The transpyloric plane, also known as Addison’s plane, is an imaginary plane located at the level of the L1 vertebral body. It is situated halfway between the jugular notch and the superior border of the pubic symphysis and serves as an important anatomical landmark. Various structures lie in this plane, including the pylorus of the stomach, the first part of the duodenum, the duodeno-jejunal flexure, both the hepatic and splenic flexures of the colon, the fundus of the gallbladder, the neck of the pancreas, the hila of the kidneys and spleen, the ninth costal cartilage, and the spinal cord termination. Additionally, the origin of the superior mesenteric artery and the point where the splenic vein and superior mesenteric vein join to form the portal vein are located in this plane. The cardio-oesophageal junction, where the oesophagus meets the stomach, is also found in this area. It is mainly intra-abdominal, 3-4 cm in length, and houses the gastro-oesophageal sphincter. The ninth costal cartilage lies at the transpyloric plane, not the eighth, and the hila of both kidneys are located here, not just the superior pole of the left kidney. The uncinate process of the pancreas, which is an extension of the lower part of the head of the pancreas, lies between the superior mesenteric vessel and the aorta, and the neck of the pancreas is situated along the transpyloric plane.

Faecal Transplant: A New Treatment Option for Severe and Recurrent C. difficile Infection

Severe and treatment-resistant C. difficile infection can be a challenging condition to manage. In cases where intravenous metronidazole is not an option, faecal microbiota transplantation (FMT) has emerged as a promising treatment option. FMT involves transferring bacterial flora from a healthy donor to the patient’s gut, which can effectively cure the current infection and prevent recurrence.

A randomized study published in the New England Journal of Medicine reported a 94% cure rate of pseudomembranous colitis caused by C. difficile with FMT, compared to just 31% with vancomycin. While FMT is recommended by the National Institute for Health and Care Excellence (NICE) in recurrent cases that are resistant to antibiotic therapy, it is still a relatively new treatment option that requires further validation.

Other treatment options, such as IV clindamycin and intravenous ciprofloxacin, are not suitable for this condition. Oral metronidazole is a second-line treatment for mild or moderate cases, but it is unlikely to be effective in severe cases that are resistant to oral vancomycin. Total colectomy may be necessary in cases of colonic perforation or toxic megacolon with systemic symptoms, but it is not a good choice for this patient.

In conclusion, FMT is a promising new treatment option for severe and recurrent C. difficile infection that is resistant to antibiotic therapy. Further research is needed to fully understand its effectiveness and potential risks.

Understanding the serology of hepatitis B virus (HBV) is important for medical exams. HBV is a virus with an envelope and DNA, containing surface protein (HBsAg), core protein (HBcAg), and envelope protein (HBeAg). A positive HBsAg indicates acute or chronic infection, while anti-HBs-positive titres indicate previous immunisation or resolved HBV infection. Anti-HBc IgM rises after 2 months of inoculation and drops after 6 months, while anti-HBc IgG is positive after 4-6 months and remains positive for life, indicating chronic infection. HBeAg was thought to imply high infectivity, but an HBeAg-negative subtype is now recognised. Incubation period shows positive HBsAg, negative anti-HBsAg, presence of HBeAg, and negative IgM and IgG anti-HBcAg. Recovery shows positive anti-HBsAg and raised IgG anti-HBcAg with or without anti-HBeAg. Acute infection shows raised IgM anti-HBcAg with or without raised IgG anti-HBcAg. Recent vaccination shows positive anti-HBsAg.

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.

Differential diagnosis of a patient with liver disease and neurological symptoms

Wilson’s disease, haemochromatosis, alcohol-related cirrhosis, viral hepatitis, and primary sclerosing cholangitis are among the possible causes of liver disease. In the case of a patient with Kayser-Fleischer rings, the likelihood of Wilson’s disease increases, as this is a characteristic sign of copper overload due to defective incorporation of copper and caeruloplasmin. Neurological symptoms such as disinhibition, emotional lability, and chorea may also suggest Wilson’s disease, although they are not specific to it. Haemochromatosis, which is characterized by iron overload, can be ruled out if the ferritin level is normal. Alcohol-related cirrhosis is less likely if the patient denies alcohol or drug abuse, but this information may not always be reliable. Viral hepatitis is a common cause of liver disease, but in this case, there are no obvious risk factors in the history. Primary sclerosing cholangitis, which is a chronic inflammatory disease of the bile ducts, does not present with Kayser-Fleischer rings. Therefore, a careful evaluation of the patient’s clinical features, laboratory tests, and imaging studies is necessary to establish the correct diagnosis and guide the appropriate treatment.

Achalasia is a condition where the lower oesophageal sphincter fails to relax during swallowing, causing difficulty in swallowing both solids and liquids. The cause is often unknown, and diagnosis involves various tests such as chest X-ray, barium swallow, oesophagoscopy, CT scan, and manometry. Treatment options include sphincter dilation using Botox or balloon dilation, and surgery if necessary. Oesophageal web is a thin membrane in the oesophagus that can cause dysphagia to solids and reflux symptoms. Chagas’ disease, scleroderma, and diffuse oesophageal spasm are other conditions that can cause similar symptoms but have different causes and treatments.

Treatment Options for Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a chronic disease that causes inflammation and sclerosis of the bile ducts. It often presents with pruritus, fatigue, and jaundice, and is more common in men and those with ulcerative colitis (UC). The only definitive treatment for PSC is liver transplantation, as endoscopic stenting is not effective due to the multiple sites of stenosis. Ursodeoxycholic acid has shown some benefit in short-term studies, but its long-term efficacy is uncertain. Fat-soluble vitamin supplementation is often required due to malabsorption, but is not a treatment for the disease. Azathioprine and steroids are not typically useful in PSC treatment, as too much immunosuppressive therapy may worsen associated bone disease. Regular surveillance is necessary after liver transplantation, as recurrence of PSC is possible.

Imaging Modalities for Abdominal Conditions: Choosing the Right Test

When a patient presents with abdominal symptoms, choosing the appropriate imaging modality is crucial for accurate diagnosis and timely treatment. Here are some considerations for different tests:

Abdominal X-ray: This is a quick and effective way to assess for conditions such as toxic megacolon, which can be life-threatening. A dilated transverse colon (>6 cm) on an abdominal X-ray is diagnostic of toxic megacolon.

Abdominal ultrasound: This test is useful for assessing the abdominal aorta for aneurysms, but it is not recommended for suspected inflammatory bowel disease.

Oesophagogastroduodenoscopy (OGD): This test is recommended for patients with suspected oesophageal or gastric pathology, but it is not useful for assessing the large colon.

Colonoscopy: While colonoscopy is a valuable tool for diagnosing ulcerative colitis, it is contraindicated during acute flares as it increases the risk of bowel perforation.

Computed tomography (CT) scan of the kidney, ureters and bladder: This test is indicated for patients with suspected kidney stones, which typically present with loin to groin pain and haematuria.

In summary, choosing the right imaging modality depends on the suspected condition and the patient’s symptoms. A prompt and accurate diagnosis can lead to better outcomes for patients.

Appropriate Management for a Patient with Dysphagia and ‘Alarm’ Symptoms

When a patient presents with dysphagia and ‘alarm’ symptoms such as weight loss, anorexia, and swallowing difficulties, prompt referral for an urgent endoscopy is necessary. In the case of a patient with a significant smoking history, male sex, and alcohol intake, there is a high suspicion for oesophageal cancer, and an immediate referral to an upper gastrointestinal surgeon is required under the 2-week-wait rule.

Continuing treatment with over-the-counter medications like Gaviscon would be inappropriate in this case, as would histamine-2 receptor antagonist therapy. Oesophageal manometry would only be indicated if the patient had an oesophageal motility disorder. Proton-pump inhibitor (PPI) therapy can be initiated in patients with gastroesophageal reflux disease, but it would not be appropriate as a sole treatment option for a patient with clinical manifestations concerning for oesophageal carcinoma.

In summary, prompt referral for an urgent endoscopy is crucial for patients with dysphagia and ‘alarm’ symptoms, and appropriate management should be tailored to the individual patient’s clinical presentation.

Neuroendocrine Tumors and Hormones: Understanding Carcinoid Syndrome and Related Hormones

Carcinoid syndrome is a condition caused by a neuroendocrine tumor, typically found in the gastrointestinal tract, that releases serotonin. Symptoms include flushing, diarrhea, and bronchospasm, and in some cases, carcinoid heart disease. Diagnosis is made by finding high levels of urine 5-hydroxyindoleacetic acid. Somatostatin, an inhibitory hormone, is used to treat VIPomas and carcinoid tumors. Vasoactive intestinal peptide (VIP) can cause copious diarrhea but does not cause valvular heart disease. Nitric oxide does not play a role in carcinoid syndrome, while ghrelin regulates hunger and is associated with Prader-Willi syndrome. Understanding these hormones can aid in the diagnosis and treatment of neuroendocrine tumors.