Management of Suspected Oesophageal Rupture

Suspected oesophageal rupture is a medical emergency that requires urgent intervention. This condition is more common in patients with a history of alcohol excess and can be associated with a triad of vomiting, chest pain, and subcutaneous emphysema. Symptoms include retrosternal chest/epigastric pain, tachypnoea, fever, pain on swallowing, and shock. A chest X-ray reveals gas within soft tissue spaces, pneumomediastinum, left pleural effusion, and left-sided pneumothorax. Without rapid treatment, the condition can be fatal.

Antibiotics are necessary to treat the infection that may result from oesophageal rupture. However, they will not address the underlying cause of the infection.

Chest drain insertion is not the correct management for pneumothorax secondary to oesophageal rupture. A chest drain would not resolve the underlying cause, and air would continue to enter the pleural cavity via the oesophagus.

Proton pump inhibitors (PPIs) are not appropriate for suspected oesophageal rupture. PPIs would be the correct management for a suspected perforated ulcer. However, the history of acute-onset pain following vomiting is more in keeping with oesophageal rupture.

Urgent endoscopy is not appropriate for suspected oesophageal rupture. Endoscopy risks further oesophageal perforation, and there is no report of haematemesis or melaena, making this a less likely cause of the patient’s symptoms.

Management of Suspected Oesophageal Rupture: Antibiotics, Chest Drain Insertion, PPIs, and Endoscopy

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.

Diaphragmatic Hiatal Hernia

Diaphragmatic hiatal hernia is a condition where the fundus or gastro-oesophageal junction of the stomach herniates upwards in the chest due to an abnormal defect in the diaphragm. A chest X-ray may reveal gastric air and fluid behind the mediastinum, and reduced air entry at the lung bases due to compression of the lung lobes. Immediate management involves stabilizing the patient with ABCDE and seeking an urgent surgical review for a possible Nissen fundoplication.

Other conditions such as early cholangitis, aspiration pneumonia of the left lower lobe of the lung, ruptured left ventricle, or ruptured right ventricle may present with different symptoms and would not cause the air and fluid level behind the mediastinum seen in diaphragmatic hiatal hernia.

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.

The Child-Turcotte-Pugh score (CTP) is used to assess disease severity in cirrhosis of liver. It consists of five clinical measures, each scored from 1 to 3 according to severity. The minimum score is 5 and maximum score is 15. Once a score has been calculated, the patient is graded A, B, or C for severity. The CTP score is primarily used to decide the need for liver transplantation. However, some criticisms of this scoring system highlight the fact that each of the five categories is given equal weighting, which is not always appropriate. Additionally, in two specific diseases, primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin cut-off levels in the table are markedly different.

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.

Criteria for Urgent Endoscopy Referral

Criteria for urgent endoscopy referral include various symptoms such as dysphagia, dyspepsia, weight loss, anaemia, vomiting, Barrett’s oesophagus, family history of upper gastrointestinal carcinoma, pernicious anaemia, upper GI surgery more than 20 years ago, jaundice, and abdominal mass. Dysphagia is a symptom that requires urgent endoscopy referral at any age. Dyspepsia combined with weight loss, anaemia, or vomiting at any age also requires urgent referral. Dyspepsia in a patient aged 55 or above with onset of dyspepsia within one year and persistent symptoms requires urgent referral. Dyspepsia with one of the mentioned conditions also requires urgent referral.

In the presented cases, the 56-year-old man has dyspepsia with an aortic aneurysm, which requires an ultrasound and vascular opinion. On the other hand, the case of unexplained weight loss, tenesmus, and upper right mass is likely to be a colonic carcinoma. It is important to be aware of these criteria to ensure timely and appropriate referral for urgent endoscopy.

Differentiating Colonic Pathologies: A Brief Overview

Melanosis Coli: A Misnomer

Prolonged laxative use can lead to melanosis coli, characterized by brown or black pigmentation of the colonic mucosa. However, the pigment is not melanin but intact lipofuscin. Macrophages ingest apoptotic cells, and lysosomes convert the debris to lipofuscin pigment. The macrophages then become loaded with lipofuscin pigment, which is best identified under electron microscopy. Hence, some authors have proposed a new name – pseudomelanosis coli. Use of anthraquinone laxatives is most commonly associated with this syndrome.

Macrophages Containing Melanin

Melanosis coli is a misnomer. The pigment is not melanin. See the correct answer for a full explanation.

Non-Caseating Granuloma

Non-caseating granulomas are characteristic of Crohn’s disease microscopic pathology, as well as transmural inflammation. However, this patient is unlikely to have Crohn’s disease, because it normally presents with diarrhoea, abdominal pain, malaise/lethargy, and weight loss.

Non-Specific Colitis

Non-specific colitis is a general term which can be found in a variety of disorders. For example, laxative abuse can cause colonic inflammation. However, melanosis coli is a more specific answer.

Crypt Abscesses

Crypt abscesses are found in ulcerative colitis, as well as mucosal and submucosal inflammation. Normally, ulcerative colitis presents with bloody diarrhoea, abdominal pain, malaise/lethargy, and weight loss. This patient’s history of constipation and a single episode of bloody diarrhoea makes ulcerative colitis unlikely.

Understanding Colonic Pathologies

Differential Diagnosis for a Patient with Iron Overload

A middle-aged man presents with skin discoloration, chronic liver disease, arthralgia, and erectile dysfunction. His serum ferritin level is significantly elevated at 623, indicating iron overload. However, liver disease can also cause an increase in serum ferritin.

Acute viral hepatitis is unlikely as his symptoms have been worsening over the past 6-9 months, and his transaminase levels are only moderately elevated. Alcoholic cirrhosis is also unlikely as his alcohol intake is modest.

Excess iron ingestion is a possibility, but it would require significant ingestion over a long period of time. Wilson’s disease, a recessively inherited disorder of copper metabolism, is also unlikely as it does not explain the symptoms of iron overload.

Overall, the differential diagnosis for this patient includes haemochromatosis, a genetic disorder that causes iron overload. Further testing and evaluation are necessary to confirm the diagnosis and determine the appropriate treatment plan.

Differential Diagnosis for Acute Hepatitis with Jaundice

Acute hepatitis with jaundice can have various causes, and a differential diagnosis is necessary to determine the underlying condition. In this case, the blood tests indicate significant hepatocellular damage as the cause of the patient’s jaundice, making viral hepatitis the most likely option.

Acute hepatitis B is a common cause of jaundice, especially in endemic regions like Asia. The patient may have acquired the infection through sexual contact or needle-sharing. The acute infection usually lasts for 1-3 months, and most patients make a full recovery.

Acute hepatitis C is less likely as it is usually asymptomatic in adults, and only a small percentage develops symptoms. Primary biliary cholangitis, on the other hand, presents with an insidious onset of pruritus and lethargy, followed by jaundice, and causes a cholestatic picture. Acute alcoholic hepatitis rarely causes an ALT >500 and should be suspected if another cause or concomitant cause is present. Non-alcoholic steatohepatitis (NASH) is chronic and usually leads to mildly abnormal liver function tests in patients with risk factors for the metabolic syndrome.

In conclusion, a thorough differential diagnosis is necessary to determine the underlying cause of acute hepatitis with jaundice, and in this case, viral hepatitis is the most likely option.