Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.

To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.

Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.

Kidney stones can form when there is an excess of calcium, oxalate, or uric acid in the urine, a lack of citrate, or insufficient water in the kidneys to dissolve waste products. Dehydration can lead to the formation of crystals that gradually build up into kidney stones. Urine typically contains chemicals that prevent crystal formation, but low levels of these inhibitors can contribute to stone formation. Most kidney stones pass on their own, but some patients may require hospitalization due to severe pain, inability to retain fluids, infection, or inability to pass the stone. Treatment involves hydration and pain relief, with methods of stone removal considered for those who do not pass the stone naturally. Intravenous furosemide and broad-spectrum antibiotics are not recommended unless there is a specific indication.

If a patient with a history of long-term steroid use suddenly experiences hypotension, hypothermia, and hypoglycemia, it is important to treat them for an Addisonian crisis. It is important to note that while textbooks often mention hyponatremia and hyperkalemia as the classic biochemical presentation, this may not always be the case in real-life situations. While the patient may also have thyroid deficiency, it is not the most immediate concern and thyroid function tests or intravenous free T3 should not be the first treatment option. Additionally, a random cortisol test may not be useful in interpreting the situation if the patient has recently taken hydrocortisone outside of the hospital.

Addison’s disease is a condition that requires patients to undergo glucocorticoid and mineralocorticoid replacement therapy. This treatment involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is usually given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Fludrocortisone is also included in the treatment regimen. Patient education is crucial in managing Addison’s disease. Patients should be reminded not to miss glucocorticoid doses, and they may consider wearing Medic Alert bracelets and steroid cards. Additionally, patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis. It is also important to discuss how to adjust the glucocorticoid dose during an intercurrent illness.

During an intercurrent illness, the glucocorticoid dose should be doubled, while the fludrocortisone dose remains the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios for managing intercurrent illness. These guidelines can be found on the CKS link for more information. Proper management of Addison’s disease is essential to ensure that patients receive the appropriate treatment and care they need to manage their condition effectively.

When a person experiences hypertensive urgency, their blood pressure rises to a severe level (systolic >180 mmHg or diastolic >110 mmHg) without causing damage to their organs. Symptoms may include nosebleeds, shortness of breath, or headaches. The goal of treatment is to lower blood pressure within 24-48 hours using oral antihypertensive medication, such as a calcium channel blocker like amlodipine. Hospitalization is typically not necessary. In contrast, hypertensive emergencies require immediate blood pressure reduction, often within minutes to hours, and may involve intravenous antihypertensives like labetalol or glyceryltrinitrate. These emergencies can include conditions like hypertensive encephalopathy or aortic dissection.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Carcinomatous meningitis is a condition that occurs in about 5% of cases of adenocarcinoma in various parts of the body, such as the breast, lung, gastrointestinal tract, melanoma, and lymphoma. The symptoms can vary and include headache, sciatic pain, cauda equina syndrome, multiple cranial nerve palsies, confusion, seizures, focal neurological deficits, or poly-radiculoneuropathy. Diagnosis can be challenging, but it is established by identifying tumor cells in the cerebrospinal fluid (CSF) using various techniques. It may take several CSF examinations to arrive at a diagnosis, and the prognosis is poor, with a median survival of 6 months. Intrathecal chemotherapy is the main treatment option. Other conditions, such as idiopathic intracranial hypertension, fungal meningitis, tuberculous meningitis, and Lyme’s disease, are less likely to be the cause of symptoms in this case.

Non-Invasive Tests for Helicobacter pylori

Tests for Helicobacter pylori that do not involve taking a tissue sample from the stomach lining include serology, urea breath testing, and stool antigen tests. These non-invasive tests are preferred by patients as they do not require an endoscopy. The urea breath test is a reliable method for detecting H. pylori, with a sensitivity of 90% and specificity of 96%. This test involves drinking a solution containing urea and then breathing into a special bag. The breath sample is then analyzed to determine the presence of H. pylori. Stool antigen tests and serology are also effective methods for detecting H. pylori, but they may not be as accurate as the urea breath test. Overall, non-invasive tests for H. pylori are a convenient and reliable way to diagnose this common bacterial infection.

Polyarteritis Nodosa rarely involves the lungs, while Churg-Strauss syndrome typically manifests as vasculitis and asthma. Pulmonary embolism and sarcoidosis are also not consistent with the symptoms described. The most probable diagnosis is Goodpasture’s syndrome, which is characterized by pulmonary bleeding, microcytic anemia, and difficulty breathing due to antibodies circulating in the alveolar basement membrane. The disease may progress to crescentic glomerulonephritis, leading to renal complications.

Anti-glomerular basement membrane (GBM) disease, previously known as Goodpasture’s syndrome, is a rare form of small-vessel vasculitis that is characterized by both pulmonary haemorrhage and rapidly progressive glomerulonephritis. This condition is caused by anti-GBM antibodies against type IV collagen and is more common in men, with a bimodal age distribution. Goodpasture’s syndrome is associated with HLA DR2.

The features of this disease include pulmonary haemorrhage and rapidly progressive glomerulonephritis, which can lead to acute kidney injury. Nephritis can result in proteinuria and haematuria. Renal biopsy typically shows linear IgG deposits along the basement membrane, while transfer factor is raised secondary to pulmonary haemorrhages.

Management of anti-GBM disease involves plasma exchange (plasmapheresis), steroids, and cyclophosphamide. One of the main complications of this condition is pulmonary haemorrhage, which can be exacerbated by factors such as smoking, lower respiratory tract infection, pulmonary oedema, inhalation of hydrocarbons, and young males.

The patient has left sided 9th, 10th, 11th and 12th nerve palsies, pulsatile tinnitus, and subjective hearing loss in the left ear, indicating a lesion in the jugular foramen, most likely caused by a glomus jugulare tumor. Foramen magnum syndrome presents with lower cranial nerve dysfunction and long tract signs, while hypoglossal canal syndrome causes isolated 12th nerve palsy. Motor neurone disease causes upper and lower motor neurone signs with absent sensory disturbance, and nasopharyngeal carcinoma presents with localizing features such as epistaxis and nasal obstruction.

Non-metastatic Manifestations of Lung Cancer

Hypercalcaemia, a condition where there is an excess of calcium in the blood, can occur in about 15% of squamous cell lung carcinoma cases due to the production of parathyroid hormone related protein (PTHrP). Interestingly, this can happen even in the absence of bony metastases, which are typically associated with cancer spreading to the bones. This is considered a non-metastatic manifestation of malignancy.

On the other hand, small cell lung cancer can lead to the inappropriate secretion of antidiuretic hormone (ADH), which can cause hyponatraemia or low sodium levels in the blood. Additionally, ectopic adrenocorticotropic hormone (ACTH) production can occur, leading to Cushing’s syndrome.

Clubbing, a condition where the fingers and toes become swollen and the nails curve abnormally, is more commonly associated with squamous cell cancers and occasionally adenocarcinoma. These non-metastatic manifestations of lung cancer can provide important clues for diagnosis and treatment.

Methanol poisoning is suspected in a woman who presents with sudden collapse and a profound metabolic acidosis with a prolonged anion gap. The absence of diabetic ketoacidosis and normal coagulation rules out paracetamol poisoning. Lactic acidosis is unlikely due to the absence of a lactate level of 5.0 mmol/l. The high anion gap and plasma osmolar gap suggest ingestion of an exogenous osmolar agent. The presence of optic disc changes and normal calcium levels point towards methanol rather than ethylene glycol poisoning. Methanol levels can confirm the diagnosis. Urgent treatment with intravenous ethanol or fomepizole, if available, is required, along with possible haemodialysis. However, even with rapid treatment, sight loss is common.