Материал: 100_Cases_in_Clinical_Medicine

ANSWER 36

This woman has diverticulitis. Colonic diverticula are small outpouchings which are most commonly found in the left colon. They are very common in the elderly Western population probably due to a deficiency in dietary fibre. Symptomatic diverticular disease has many of the features of irritable bowel syndrome. Inflammation in a diverticulum is termed diverticulitis. In severe cases, perforation, paracolic abscess formation or septicaemia may develop. Other potential complications include bowel obstruction. formation of a fistula into rectum or vagina, and haemorrhage.

The barium enema from 4 years ago shows evidence of diverticular disease with outpouchings of the mucosa in the sigmoid colon. This would be consistent with the long-standing history of abdominal pain of colonic type and tendency to constipation. The recent problems with increased pain, tenderness, fever, raised white cell count and CRP and a mass in the left iliac fossa would be compatible with an acute exacerbation of her diverticular disease. In her case there is no evidence of peritonitis which would signal a possible perforation of one of the diverticula.

The differential diagnosis, with the suggestion of a mass and change in bowel habit, would be carcinoma of the colon and Crohn’s disease. In the absence of evidence of perforation with leak of bowel contents into the peritoneum (no peritonitis) or obstruction (normal bowel sounds, no general distension), treatment should be based on the presumptive diagnosis of diverticulitis. A colonoscopy should be performed at a later date to exclude the possibility of a colonic neoplasm.

A CT scan of the abdomen will delineate the mass and suggest whether there is evidence of local abscess formation. Treatment should include broad-spectrum antibiotics, intravenous fluids and rest. Further investigations are indicated, including electrolytes, urea and creatinine, glucose, liver function tests and blood cultures. Repeated severe episodes, bleeding or obstruction may necessitate surgery.

KEY POINTS

•Diverticular disease is a common finding in the elderly Western population and may be asymptomatic or cause irritable bowel syndrome-type symptoms.

•Diverticular disease is a common condition; its presence can distract the unwary doctor from pursuing a co-incident condition.

•Diverticulitis needs to be treated with antibiotics to reduce the chance of complications such as perforation or fistula formation occurring.

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CASE 37: HIGH BLOOD PRESSURE

History

A 36-year-old woman is referred by her general practitioner (GP) to a hypertension clinic. She was noted to be hypertensive when she joined the practice 2 years previously. Her blood pressure has been difficult to control and she is currently taking four agents (bendrofluazide, atenolol, amlodipine and doxazosin). She had normal blood pressure and no pre-eclampsia during her only pregnancy 9 years previously. There is no family history of premature hypertension. She smokes 20 cigarettes a day and drinks less than 10 units a week. She is not on the oral contraceptive pill. She works part time as a teaching assistant.

Examination

She is not overweight and looks well. Her pulse rate is 68/minute and blood pressure 180/102 mmHg. There is no radiofemoral delay. There are no café-au-lait spots or neurofibromas. Examination of the cardiovascular, respiratory and abdominal systems is normal. The fundi show no significant changes of hypertension.

INVESTIGATIONS

Urinalysis: no protein; no blood

Renal ultrasound: normal size kidneys

Results of a renal angiogram are shown in Fig. 37.1.

Figure 37.1 Renal angiogram.

Questions

•What is the diagnosis?

•How would you further manage this patient?

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ANSWER 37

This woman has hypertension due to renovascular disease. The vast majority of cases of hypertension are due to essential hypertension. Risk factors for essential hypertension include a family history of hypertension, obesity and lack of exercise. She does not have paroxysmal symptoms of sweating, palpitations and anxiety to suggest a phaeochromocytoma. There are no clinical features to suggest coarctation of the aorta (radiofemoral delay) or neurofibromatosis (café-au-lait spots/neurofibromas). Serum potassium is not low making Conn’s syndrome or Cushing’s syndrome unlikely. The principal abnormality is the modestly raised creatinine suggesting mildly impaired renal function. The absence of haematuria and proteinuria excludes glomerulonephritis. Therefore renovascular disease needs to be considered. The absence of a renal bruit does not exclude the possibility of renovascular disease. The renal angiogram shows bilateral fibromuscular dysplasia (FMD).

The commonest cause of renovascular disease is atherosclerotic renal artery stenosis (ARAS). This is common in elderly patients with evidence of generalized atherosclerosis (peripheral vascular disease and coronary artery disease). Ultrasound will often show small kidneys, and renal impairment is common. ARAS is a common cause of end-stage renal failure in the elderly.

At this woman’s age atherosclerotic renovascular disease is very unlikely. FMD is the second most common cause of renovascular disease. The commonest form is medial fibroplasia with thinning of the intima and media leading to formation of aneurysms alternating with stenoses, leading to the classic ‘string of beads’ appearances on angiography. It predominantly affects young and middle-aged women with a peak incidence in the fourth decade of life. Cigarette smoking is a risk factor. FMD usually presents with hypertension, but can rarely present with ‘flash’ pulmonary oedema. FMD can also affect the carotid arteries causing a variety of neurological symptoms.

Treatment is with percutaneous transluminal renal angioplasty. Unlike atheromatous renovascular disease, the hypertension in FMD cases is often cured leading to complete cessation of blood pressure medication. Restenosis is rare.

KEY POINTS

•FMD is an important cause of hypertension in young and middle-aged women.

•Renal artery angioplasty will improve or even cure hypertension in many patients with FMD.

•FMD is a very rare cause of end-stage renal failure.

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CASE 38: SWELLING ON THE LEGS

History

A 34-year-old woman presents to her general practitioner (GP) complaining of a rash. Over the past 2 weeks she has developed multiple tender red swellings on her shins and forearms. The older swellings are darker in colour and seem to be healing from the centre. She feels generally unwell and tired and also has pains in her wrists and ankles. She has not had a recent sore throat. Over the past 2 years she has had recurrent aphthous ulcers in her mouth. She has had no genital ulceration but she has been troubled by intermittent abdominal pain and diarrhoea. She works as a waitress and is unmarried. She smokes about 15 cigarettes per day and drinks alcohol only occasionally. She has had no other previous medical illnesses and there is no relevant family history that she can recall.

Examination

She is thin but looks well. There are no aphthous ulcers to see at the time of the examination. Her joints are not inflamed and the range of movement is not restricted or painful. Examining the skin there are multiple tender lesions on the shins and forearms. The lesions are raised and vary from 1 to 3 cm in diameter. The fresher lesions are red and the older ones look like bruises. Physical examination is otherwise normal.

INVESTIGATIONS

Questions

•What is the diagnosis?

•What are the major causes of this condition?

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