For your information... Chvostek's and Trousseau's Sign

This question was taken from the Sheffield Feb 2014 exam.

Both Chvostek's and Trousseau's sign are clinical signs elicited in patient's who have Hypocalcaemia

Chvostek's Sign
There are 2 variations to this sign but the most common practiced variation is where the practitioner uses either a finger or a hammer to tap at the angle of the jaw. In a patient with hypocalcaemia, this results in ipsilateral contraction of some or all of the muscles innervated by the facial nerve.

The technique described above involves using a finger to tap on Point A

Trousseau's sign

A blood pressure cuff is inflated to above systolic blood pressure and sustained for 3 mins. The subsequent lack of blood flow will induce spams of the muscles of the hands and forearms.

• Flex
• Wrist and Metocarpophalangeal joints
• Extend
• Distal and Proximal Interphalangeal joints
• Adduct
• Fingers

Question of the Day... Barrett's Oesophagus

This question was taken from the Glasgow Oct 2013 Exam. It was a communications skills station, however some basic knowledge is still required.

Question:
Mr. Brown has had a Barium swallow that shows a stricture. Please counsel him for OGD and dilatation.

Answer:
Risk factors for oesophageal cancer:

• Age - >60
• Gender - Males > Females
• Smoking and heavy alcohol use - use together increases risk more than either individually.
• GORD - Gastro-Oesophageal Reflux Disease and Barretts Oesophagus
• Obesity
• Previous Radiation
• Family History of Oesophageal Ca

Clinical Evaluation

• Gold standard - OGD
• Imaging - Barium swallow/barium meal

Biopsies taken during OGD are then examined histologically for signs of malignancy.

Staging scans:

• CT Thorax/Abdomen/Pelvis - to determine distal metastases, espcially LN and liver
• EUS - provides T staging

Location of the tumour determined by distance from incisors.

Red flags

• Dysphagia
• Anorexia/early satiety
• Jaundice
• Persistent projectile vomiting
• Palpable Abdominal Mass
• Unexplained weight loss >10% body weight or 3kg
• Anaemia
• PR bleeding/Melaena/Haematemesis

Barrett's Oesophagus

Definition = metaplasia of lower oesophageal epithelium from normal stratified squamous epithelium to simple columnar epithelium with Goblet cells.

• Strong association with adenocarcinoma
• Diagnosis of Barrett's requires histological confirmation of the presence of Goblet cells (Specialize Intestinal Metaplasia or SIM)

Pathophysiology

GORD causes chronic inflammation that causes damage to the cells of the gastro-oesophageal junction.

Epidermal Growth Factor Receptor inhibited by bile acids causes intestinal differentiation.

Biopsy Protocol

The Seattle Biopsy protocol requires 4 quadrant biopsies every 2 cm with targetted biopsies on macroscopically visible lesions. Distal biopsies taken 1st starting 1-2 cm above GOJ and advancing proximally to minimise obscured view from bleeding.

For Your Information... Refeeding Syndrome

A question on Refeeding Syndrome was asked on the February 2013 London Exam.

Refeeding syndrome

Definition
Metabolic disturbances that result from reinstitution of nutrition to patients who are starved or severely malnourished.

Pathogenesis
During prolonged fasting the body conserves muscle and protein breakdown by metabolising fatty acids to ketone bodies as its main energy source. The liver reduces gluconeogenesis, thus conserving muscle and protein.

Insulin secretion Decreased, Glucagon secretion Increased

Intracellular minerals are severely depleted in order to keep serum levels normal.

Once patients start feeding again the following occurs:

1. Increased blood sugar stimulates insulin secretion
2. Glycogen, Fat and Protein synthesis increases
3. Basal metabolic rate rises
4. Serum electrolytes move into intracellular space
5. Serum levels of phosphate, magnesium and potassium are quickly used up in the formation ATP and phosphorylation of carbohydrates
6. The precipitous drop in serum mineral levels causes cardiac arrhythmias, confusion, coma, cardiac failure and death.

Treatment

• High index of suspicion
• Close monitoring of blood biochemistry with adequate replacement either enterically or parenterally if required
• Thiamine and Vit B Complex supplementation is recommended
• Limit energy intake for first 3-5 days of commencement of feeding to 50-70% of normal daily requirements

Question of the Day... Pseudomembranous colitis

This question was taken from May Edinburgh 2013 exam.

Question:

What is pseudomembranous colitis? What is the organism responsible and what is the pathophysiology?

Answer:

Pseudomembranous colitis is inflammation of the bowel associated with clostridium dificile and is a cause of antibiotic-associated diarrhoea.

Pathophysiology

The use of broad spectrum antibiotics such as cephalosporins or penicillin based antibiotics such as amoxicillin cause alteration of the normal bowel flora. The antibiotic kills off other competing bacteria in the intestine and any bacteria that remains has less competition for space and nutrients. Clostridium dificile may colonize the gut usually but when over-extensive growth due to less competition, in conjunction with toxins produced by the Clostridium dificile results in pseudomembranous colitis

Pseudomembranous colitis

The pseudomembranes on the mucosa of the colon or rectum is diagnostic. The pseudomembranes are composed of an exudate made of inflammatory debris, white blood cells.

Mnemonics... Pancreatitis

Here is a common but neat way to remember the causes of Pancreatitis:

I - Idiopathic

G - Gallstones
E - Ethanol (Alcohol consumption)
T - Trauma

S - Steroids
M - Mumps
A - Autoimmune (SLE, RA)
S - Scorpion sting
H - Hyperlipidaemia
E - ERCP (Iatrogenic)
D - Drugs

For Your Information... Granuloma

What is a Granuloma?

A granuloma is a collection of activated macrophages!