Diagnostic Tests for Chronic Diarrhoea: A Comparison

Chronic diarrhoea can have various causes, including intestinal parasitic infection and malabsorption syndromes like tropical sprue. Here, we compare different diagnostic tests that can help in identifying the underlying cause of chronic diarrhoea.

Small Intestinal Biopsy: This test can diagnose parasites like Giardia or Cryptosporidium, which may be missed in stool tests. It can also diagnose villous atrophy, suggestive of tropical sprue.

Colonoscopy: While colonoscopy can show amoebic ulcers or other intestinal parasites, it is unlikely to be of use in investigating malabsorption.

Lactose Breath Test: This test diagnoses lactase deficiency only and does not tell us about the aetiology of chronic diarrhoea.

Serum Vitamin B12 Level: This test diagnoses a deficiency of the vitamin, but it will not tell about the aetiology, eg dietary insufficiency or malabsorption.

Small Intestinal Aspirate Culture: This test is done if bacterial overgrowth is suspected, which occurs in cases with a previous intestinal surgery or in motility disorders like scleroderma. However, there is no mention of this history in the case presented here.

In conclusion, the choice of diagnostic test depends on the suspected underlying cause of chronic diarrhoea. A small intestinal biopsy is a useful test for diagnosing both parasitic infections and malabsorption syndromes like tropical sprue.

Understanding Spontaneous Bacterial Peritonitis: Mortality, Prevention, and Treatment

Spontaneous bacterial peritonitis (SBP) is a serious complication of ascites, occurring in 8% of cirrhosis cases with ascites. This condition has a high mortality rate of 25% and recurs in 70% of patients within a year. While there is some evidence that secondary prevention with oral quinolones may decrease mortality in certain patient groups, it is not an indication for liver transplantation. The most common infecting organisms are enteric, such as Escherichia coli, Klebsiella, Streptococcus, and Enterococcus. While an ascitic tap can decrease discomfort, it cannot prevent recurrence. Understanding the mortality, prevention, and treatment options for SBP is crucial for managing this serious complication.

Management of Oral Candidiasis: Understanding the Treatment Options and Indications for Referral

Oral candidiasis is a common fungal infection that can affect individuals of all ages, particularly infants, older patients who wear dentures, diabetics, and immunosuppressed patients. The infection is caused by the yeast Candida albicans and typically presents as white lesions in the mouth that can be easily scraped off with a tongue blade.

The first-line treatment for localised disease involves topical treatment with nystatin suspension, which is swished and swallowed in the mouth three to four times a day. However, immunosuppressed patients may suffer from widespread C. albicans infections, such as oesophageal candidiasis and candidaemia, which require more aggressive treatment with intravenous antifungal medications like amphotericin B.

It is important to note that testing for Epstein-Barr virus (EBV) is not required in patients with isolated oral thrush. However, immediate specialist referral would be necessary if oropharyngeal cancer was being considered in the differential diagnosis. The two-week wait referral is also indicated for unexplained oral ulceration lasting more than three weeks and persistent, unexplained cervical lymph node enlargement.

In conclusion, understanding the appropriate treatment options and indications for referral is crucial in managing oral candidiasis effectively. Topical treatment with nystatin suspension is the first-line therapy for localised disease, while more aggressive treatment with intravenous antifungal medications is necessary for disseminated fungal infections. Referral to a specialist is necessary in cases where oropharyngeal cancer is suspected or when there is unexplained oral ulceration or persistent cervical lymph node enlargement.

Liver Tumours: Types, Risk Factors, and Diagnostic Methods

Liver tumours are abnormal growths that develop in the liver. The most common primary liver tumour is hepatocellular carcinoma (HCC), which is often associated with hepatitis B infection, cirrhosis, male gender, and increasing age. Chronic hepatitis B is the major risk factor worldwide, while hepatitis C is the major risk factor in Europe. Patients with underlying cirrhosis may present with decompensation of liver disease, such as ascites, jaundice, worsening liver function tests, and variceal haemorrhage. Examination may reveal hepatomegaly or a right hypochondrial mass. Vascularity of the tumour may result in an audible bruit on auscultation.

Diagnostic methods for liver tumours include increased α-fetoprotein, which is produced by 60% of HCCs. Ultrasound scanning will reveal focal lesions and may also show involvement of the portal vein. Helical triple-phase computed tomography (CT) scanning will identify HCC due to its hypervascular nature. Alternatively, magnetic resonance imaging (MRI) may be used.

Other types of liver tumours include fibrosarcoma, which is an extremely rare primary tumour of the liver, cholangiocarcinoma, which are usually adenocarcinomas and are the second most common primary tumour of the hepatobiliary system, affecting biliary ducts, hepatoblastoma, which is a liver tumour that typically presents in childhood, in the first 3 years of life, and leiomyosarcoma, which is another rare primary tumour of the liver. Leiomyosarcoma is thought to affect women more than men and typically seems to present later in life, in the fifth and sixth decades of life. However, greater understanding of the epidemiology of these rare tumours is required.

Autoimmune Diseases: Causes and Symptoms

Autoimmune diseases are conditions where the body’s immune system attacks its own tissues and organs. Here are some examples of autoimmune diseases and their causes and symptoms:

Coeliac Disease
Coeliac disease is caused by an autoimmune reaction to gluten, a protein found in wheat. Symptoms include chronic diarrhoea, weight loss, and fatigue.

Graves’ Disease
This autoimmune disease affects the thyroid gland, resulting in hyperthyroidism. It is associated with anti-thyroid-stimulating hormone (TSH) receptor antibodies.

Pemphigus Vulgaris
This rare autoimmune disease causes blistering of the skin and mucosal surfaces due to autoantibodies against desmoglein.

Systemic Lupus Erythematosus
This multisystem autoimmune disease is associated with a wide range of autoantibodies, including anti-nuclear antibody (ANA) and anti-double-stranded (ds) DNA. Symptoms can include joint pain, fatigue, and skin rashes.

Type 1 Diabetes Mellitus
This autoimmune disease results in the destruction of islet cells in the pancreas. Islet cell autoantibodies and antibodies to insulin have been described as causes. Symptoms include increased thirst and urination, weight loss, and fatigue.

In summary, autoimmune diseases can affect various organs and tissues in the body, and their symptoms can range from mild to severe. Understanding their causes and symptoms is crucial for early diagnosis and effective treatment.

Differential diagnosis of hepatosplenomegaly and portal hypertension

Hepatosplenomegaly and portal hypertension can have various causes, including pre-hepatic, hepatic, and post-hepatic problems. One potential cause is Budd-Chiari syndrome, which results from hepatic vein thrombosis and is associated with pregnancy and oral contraceptive use. Alcoholic cirrhosis is another possible cause, but is unlikely in the absence of alcohol excess. Pylephlebitis, a rare complication of appendicitis, is not consistent with the case history provided. Splenectomy cannot explain the palpable splenomegaly in this patient. Tricuspid valve incompetence can also lead to portal hypertension and hepatosplenomegaly, but given the postpartum status of the patient, Budd-Chiari syndrome is a more probable diagnosis.

Factors Contributing to Oesophageal Cancer

Oesophageal cancer is a common and aggressive tumour that can be caused by various factors. The two most common types of oesophageal cancer are squamous cell carcinoma and adenocarcinoma. In developed countries, adenocarcinoma is more prevalent, while squamous cell carcinoma is more common in the developing world.

Gastro-oesophageal reflux disease (GORD) is the most common predisposing factor for oesophageal adenocarcinoma. Acid reflux can cause irritation that progresses to metaplasia, dysplasia, and eventually adenocarcinoma. Approximately 10-15% of patients who undergo endoscopy for reflux symptoms have Barrett’s epithelium.

Cigarette smoking and chronic alcohol exposure are the most common aetiological factors for squamous cell carcinoma in Western cultures. However, no association has been found between alcohol and oesophageal adenocarcinoma. The risk of adenocarcinoma is also increased among smokers.

Achalasia, a condition that affects the oesophagus, increases the risk of both adeno and squamous cell carcinoma. However, dysphagia is not mentioned as a contributing factor.

Limited evidence suggests that excessive fruit and vegetable consumption may be protective against both types of cancer. Helicobacter pylori infection, which can cause stomach cancer, has not been associated with oesophageal cancer.

Factors Contributing to Oesophageal Cancer

Liver Metastases: Causes and Differential Diagnosis

Liver metastases are a common cause of nodular hepatomegaly, with the most frequent primary sites being the bowel and breast. While palpable metastases may not affect liver function, obstruction to the biliary tract or involvement of over half of the liver can lead to impaired function and the presence of ascites. Autopsy studies have shown that 30-70% of cancer patients have liver metastases, with the frequency depending on the primary site. Most liver metastases are multiple and affect both lobes.

When considering a differential diagnosis, cirrhosis can be ruled out as it is the end-stage of chronic liver disease and would typically present with elevated serum alanine aminotransferase (ALT). Hepatoma is less common than metastases and lymphoma may present with evidence of involvement in other sites, such as lymphadenopathy. Myelofibrosis, which is associated with bone marrow fibrosis and abnormal stem cell appearance in the liver and spleen, may be asymptomatic in its early stages or present with leuko-erythroblastic anemia, malaise, weight loss, and night sweats. However, it is much less common than liver metastases.

In summary, liver metastases should be considered as a potential cause of nodular hepatomegaly, particularly in patients with a history of cancer. A thorough differential diagnosis should be conducted to rule out other potential causes.

Understanding Liver Diseases: NAFLD, Viral Hepatitis, Alcohol-related Cirrhosis, Wilson’s Disease, and Haemochromatosis

Liver diseases can have various causes and presentations. One of the most common is non-alcoholic fatty liver disease (NAFLD), which is closely associated with obesity, hypertension, diabetes, and dyslipidaemia. NAFLD is often asymptomatic, but some patients may experience tiredness or epigastric fullness. Weight loss is the primary treatment, although glitazones have shown promising results in improving liver function.

Viral hepatitis is another common liver disease, but there are no indicators of it in this patient’s history. Alcohol-related cirrhosis is often caused by excessive alcohol intake, but this patient denies alcohol consumption, making NAFLD a more likely diagnosis.

Wilson’s disease typically presents with neuropsychiatric symptoms or signs, and the presence of Kayser-Fleischer rings is a key diagnostic feature. Haemochromatosis, on the other hand, results from iron overload and is often associated with diabetes mellitus and bronzing of the skin.

Understanding the different types of liver diseases and their presentations is crucial in making an accurate diagnosis and providing appropriate treatment.

Magnetic resonance defecography is the most appropriate investigation for a patient with abnormal pelvic floor muscle tone, perineal descent, and symptoms of incomplete evacuation during defecation. This test evaluates global pelvic floor anatomy and dynamic motion, identifying prolapse, rectocele, and pelvic floor dysfunctions. Other tests, such as abdominal ultrasound, barium enema, colonoscopy, and CT abdomen, may not provide sufficient information on the underlying pathology of the patient’s symptoms.