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

The patient is exhibiting symptoms of abetalipoproteinaemia, a rare genetic disorder that results in defective lipoprotein synthesis and fat malabsorption. This leads to deficiencies in fat-soluble vitamins, including vitamin E, which is responsible for the neurological symptoms and visual problems. Vitamin A deficiency may also contribute to visual problems, while vitamin D deficiency can cause low calcium and phosphate levels and metabolic bone disease. Fomepizole is used to treat methanol poisoning, which presents with neurological symptoms and metabolic acidosis. However, this does not explain the patient’s cheilosis or glossitis. IV thiamine is used to treat Wernicke’s encephalopathy, a result of vitamin B deficiency commonly seen in malnourished patients with a history of alcohol abuse. Pancreatic enzyme supplements are used in chronic pancreatitis with exocrine insufficiency, while oral zinc therapy is used in Wilson’s disease, an autosomal recessive condition that causes excessive copper accumulation and can present with extrapyramidal features or neuropsychiatric manifestations.

Causes of Ascites: Differentiating between Transudative and Exudative Ascites

Ascites refers to the accumulation of fluid in the peritoneal cavity. The causes of ascites can be classified based on the protein content of the fluid. Transudative ascites, which has a protein content of less than 30 g/l, is commonly associated with portal hypertension, cardiac failure, fulminant hepatic failure, and Budd-Chiari syndrome. On the other hand, exudative ascites, which has a protein content of more than 30 g/l, is often caused by infection or malignancy. In the case of the patient scenario described, a malignant cause is more likely. It is important to differentiate between transudative and exudative ascites to determine the underlying cause and guide appropriate treatment.

When differentiating between ulcerative colitis and Crohn’s disease, it is important to note that crypt abscesses are typical for ulcerative colitis, while other options are more commonly found in Crohn’s disease. Ulcerative colitis is the most common form of inflammatory bowel disease, with inflammation starting in the rectum and spreading upwards in a contiguous fashion. Patients typically experience left-sided abdominal pain, cramping, bloody diarrhea with mucous, and unintentional weight loss. Extra-intestinal manifestations may include seronegative arthropathy and pyoderma gangrenosum. Barium enema and colonoscopy are used to diagnose ulcerative colitis, with the latter revealing diffuse and contiguous ulceration and inflammatory infiltrates affecting the mucosa and submucosa only. Complications of long-term ulcerative colitis include large bowel adenocarcinoma, toxic megacolon, and primary sclerosing cholangitis. In contrast, Crohn’s disease usually presents with right-sided abdominal pain, watery diarrhea, and weight loss. Barium enema and colonoscopy reveal multiple ulcers and bowel wall thickening, with the microscopic appearance showing a mixed acute and chronic transmural inflammatory infiltrate with non-caseating granulomas. Terminal ileum involvement is typical for Crohn’s disease, while stricturing and fistula formation are common complications due to its transmural inflammatory nature. Overall, while both ulcerative colitis and Crohn’s disease are systemic illnesses, they have distinct differences in their clinical presentation and diagnostic features.

Understanding Hepatitis A Infection

Hepatitis A infection is a common viral infection that spreads through the faeco-oral route, particularly in areas like North Africa. It is usually acquired through exposure to contaminated food or water. The infection typically presents with a prodrome of flu-like symptoms, followed by acute hepatitis with right upper quadrant tenderness, jaundice, pale stools, and dark urine.

Fortunately, hepatitis A is a self-limiting condition, and most people recover within 2-6 months without any significant complications. Death from hepatitis A is rare, occurring in only 0.2% of cases. However, relapsing hepatitis A can occur in up to 20% of cases, with each relapse being milder than the previous one.

Treatment for hepatitis A is mainly supportive, and there is no significant risk of progression to cirrhosis. Unlike hepatitis B and C, which are transmitted through blood products and sexual intercourse, hepatitis A and E are transmitted through the faeco-oral route. Therefore, practicing good hygiene and sanitation is crucial in preventing the spread of the infection.

Interpreting Abnormal Lab Results in a Patient with Dyspepsia

The patient in question is experiencing dyspepsia, likely due to peptic ulcer disease. One potential cause of this condition is primary hyperparathyroidism, which can lead to excess gastric acid secretion by causing hypercalcemia (elevated serum calcium). However, reduced plasma glucose, decreased serum sodium, and elevated serum potassium are not associated with dyspepsia.

On the other hand, long-standing diabetes mellitus can cause autonomic neuropathy and gastroparesis with delayed gastric emptying, leading to dyspepsia. Decreased serum ferritin is often seen in iron deficiency anemia, which can be caused by a chronically bleeding gastric ulcer or gastric cancer. However, this patient’s symptoms do not suggest malignancy, as they began only a month ago and there is no weight loss or lymphadenopathy.

In summary, abnormal lab results should be interpreted in the context of the patient’s symptoms and medical history to arrive at an accurate diagnosis.

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.

Liver Diseases and Their Differentiating Factors

Liver diseases can lead to cirrhosis and eventually portal hypertension and oesophageal varices. However, differentiating factors can help identify the specific condition.

Haemochromatosis is an autosomal recessive condition that results in abnormal iron metabolism and deposition of iron in body tissues. Elevated ferritin levels and bronze skin coloration are common indicators.

Primary biliary cholangitis can also lead to cirrhosis and portal hypertension, but the ALP would be raised, and the patient would more likely be a woman.

Wilson’s disease is a genetically inherited condition that results in abnormal copper metabolism and deposition of copper in the tissues. Kayser–Fleischer rings in the eyes, psychiatric symptoms, and cognitive impairment are common indicators.

Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome and high-fat diets. Ferritin levels would not be expected to be raised.

Chronic viral hepatitis caused by hepatitis B or C can result in cirrhosis and portal hypertension. A history of injection drug use is a common indicator, and ferritin levels would not be raised.

In conclusion, identifying differentiating factors can help diagnose specific liver diseases and provide appropriate treatment.

Causes and Management of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding can be caused by various conditions, including oesophageal varices, Mallory-Weiss tear, peptic ulcer, gastric ulcer, and oesophagitis. In cases of suspected oesophageal varices, examination findings of splenomegaly and spider naevi suggest chronic liver failure with portal hypertension. Immediate management includes resuscitation, PPI levels, and urgent endoscopy to diagnose and treat the source of bleeding. Peptic ulcer is the most common cause of serious upper GI bleeding, but sudden-onset haematemesis of large volume of fresh blood is more suggestive of a bleed from oesophageal varices. OGD can diagnose both oesophageal varices and peptic ulcers. Oesophagitis may cause pain but is unlikely to lead to significant haematemesis.

Management of Toxic Megacolon in Ulcerative Colitis: Medical and Surgical Options

Toxic megacolon (TM) is a rare but life-threatening complication of ulcerative colitis (UC) characterized by severe colon dilation and systemic toxicity. The initial management of TM involves aggressive medical therapy with intravenous (IV) hydrocortisone, low-molecular-weight heparin (LMWH), and IV fluids to restore hemodynamic stability. Oral mesalazine is indicated for mild to moderate UC or for maintenance of remission. If the patient fails to respond to medical management after 72 hours, urgent surgery, usually subtotal colectomy with end ileostomy, should be considered.

Infliximab and vedolizumab are second-line management options for severe active UC in patients who fail to respond to intensive IV steroid treatment. However, their role in the setting of TM is unclear. LMWH is required for UC patients due to their high risk of venous thromboembolism.

Prompt recognition and management of TM is crucial to prevent mortality. A multidisciplinary approach involving gastroenterologists, surgeons, and critical care specialists is recommended for optimal patient outcomes.