose stools for over 6 weeks, which is a red flag indicator. Given her age of over 60 years, it is important to discuss the potential of an underlying cancer and refer her to secondary care for further testing within 2 weeks to rule out the possibility of bowel cancer.

Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.

An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.

The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.

The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.

Possible Causes of Jaundice: A Differential Diagnosis

Jaundice is a common clinical manifestation of various diseases. In this case, the patient presents with jaundice, and the differential diagnosis includes several inherited disorders of bilirubin metabolism, chronic haemolytic disorders, and infectious diseases.

Gilbert Syndrome: This is a relatively mild inherited disorder caused by a deficiency of glucuronosyl transferase, resulting in an accumulation of unconjugated bilirubin. The jaundice usually subsides in a few days and may be more obvious during an intercurrent illness.

Dubin–Johnson Syndrome: This is another inherited disorder of bilirubin metabolism, but in this case, there is a defect in the secretion of bilirubin from the liver. The bilirubin that accumulates in the plasma is conjugated, water-soluble, and excreted in the urine. Onset of jaundice may commonly first occur during puberty or early adulthood and can be precipitated by alcohol, infection, pregnancy, or contraceptive pill use.

Hereditary Spherocytosis: This is a chronic haemolytic disorder due to a defect in the red cell membrane, most frequently in spectrin, a structural protein. It can present with a wide range of severity, from jaundice at birth to asymptomatic anaemia or jaundice in adults.

Infectious Mononucleosis: This viral infection can cause hepatitis and jaundice, but elevated transaminase activity would be expected.

Rotor Syndrome: This is a possible differential diagnosis, but this condition would cause a mixed hyperbilirubinaemia. Therefore, Gilbert’s disease is the more likely diagnosis in this scenario.

In conclusion, the differential diagnosis of jaundice includes several inherited disorders of bilirubin metabolism, chronic haemolytic disorders, and infectious diseases. A thorough evaluation of the patient’s medical history, physical examination, and laboratory tests is necessary to establish the correct diagnosis and provide appropriate treatment.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting that occurs during pregnancy and can lead to fluid and electrolyte imbalances, ketosis, and weight loss. It often affects the liver, with abnormal ALT levels in about half of patients. Jaundice may also occur in severe cases. While HG typically resolves by the end of the third trimester, it can persist throughout pregnancy in some cases.

Acute fatty liver of pregnancy (AFLP) is a rare condition that occurs in about 5 out of 100,000 pregnancies. It often presents in the third trimester with symptoms such as nausea, vomiting, abdominal pain, fever, headache, and pruritus. Jaundice may also occur and can become severe. AFLP is typically managed by prompt delivery and supportive care, but it is unlikely to be the diagnosis for a patient in the first trimester.

HELLP syndrome is a condition that can occur in patients with severe pre-eclampsia, with symptoms including abnormal pain and elevated AST levels. It is most likely to occur close to delivery, but it can occur as early as 20 weeks. However, this patient is only 13 weeks pregnant, making HELLP syndrome an unlikely diagnosis.

Intrahepatic cholestasis of pregnancy (ICP) is a common condition that should be considered in cases of abnormal liver function tests in the second trimester. It is characterized by itching, and severe cases may lead to jaundice. Affected pregnancies are at an increased risk of prematurity and stillbirth, so early delivery may be necessary.

Pre-eclampsia is a condition that typically occurs in the second half of pregnancy and is characterized by high blood pressure and proteinuria. It may also cause peripheral edema, abdominal pain, headache, and visual problems. Treatment involves delivery.

Calcium channel blockers may be utilized to assist in the natural passage of the stone.

Management and Prevention of Renal Stones

Renal stones, also known as kidney stones, can cause severe pain and discomfort. The British Association of Urological Surgeons (BAUS) has published guidelines on the management of acute ureteric/renal colic. Initial management includes the use of NSAIDs as the analgesia of choice for renal colic, with caution taken when prescribing certain NSAIDs due to increased risk of cardiovascular events. Alpha-adrenergic blockers are no longer routinely recommended, but may be beneficial for patients amenable to conservative management. Initial investigations include urine dipstick and culture, serum creatinine and electrolytes, FBC/CRP, and calcium/urate levels. Non-contrast CT KUB is now recommended as the first-line imaging for all patients, with ultrasound having a limited role.

Most renal stones measuring less than 5 mm in maximum diameter will pass spontaneously within 4 weeks. However, more intensive and urgent treatment is indicated in the presence of ureteral obstruction, renal developmental abnormality, and previous renal transplant. Treatment options include lithotripsy, nephrolithotomy, ureteroscopy, and open surgery. Shockwave lithotripsy involves generating a shock wave externally to the patient, while ureteroscopy involves passing a ureteroscope retrograde through the ureter and into the renal pelvis. Percutaneous nephrolithotomy involves gaining access to the renal collecting system and performing intracorporeal lithotripsy or stone fragmentation. The preferred treatment option depends on the size and complexity of the stone.

Prevention of renal stones involves lifestyle modifications such as high fluid intake, low animal protein and salt diet, and thiazide diuretics to increase distal tubular calcium resorption. Calcium stones may also be due to hypercalciuria, which can be managed with thiazide diuretics. Oxalate stones can be managed with cholestyramine and pyridoxine, while uric acid stones can be managed with allopurinol and urinary alkalinization with oral bicarbonate.

The diagnosis and management of IBS have been addressed by NICE in their guidance. The first line of pharmacological treatment includes antispasmodics such as Hyoscine or mebeverine, loperamide for diarrhea, and laxatives for constipation. Lactulose should be avoided. If the above treatments have not helped, second-line options include tricyclic antidepressants such as up to 30 mg amitriptyline. Third-line options include serotonin selective reuptake inhibitors. Linaclotide can be considered if the patient has had constipation for at least 12 months and has not benefited from different laxatives. Other management options include dietary advice and psychological treatments. However, acupuncture and reflexology are not recommended for managing IBS.

Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.

The patient is presenting with cholestatic jaundice, likely caused by the oral contraceptive pill. This results in intrahepatic jaundice, dark urine, and pale stools. Paracetamol overdose and viral hepatitis would cause hepatocellular jaundice, while Gilbert’s syndrome is an unconjugated hyperbilirubinaemia. Choledocholithiasis could also cause obstructive cholestasis. It is appropriate to stop the pill and consider alternative contraception methods, and additional imaging may be necessary if jaundice doesn’t resolve.

Drug-induced liver disease can be categorized into three types: hepatocellular, cholestatic, or mixed. However, there can be some overlap between these categories, as some drugs can cause a range of liver changes. Certain drugs tend to cause a hepatocellular picture, such as paracetamol, sodium valproate, and statins. On the other hand, drugs like the combined oral contraceptive pill, flucloxacillin, and anabolic steroids tend to cause cholestasis with or without hepatitis. Methotrexate, methyldopa, and amiodarone are known to cause liver cirrhosis. It is important to note that there are rare reported causes of drug-induced liver disease, such as nifedipine.