Differential Diagnosis for Cholestatic Jaundice in a Patient with UC

Primary sclerosing cholangitis (PSC) is a condition that should be considered in a patient with UC who presents with a raised alkaline phosphatase level. This is because approximately two-thirds of patients with PSC also have coexisting UC, and between 3% and 8% of UC sufferers will develop PSC. Chronic cholecystitis would present with pain, which is not present in this patient, making PSC the more likely diagnosis. Acute cholecystitis would present with right upper quadrant pain and obstructive liver function tests, which are not present in this case. Primary biliary cholangitis is more likely to affect women aged 30-60, and given the patient’s history of UC, PSC is more likely. Pancreatic carcinoma would be associated with weight loss and obstructive liver function tests. Therefore, in a patient with UC presenting with cholestatic jaundice, PSC should be considered as a possible diagnosis.

Considerations for Non-Responsive Coeliac Disease

Coeliac disease, also known as gluten-sensitive enteropathy, is associated with specific human leukocyte antigen subtypes. The hallmark of this disease is the disappearance of clinical features and intestinal histologic findings upon discontinuing gluten in the diet. However, in cases where patients who were previously responding well to a gluten-free diet stop responding, the possibility of intestinal T-cell lymphoma, a complication of coeliac disease, should be strongly considered.

Other conditions, such as tropical sprue, dermatitis herpetiformis, collagenous sprue, and refractory sprue, may also present with similar symptoms but have different responses to gluten restriction. Tropical sprue does not respond to gluten restriction, while dermatitis herpetiformis is a skin disease associated with coeliac disease and does not cause failure of response to a gluten-free diet. Collagenous sprue is characterized by the presence of a collagen layer beneath the basement membrane and does not respond to a gluten-free diet. Refractory sprue, on the other hand, is a subset of coeliac disease where patients do not respond to gluten restriction and may require glucocorticoids or restriction of soy products.

In conclusion, when a patient with coeliac disease stops responding to a gluten-free diet, it is important to consider the possibility of intestinal T-cell lymphoma and differentiate it from other conditions that may present with similar symptoms but have different responses to gluten restriction.

The vagus nerves are part of the tenth pair of cranial nerves and work with sympathetic nerves to form the oesophageal plexus. They have a parasympathetic function, stimulating peristalsis and supplying smooth muscle. The lower oesophageal sphincter, which relaxes to allow food into the stomach, is influenced by the vagus nerve. Oesophageal achalasia can occur when there is increased tone of the lower oesophageal sphincter, incomplete relaxation, and lack of peristalsis, leading to dysphagia and regurgitation.

The glossopharyngeal nerves are mixed cranial nerves that supply motor fibres to the stylopharyngeus muscle and parasympathetic fibres to the parotid gland. They also form the pharyngeal plexus with the vagus nerve, supplying the palate, larynx, and pharynx.

The greater splanchnic nerves contribute to the coeliac plexus, which supplies the enteric nervous system and the adrenals. The intercostal nerves arise from the anterior rami of the first 11 thoracic spinal nerves and supply various structures in their intercostal space. The phrenic nerves supply the diaphragm.

Understanding Mesenteric Ischaemia: Common Sites of Affection

Mesenteric ischaemia is a condition that can be likened to angina of the intestine. It is typically seen in patients who have arteriopathy or atrial fibrillation, which predisposes them to arterial embolism. When these patients eat, the increased vascular demand of the bowel cannot be met, leading to ischaemia and abdominal pain. The most common site of mesenteric ischaemia is at the splenic flexure, which is the watershed between the superior and inferior mesenteric arterial supplies.

Acute mesenteric ischaemia occurs when a blood clot blocks the blood supply to a section of the bowel, causing acute ischaemia and severe abdominal pain. While the sigmoid colon may be affected in mesenteric ischaemia, it is not the most common site. It is supplied by the inferior mesenteric artery. The hepatic flexure, which is supplied by the superior mesenteric artery, and the ileocaecal segment, which is also supplied by the superior mesenteric artery, are not the most common sites of mesenteric ischaemia. The jejunum, which is supplied by the superior mesenteric artery, may also be affected, but it is not the most common site.

The patient’s symptoms of intermittent dysphagia without odynophagia, abnormal blood tests, or constitutional symptoms suggest a diagnosis of diffuse esophageal spasm. This condition is characterized by increased simultaneous and intermittent contractions of the distal esophagus, often accompanied by retrosternal chest pain, heartburn, and globus sensation. Oesophageal manometry is the first-line investigation for diffuse esophageal spasm, revealing increased simultaneous contractions of the esophageal body with normal lower esophageal sphincter tone. Barium radiography may show a corkscrew esophagus, but it has low sensitivity for diagnosing this condition. Troponin levels would only be indicated if the patient had cardiac-related chest pain, which is unlikely given their age and normal ECG. A chest X-ray would be useful if a cardiac or respiratory condition were suspected, while a lateral cervical spine radiograph is only necessary if cervical osteophytes are thought to be the cause of difficult swallowing, which is unlikely in this young patient.

Abdominal Signs and Their Meanings

Abdominal signs are physical findings that can help diagnose certain conditions. Here are some common abdominal signs and their meanings:

Cope’s Sign (Obturator Sign)
This sign indicates appendicitis and is elicited by flexing and internally rotating the hip. It suggests that the inflamed appendix is close to the obturator internus muscle.

Murphy’s Sign
This sign is a test for gallbladder disease. It involves palpating the right upper quadrant of the abdomen while the patient takes a deep breath. If there is pain during inspiration, it suggests inflammation of the gallbladder.

Pemberton’s Sign
This sign is seen in patients with superior vena cava obstruction. When the patient raises their hands above their head, it increases pressure over the thoracic inlet and causes venous congestion in the face and neck.

Psoas Sign
This sign is a test for appendicitis. It involves extending the patient’s leg while they lie on their side. If this reproduces their pain, it suggests inflammation of the psoas muscle, which lies at the border of the peritoneal cavity.

Rovsing’s Sign
This sign is another test for appendicitis. It involves palpating the left iliac fossa, which can reproduce pain in the right iliac fossa. This occurs because the nerves in the intestine do not localize well to an exact spot on the abdominal wall.

In summary, abdominal signs can provide valuable information in the diagnosis of certain conditions. It is important to understand their meanings and how to elicit them properly.

The only definitive treatment for advanced hepatic disease in primary sclerosing cholangitis (PSC) is orthotopic liver transplantation (OLT). Patients with intractable pruritus and recurrent bacterial cholangitis are specifically indicated for transplant. Although there is a 25-30% recurrence rate in 5 years, outcomes following transplant are good, with an 80-90% 5-year survival rate. PSC has become the second most common reason for liver transplantation in the United Kingdom. Other treatments such as steroids, azathioprine, methotrexate, and pentoxifylline have not been found to be useful. Antibiotic prophylaxis with ciprofloxacin or co-trimoxazole can be used to treat bacterial ascending cholangitis, but it will not alter the natural course of the disease.

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.

Prophylactic Antibiotics for Gut Surgery

Prophylactic antibiotics are commonly used in gut surgery to prevent wound infections, which can occur in up to 60% of cases. The use of prophylactic antibiotics has been shown to significantly reduce the incidence of these infections. Co-amoxiclav is the preferred choice for non-penicillin allergic patients, as it is effective against the types of bacteria commonly found in the gut, including anaerobes, enterococci, and coliforms.

While cefotaxime is often used to treat meningitis, it is not typically used as a prophylactic antibiotic in gut surgery. In patients with mild penicillin allergies, cefuroxime and metronidazole may be used instead. However, it is important to note that cephalosporins should be avoided in elderly patients whenever possible, as they are at a higher risk of developing C. difficile infections. Overall, the use of prophylactic antibiotics is an important measure in preventing wound infections in gut surgery.

Medications for Oesophageal Variceal Bleeds

Oesophageal variceal bleeds are a serious medical emergency that require prompt treatment. The most important medication to administer in this situation is terlipressin, which reduces bleeding by constricting the mesenteric arterial circulation and decreasing portal venous inflow. Clopidogrel, an antiplatelet medication, should not be used as it may worsen bleeding. Propranolol, a beta-blocker, can be used prophylactically to prevent variceal bleeding but is not the most important medication to start in an acute setting. Omeprazole, a proton pump inhibitor, is not recommended before endoscopy in the latest guidelines but is often used in hospital protocols. Tranexamic acid can aid in the treatment of acute bleeding but is not indicated for oesophageal variceal bleeds. Following terlipressin administration, band ligation should be performed, and if bleeding persists, TIPS should be considered.