When a patient experiences a mild-moderate flare of ulcerative colitis that extends beyond the left-sided colon, it is recommended to add oral aminosalicylates to rectal aminosalicylates. This is because enemas can only reach a certain point and the addition of an oral medication ensures proper treatment. In this case, the patient’s colonoscopy showed extensive disease, making the use of an oral aminosalicylate necessary. Therefore, this is the correct option and using rectal mesalazine alone is not sufficient.

Using oral steroids like prednisolone and dexamethasone as a first-line treatment is not recommended.

Metronidazole is used to treat bacterial infections, but there is no indication of such an infection in this case.

Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

Coeliac Disease and Gluten-Free Alcohol

Patients with coeliac disease must avoid consuming foodstuffs that contain gluten. This means that anything made with wheat, barley, and oats (in some cases) should be avoided. When it comes to alcohol, beers, lagers, stouts, and real ales, whether alcoholic or not, must be avoided due to their gluten content. However, there are now several gluten-free beers and lagers available in the market.

On the other hand, wine, champagne, port, sherry, ciders, liqueurs, and spirits, including whiskey, are all gluten-free. Although whiskey is initially made from barley, the distilling process involved in its production removes the gluten, making it safe for coeliacs to consume. It is essential for individuals with coeliac disease to be mindful of their alcohol intake and to choose gluten-free options to avoid any adverse reactions.

Choosing the Right Pain Medication for a Patient with Rheumatoid Arthritis and a History of Myocardial Infarction

When selecting a pain medication for a patient with rheumatoid arthritis and a history of myocardial infarction, it is important to consider the potential cardiovascular and gastrointestinal risks associated with each option. Tramadol is often the drug of choice due to its lower risk of cardiovascular and gastrointestinal problems, but it may still cause toxicity in some patients. Celecoxib, a cyclo-oxygenase-2 selective inhibitor, carries a lower risk of gastrointestinal side-effects but should be avoided in patients with a history of thrombotic events. Diclofenac and misoprostol carry an intermediate risk of gastrointestinal side-effects and increase the risk of thrombotic events. Ibuprofen and naproxen have lower gastrointestinal risks, but their use may be problematic in patients taking antiplatelet medication. Ultimately, the choice of pain medication should be made on a case-by-case basis, taking into account the patient’s individual medical history and risk factors.

As part of a coeliac screen, IgA tissue transglutaminase (tTG) is one of the blood tests conducted along with total IgA and possibly anti-endomysial antibodies. According to the 2015 NICE guidance on Coeliac Disease, patients who test positive for this should be referred to gastroenterology for an intestinal endoscopy and biopsy to confirm the condition. Only after confirmation should the patient start a gluten-free diet under the guidance of a dietician.

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.

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.

The first-line treatment for maintaining remission in patients with ulcerative colitis who have proctitis or proctosigmoiditis is a daily rectal aminosalicylate, with the addition of an oral aminosalicylate if necessary. Topical and/or oral aminosalicylates are also the first-line treatment for inducing and maintaining remission in mild-moderate ulcerative colitis, with the route of administration depending on the location of the disease. If aminosalicylates fail to induce remission, a short-term course of oral or topical corticosteroids may be added. Severe colitis requires hospital admission and treatment with IV corticosteroids, with the addition of IV ciclosporin if necessary. Surgery is the last resort. Twice-weekly corticosteroid enemas, daily azathioprine, and daily low-dose oral prednisolone for 3 months are not correct treatments for maintaining remission in ulcerative colitis.

Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

Diagnosing Liver Cirrhosis in Patients with Chronic Hepatitis C Infection

Liver cirrhosis is a common complication of chronic hepatitis C infection and can be caused by other factors such as alcohol consumption. Patients with chronic hepatitis C infection who are over 55 years old, male, and consume moderate amounts of alcohol are at higher risk of developing cirrhosis. However, cirrhosis can be asymptomatic until complications arise. An ultrasound scan can detect cirrhosis and its complications, but a liver biopsy is the gold standard for diagnosis. Abnormal liver function tests may indicate liver damage, but they are not always conclusive. The absence of signs doesn’t exclude a diagnosis of liver cirrhosis. Further investigation is necessary before considering a liver biopsy.

Patients who are over the age of 74 are no longer eligible for bowel cancer screening within the NHS screening program. However, they can still receive a home test kit every 2 years by self-referral (helpline number on NHS website). It is important to note that if a patient develops symptoms of bowel cancer, they should be formally investigated according to NICE suspected cancer guidelines. Additionally, in areas where bowel scope screening has been rolled out, patients can self-refer up to the age of 60 for one-off bowel scope screening.

Colorectal Cancer Screening with FIT Test

Overview:
Colorectal cancer is often developed from adenomatous polyps. Screening for this cancer has been proven to reduce mortality by 16%. The NHS provides home-based screening for older adults through the Faecal Immunochemical Test (FIT). Although a one-off flexible sigmoidoscopy was trialled in England, it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was further exacerbated by the COVID-19 pandemic. However, the trial showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used in future bowel screening programmes.

Faecal Immunochemical Test (FIT) Screening:
The NHS offers a national screening programme 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 FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests as it only detects human haemoglobin, not animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. Although a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy.

Colonoscopy:
Approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

Understanding Crohn’s Disease

Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.

Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include nonspecific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.

To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.

Interpreting Liver Enzyme Results: Differential Diagnosis

When interpreting liver enzyme results, it is important to consider the pattern of elevation and accompanying symptoms to arrive at a differential diagnosis. Here are some possible diagnoses for a patient with elevated alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) levels:

Gallstones: A cholestatic picture with a more significant rise in ALP and GGT over alanine transaminase (ALT) and aspartate transaminase (AST) suggests an obstructive or cholestatic condition. Accompanied by right upper-quadrant pain after eating, gallstones are the most likely diagnosis.

Alcohol abuse: Disproportionate elevation of GGT compared to other liver enzymes may indicate alcohol abuse or alcoholic liver disease. In this case, the ALP is also elevated to the same extent as the GGT, but the patient drinks below the recommended alcohol intake per week.

Paget’s disease: Paget’s disease may cause bone pain and elevated ALP levels. However, the accompanying rise in GGT provides a sensitive indicator of hepatobiliary disease, which is not associated with skeletal disease.

Pancreatitis: Although raised GGT levels have been reported in pancreatic disease, the accompanying derangement of other liver enzymes suggests a liver or biliary cause.

Viral hepatitis: A cholestatic picture with more significant rises in ALP and GGT over ALT and AST is not typical of acute hepatitis, which presents with a hepatocellular picture.

In summary, interpreting liver enzyme results requires careful consideration of the pattern of elevation and accompanying symptoms to arrive at a differential diagnosis.

Dermatitis herpetiformis is a skin disease that causes blisters and is linked to coeliac disease. Both conditions are thought to be caused by autoantibodies that attack transglutaminase enzymes. DH is often seen in patients with coeliac disease, with around 80% of DH patients also showing signs of coeliac disease on small intestine biopsy. A rectal biopsy showing neutrophil infiltration would not be enough to diagnose coeliac disease, as a biopsy from the small intestine is needed to confirm the condition. Coeliac disease is a genetic disorder, and if one family member has it, there is a chance that their first-degree relatives may also be affected. Metronidazole would not help with coeliac disease symptoms, but may be used to treat other gastrointestinal conditions. Hydrogen breath testing is used to diagnose bacterial overgrowth and carbohydrate malabsorption, as bacteria in the intestine produce hydrogen during carbohydrate breakdown.

Breast cancer screening is available to women aged 50-70 years, with a mammogram offered every 3 years. Women over 70 can self-refer. Bowel cancer screening, on the other hand, involves a home test kit every 2 years for individuals aged 60 to 74. It is important to note that breast cancer screening is not recommended for women aged 48-72, and the correct screening interval is every 3 years.

Breast Cancer Screening and Familial Risk Factors

Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

Patients who have cyclical vomiting syndrome have a high probability of developing migraines. The diagnosis of cyclical vomiting syndrome, along with the presence of migraine symptoms such as abdominal pain (which can occur in children), makes migraine the most likely diagnosis. Meningitis is unlikely due to normal examination findings, and meningioma is rare in children and less common than migraine. Gastroenteritis cannot explain the headache or sensitivity to light and noise. There is no indication in the patient’s history of drug overdose.

Understanding Cyclical Vomiting Syndrome

Cyclical vomiting syndrome is a rare condition that is more commonly seen in children than adults. Females are slightly more affected than males. The exact cause of this condition is unknown, but it has been observed that 80% of children and 25% of adults who develop CVS also have migraines.

The symptoms of CVS include severe nausea and sudden vomiting that can last for hours to days. Patients may also experience intense sweating and nausea before an episode. However, they may feel well in between episodes. Other symptoms that may be present include weight loss, reduced appetite, abdominal pain, diarrhea, dizziness, photophobia, and headache.

To diagnose CVS, doctors may perform routine blood tests to exclude any underlying conditions. A pregnancy test may also be considered in women. Treatment for CVS involves avoiding triggers and using prophylactic medications such as amitriptyline, propranolol, and topiramate. During acute episodes, medications such as ondansetron, prochlorperazine, and triptans may be used.

In summary, cyclical vomiting syndrome is a rare condition that can be challenging to diagnose and manage. However, with proper treatment and avoidance of triggers, patients can experience relief from their symptoms.

To accurately test for coeliac disease, patients must consume gluten for a minimum of 6 weeks before undergoing the first-line test, which involves measuring serum total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) levels. Failure to consume gluten prior to the test may result in a false negative result. If a patient refuses to consume gluten, they should be referred to a Gastroenterologist, but it should be noted that even an endoscopy and biopsy may yield a negative result if gluten has been excluded from the diet.

Investigating Coeliac Disease

Coeliac disease is a condition caused by sensitivity to gluten, which leads to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis is made through a combination of serology and endoscopic intestinal biopsy, with villous atrophy and immunology typically reversing on a gluten-free diet.

To investigate coeliac disease, NICE guidelines recommend using tissue transglutaminase (TTG) antibodies (IgA) as the first-choice serology test, along with endomyseal antibody (IgA) and testing for selective IgA deficiency. Anti-gliadin antibody (IgA or IgG) tests are not recommended. The ‘gold standard’ for diagnosis is an endoscopic intestinal biopsy, which should be performed in all suspected cases to confirm or exclude the diagnosis. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Rectal gluten challenge is a less commonly used method.

In summary, investigating coeliac disease involves a combination of serology and endoscopic intestinal biopsy, with NICE guidelines recommending specific tests and the ‘gold standard’ being an intestinal biopsy. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, and lymphocyte infiltration.

Abdominal Migraine: Recurrent Episodes of Midline Abdominal Pain in Children

Abdominal migraine is a disorder that mainly affects children and is characterized by recurrent episodes of midline abdominal pain. The pain can last from 1-72 hours and is of moderate to severe intensity. During the attacks, patients may experience anorexia, nausea, and vomiting. Marked pallor is commonly noted, and some patients may appear flushed. The pain is severe enough to interfere with normal daily activities, and many children describe their mood during the attack as one of intense misery. However, patients are completely symptom-free between attacks.

Abdominal migraine is an idiopathic disorder, meaning that the cause is unknown. It is unlikely to be school avoidance as the symptoms are episodic and can occur outside of school times.

The Role of Carcinoembryonic Antigen (CEA) in Cancer Management

Carcinoembryonic antigen (CEA) is a glycoprotein that is primarily produced by cells in the gastrointestinal tract during embryonic development. While its levels are low in adults, CEA is a useful tumour marker for colorectal cancers. In this article, we explore the different ways in which CEA is used in cancer management.

Postoperative Follow-up
CEA levels are expected to fall to normal following successful removal of colorectal cancer. A rising CEA level thereafter may indicate possible progression or recurrence of the cancer. However, temporary rises can occur during chemotherapy and radiotherapy, so changes during treatment may not necessarily indicate cancer progression.

Staging
CEA levels are not used in staging as there are many variables that can affect the levels. More reliable investigations are used for staging.

Indicator for Operability
While a CEA level at diagnosis higher than 100 ng/ml usually indicates metastatic disease, other investigations are used in the initial assessment of a newly diagnosed cancer to determine suitability for operative management.

Screening Method
CEA is not sensitive or specific enough to use for diagnosis or screening. Cancers of the pancreas, stomach, breast, lung, medullary carcinoma of the thyroid, and ovarian cancer may also elevate CEA. Some non-malignant conditions such as cirrhosis, pancreatitis, and inflammatory bowel disease also cause blood levels to rise.

Detection of Early Stage
CEA is not used for the diagnosis of colorectal cancers as it is not sufficiently sensitive or specific. Early tumours may not cause significant blood elevations, nor may some advanced tumours.

Possible Causes of a Patient’s Abdominal Symptoms: A Differential Diagnosis

The patient presents with abdominal symptoms including cramps, bloating, and diarrhea. The following are possible causes of these symptoms:

1. Giardiasis: Caused by the protozoan parasite Giardia lamblia, transmitted by poor hygiene, and often associated with travel to areas with poor sanitation. Symptoms include diarrhea, flatulence, cramps, bloating, and nausea. Treatment is with metronidazole.

2. Typhoid fever: Caused by Salmonella typhi, often associated with travel to India, Pakistan, and Bangladesh. Symptoms include fever, but not present in this case.

3. Cryptosporidiosis: A parasite infection often causing sudden onset of watery diarrhea, abdominal cramps, and fever. Can be foodborne, waterborne, or transmitted through direct contact with livestock or infected people. Self-limiting, but may require treatment with metronidazole.

4. Salmonella enteritidis infection: The most common cause of salmonella gastroenteritis, often associated with contaminated food or poor hygiene. Symptoms include fever, which is not reported in this case.

5. Tapeworm infection: Caused by ingestion of uncooked or undercooked meat/fish containing tapeworm larvae. Symptoms vary depending on the type of tapeworm and may include abdominal discomfort, weight loss, and abnormal LFTs. Eggs may be found on stool examination, not cysts as in this case.

Overall, giardiasis and cryptosporidiosis are the most likely diagnoses given the patient’s symptoms and travel history. However, further testing and evaluation may be necessary to confirm the diagnosis and determine the appropriate treatment.

Understanding Chronic Hepatitis B Infection

Chronic hepatitis B infection occurs in up to 10% of adults who contract the virus. This means that the virus remains in the body long-term, with the surface antigen (HBsAg) persisting in the serum. However, up to two-thirds of people in the chronic phase remain well and do not experience any liver damage or other issues. This is known as the carrier state or chronic inactive hepatitis B, where HBeAg is absent, anti-HBe is present, and HBV DNA levels are low or undetectable. While carriers can still transmit the virus, their infectivity is lower than those with chronic active hepatitis.

Around 20% of carriers will eventually clear the virus naturally, but this can take several years. However, some carriers may experience spontaneous reactivation of hepatitis B due to the emergence of the HBeAg-negative strain of the virus. The remaining individuals with chronic hepatitis B experience persistent liver inflammation, also known as chronic active hepatitis B. Symptoms can include muscle aches, fatigue, nausea, lack of appetite, intolerance to alcohol, liver pain, jaundice, and depression. HBeAg is usually still present, and the virus is still replicating, with raised HBV DNA levels and high infectivity. Transaminase levels may be elevated, but not always significantly.

If left untreated, chronic active hepatitis B can lead to cirrhosis and even hepatocellular carcinoma. It’s important to note that hepatitis D is a separate virus that only infects individuals who are already infected with hepatitis B. Understanding the different phases and potential outcomes of chronic hepatitis B infection is crucial for proper management and treatment.

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.

The probable reason for the patient’s condition is Clostridium difficile, which could have been caused by the administration of broad-spectrum antibiotics during the operation. According to NICE guidelines, patients undergoing clean surgery with prosthesis or implant placement, clean-contaminated surgery, contaminated surgery, or surgery on a dirty or infected wound should receive antibiotics to prevent surgical site infections. In cases of contaminated or infected wounds, prophylaxis should be accompanied by antibiotic treatment.

Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

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.

Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis

Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. According to the National Institute for Health and Care Excellence (NICE), patients over 50 years old with unexplained rectal bleeding or over 60 years old with a change in bowel habit should be referred for an appointment within 2 weeks for suspected colorectal cancer. However, other conditions can also cause similar symptoms, and differential diagnosis is important to ensure appropriate management.

Rectal Bleeding in a Multiparous Woman

Rectal bleeding is a common symptom that can be caused by various conditions, including haemorrhoids. In a 40-year-old multiparous woman, routine referral would be appropriate if piles could not be identified.

Change in Bowel Habit in a 60-Year-Old Man

A change in bowel habit in a 60-year-old man is more likely to be caused by an acute infection, such as enterohaemorrhagic E. coli or Shigella. Investigations should be directed to finding the cause.

Constipation in an 80-Year-Old Woman

Constipation is a common symptom in the elderly, and dietary factors may play a role. In an 80-year-old woman with intermittent constipation and no teeth, the symptom is likely to be longstanding and not indicative of colorectal cancer.

Anal Fissure in a 70-Year-Old Man

Anal fissure is a possible cause of rectal bleeding in a 70-year-old man. Further investigation is needed to confirm the diagnosis and rule out other conditions.

Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis

Thrombosed haemorrhoids are characterized by severe pain and the presence of a tender lump. Upon examination, a purplish, swollen, and tender subcutaneous perianal mass can be observed. If the patient seeks medical attention within 72 hours of onset, referral for excision may be necessary. However, if the condition has progressed beyond this timeframe, patients can typically manage their symptoms with stool softeners, ice packs, and pain relief medication. Symptoms usually subside within 10 days.

Caloric and Fat Content of Selected Foods

When it comes to watching our calorie and fat intake, it’s important to be mindful of the foods we consume. Here’s a breakdown of the caloric and fat content of some common foods:

Cheddar Cheese 100g
This amount of cheddar cheese contains a whopping 413 kcal and 34g of fat, making it the highest in both categories compared to the other foods listed.

Banana 100g
A 100g banana contains 95 kcal and is a great source of potassium and fiber.

Cornflakes 30g
A 30g serving of cornflakes with 125 ml of semi-skimmed milk contains 173 kcal and 2.5g of fat.

Orange Juice Unsweetened 140ml
140 ml of unsweetened orange juice contains roughly 50 kcal. While it’s important to be mindful of sugar intake, consuming a small glass of fruit juice each day can count towards our recommended daily intake of fruits and vegetables.

Plain Scone 48g
A plain scone weighing 48g contains around 173 kcal and 7g of fat. It’s important to enjoy treats in moderation and balance them with healthier options.

IBS patients should steer clear of insoluble sources of fiber like bran and wholemeal.

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.

Investigating Bowel Symptoms in Patients with Irritable Bowel Syndrome

A patient with a history of irritable bowel syndrome (IBS) presenting with acute bowel symptoms is a common scenario. However, if their symptoms have undergone a marked change and become more persistent than usual, it is important to consider the possibility of colorectal cancer. In this context, an abdominal X-ray or ultrasound is not appropriate, and testing for inflammatory markers such as ESR doesn’t provide specific information that would aid referral. Tumour marker testing is also not an appropriate primary care investigation.

According to NICE guidelines, quantitative faecal immunochemical tests should be offered to assess for colorectal cancer in adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss, or aged under 60 with changes in their bowel habit or iron-deficiency anaemia. It is important to follow these guidelines to ensure appropriate investigation and referral for patients with IBS and changing bowel symptoms.

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.

Psoriasis is an extraintestinal manifestation that is not associated with the activity of the disease.

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.

Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

Treatment Options for Moderate Exacerbation of Ulcerative Colitis

When a patient experiences a moderate exacerbation of ulcerative colitis, there are several treatment options available. The most appropriate choice is a dose of 20-40 mg of oral prednisolone per day, which should be continued until the patient enters remission. If there is an inadequate response after 2-4 weeks, ciclosporin tablets can be added to the regimen to induce remission. However, these should only be prescribed by specialists in secondary care. Anti-motility drugs such as co-phenotrope should not be used as they may precipitate paralytic ileus and megacolon in active ulcerative colitis. Topical mesalazine is only effective for distal disease, so it is not appropriate for patients with diffuse disease. Topical corticosteroids in the form of prednisolone retention enemas can be used to induce remission in patients with proctitis, but for diffuse disease, oral corticosteroids are more effective.