Материал: 100_Cases_in_Clinical_Medicine

CASE 81: ABDOMINAL PAIN

History

A 38-year-old man has a 2-month history of abdominal pain. The pain is epigastric or central and is intermittent. He had a similar episode a year before. On that occasion he took some indigestion mixture obtained from a retail pharmacy, and the symptoms resolved after 10 weeks. The pain usually lasts for 30–60 min. It often occurs at night, when it can wake him up, and seems to improve after meals. Some foods such as curries and other spicy foods seem to bring on the pain on occasions.

He has smoked 10–15 cigarettes per day for 25 years and drinks around 30 units of alcohol each week. He is not taking any medication at present. There is no other relevant medical history. He works as a financial broker in the City. He has been feeling more tired recently and had put this down to pressure of work. A blood count was sent.

Examination

There is mild tenderness in the epigastrium, but no other abnormalities.

INVESTIGATIONS

The blood film is reported as showing microcytic, hypochromic red cells.

Questions

•How do you interpret these findings?

•What is the likely diagnosis and how should it be confirmed?

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ANSWER 81

The blood count shows anaemia with a low MCV indicating a microcytic anaemia. The high red cell count with low haemoglobin shows that the haemoglobin content of the cells is reduced. The low serum iron and ferritin with a high total iron-binding capacity (TIBC) confirm that this is related to true iron deficiency. The blood film confirms that the cells are microcytic and low in haemoglobin (hypochromasia). In anaemia of chronic disease the cells may be microcytic and serum iron low but the TIBC would be low also and ferritin normal. The diagnosis is most likely to be a peptic ulcer.

The commonest cause of iron-deficiency anaemia in a man is gastrointestinal blood loss. In a premenopausal woman menstrual blood loss would be the most common cause. The abdominal pains would be consistent with those from a peptic ulcer, especially a duodenal ulcer when there is more often some relief from food. The diagnosis should be established by endoscopy because alternative diagnoses such as carcinoma of the stomach cannot be ruled out from the history. The site of the blood loss causing the iron deficiency should be established. At the same time the presence of Helicobacter pylori should be investigated.

In this case, an endoscopy confirmed an active duodenal ulcer and samples were positive for Helicobacter pylori. This is associated with gastritis and with over 90 per cent of duodenal ulcers. Tests of expired breath and serum antibodies are alternative diagnostic tests. The H. pylori was treated by a combined regime of omeprazole for 6 weeks and triple therapy with lansoprazole, amoxicillin and clarithromycin for 7 days. He was given strong recommendations to stop smoking and to address his excessive alcohol consumption. The iron deficiency was corrected by additional oral iron which was continued for 3 months to replenish the iron stores in the bone marrow. Repeat endoscopy to show healing confirms the original diagnosis of benign ulceration.

KEY POINTS

•Various antibiotic regimes have been shown to temporarily remove Helicobacter pylori and prevent or postpone recurrence of symptoms and ulceration.

•Replenishment of iron stores in the bone marrow needs 3 months’ treatment with oral iron after the haemoglobin has returned to normal.

•Ferritin is an acute-phase protein and will be raised in the presence of acute illness even in the presence of iron deficiency.

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CASE 82: ACHES AND PAINS

History

A 76-year-old woman has felt non-specifically unwell for about 10 weeks. She feels stiff especially when she gets up in the morning. She struggles to get out of bed by herself and she has difficulty lifting her hand to comb her hair. She has also noticed some pain in her knees and fingers. She has lost 4 kg in weight, and has noticed some sweats which seem to occur at night. She has come to see her general practitioner (GP) because a new problem has arisen. For the last few days she has had a constant severe headache. On direct questioning she says that she has had pain in her jaw when chewing. She has previously been fit with no significant past medical history. She lives alone. She has not smoked for 40 years and she only drinks alcohol at Christmas. She is taking no regular medication. She has tried some paracetamol but this has not helped the headache.

Examination

She is thin. She is markedly tender to palpation over parts of her scalp. Her blood pressure is 138/84 mmHg. Examination of her cardiovascular, respiratory and abdominal systems is normal. Power is slightly reduced in the proximal muscles of her arms and legs. Neurological examination is otherwise normal.

INVESTIGATIONS

Questions

•What is the diagnosis?

•How would you investigate and manage this patient?

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ANSWER 82

This woman has the typical clinical symptoms of polymyalgia rheumatica/giant cell arteritis. Most patients are over 65 years. The onset of symptoms is often sudden. Patients may present primarily with polymyalgia-type symptoms (proximal muscle pain and stiffness most marked in the mornings) or temporal arteritis symptoms (severe headaches with tenderness over the arteries involved). Patients may have systemic symptoms such as general malaise, weight loss and night sweats. Characteristically, the ESR is very elevated (at least 40 mm/h) and there is a mild anaemia and leucocytosis. The liver enzymes are often slightly raised. In polymyalgia, the main symptoms are muscle stiffness and pain which may simulate muscle weakness. The creatine kinase is normal, unlike in polymyositis.

The diagnosis of polymyalgia rheumatica is essentially a clinical diagnosis. A very elevated ESR is useful. Around 25 per cent of patients with giant cell arteritis have polymyalgia. When there are headaches and giant cell arteritis is suspected, a temporal artery biopsy should be performed. However, the histology may be normal because the vessel involvement with inflammation is patchy. Nevertheless, a positive result provides reassurance about the diagnosis and the need for long-term steroids.

This patient has clear evidence of giant cell arteritis (also known as temporal arteritis although other vessels are involved), and is at risk of irreversible visual loss either due to ischaemic damage to the ciliary arteries causing optic neuritis, or central retinal artery occlusion. The patient should immediately be started on high-dose prednisolone (before the biopsy result is available). The steroid dose should be slowly tapered according to clinical features and ESR, but is likely to need to be continued for around 2 years. Bone protection measures should be part of the management.

!Differential diagnoses of proximal muscle weakness and stiffness

•Polymyositis

•Systemic vasculitis

•Systemic lupus erythematosus

•Parkinsonism

•Hypothyroidism/hyperthyroidism

•Osteomalacia

KEY POINTS

•Polymyalgia rheumatica and giant cell arteritis often co-exist.

•Patients with these conditions have markedly elevated ESR levels.

•There is a risk of blindness in giant cell arteritis, and steroids should be started immediately.

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