Gastro-oesophageal reflux disease (GORD) is defined as a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Many patients with GORD complications such as oesoph...Gastro-oesophageal reflux disease (GORD) is defined as a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Many patients with GORD complications such as oesophagitis, and up to a third of patients with Barrett's oesophagus have no reflux or heartburn symptoms. Conversely, patients can be symptomatic even when normal reflux levels are found and there is an absence of mucosal damage. Significant GORD symptoms occur at least once a week in 8.8-26% of Europeans, with equal prevalence of symptoms in men and women. The frequency and severity of symptoms do not accurately predict the degree of oesophageal damage. If patients with GORD also describe symptoms of dyspepsia this should be considered first with H. py/oritesting or direct referral for gastroscopy if the patient is over 55 given the risk of gastric cancer in these patients. Oesophageal disease can account for up to 20% of cases of chronic cough. Symptoms of GORD occur in more than 45% of patients with asthma, and erosive oesophagitis on endoscopy has a 50% higher likelihood of a diagnosis of asthma. GORD is a risk factor for Barrett's oesophagus and oesophageal adenocarcinoma. The risk increases with duration, severity and frequency. Endoscopy should not be routinely offered at initial presentation unless the patient has dysphagia or other symptoms suggestive of upper GI cancer. Smoking cessation and weight loss are beneficial in reducing GORD symptoms. Abdominal obesity causes GORD by elevating intra-abdominal pressure, which promotes reflux and the development of hiatus hernia. GORD symptoms are increased by 70% among daily smokers who have been smoking for more than 20 years.
Manickavasagar T, Gilson C, Chowdhury S
… +1 more, Kirby R
Practitioner
· 2015 Apr · PMID 26529826
Metastatic prostate cancer is still commonly a lethal condition. The concept that 'men with prostate cancer die with rather than of their cancer' has been shown to be false. It is estimated that 10-20% of men in the UK p...Metastatic prostate cancer is still commonly a lethal condition. The concept that 'men with prostate cancer die with rather than of their cancer' has been shown to be false. It is estimated that 10-20% of men in the UK present with locally advanced disease. Median overall survival remains only 3.5 years for men presenting with metastatic disease. The use of LHRH analogues to achieve medical castration has become the gold standard for both locally advanced prostate cancer, combined with radiotherapy, and metastatic disease. Androgen deprivation therapy (ADT) is the standard first-line treatment for advanced disease resulting in improvements in symptoms, radiological findings and PSA levels. Ultimately the majority of men with advanced prostate cancer will develop resistance to ADT Docetaxel is the standard first-line therapy recommended by international guidelines for patients with symptomatic metastatic castrate refractory prostate cancer who are suitable candidates for chemotherapy. More than 90% of patients with castrate refractory prostate cancer have bone metastases. Radium-223 dichloride is a novel alpha-emitting radiopharmaceutical agent, which mimics calcium and therefore targets bone metastases. It is indicated in patients with metastatic castrate refractory prostate cancer who have symptomatic bone metastases without visceral metastases.
Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacter...Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis presents with acute onset pelvic pain which may or may not be related to voiding, lower urinary tract symptoms, sometimes haematuria or haematospermia and systemic symptoms such as fever and rigors. A documented history of recurrent urinary tract infections is the key feature of chronic bacterial prostatitis. Duration of symptoms > 3 months defines chronicity. The key symptom of chronic pelvic pain syndrome is pain. Patients may describe pain during or after ejaculation as their predominant symptom. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules. In acute bacterial prostatitis the MSU is the only laboratory investigation required. Chronic pelvic pain syndrome may be multifactorial and part of a more generalised pain disorder. Pelvic floor muscle abnormalities, altered neuroendocrine pathways, chemically induced inflammation, bacterial infection, autoimmune processes, dysfunctional voiding as well intraprostatic ductal reflux mechanisms have all been identified in men with chronic pelvic pain syndrome.
Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especial...Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. UV radiation is the most important risk factor for non-melanoma skin cancer (NMSC). The tumours most commonly arise in fair-skinned individuals on sun-damaged skin, especially the face. Incidence rises with age. Patients with one NMSC have a higher risk of developing another NMSC and of malignant melanoma. SCCs are frequently more difficult to diagnose than BCCs. Well differentiated lesions have a pronounced keratotic element. Poorly differentiated SCCs tend to be pink or red papules or nodules, lacking keratin, which may ulcerate. Around 5% of SCCs metastasise. High-risk SCCs include those: on the ear, lip, or sites unexposed to the sun and in chronic ulcers, scars or Bowen's disease. SCCs > 20 mm in diameter or > 4 mm in depth are high risk. Patients who are immunosuppressed, have poorly differentiated tumours or recurrent disease are also at increased risk. Patients with a slowly evolving or persistent skin lesion where cancer is a possibility should be referred to a dermatologist. Lesions suspected of being BCC should be referred routinely. Urgent referral should be reserved for cases where there is concern that a delay may have a significant impact because of the size or site of the lesion. Any non-healing lesions >1 cm with marked induration on palpation, showing significant expansion over eight weeks, should be referred urgently as they may be SCCs.
Most illnesses associated with fever are self-limiting and children recover with no specific treatment. However, fever can also be the presenting feature of serious illness, which may be life threatening if not diagnosed...Most illnesses associated with fever are self-limiting and children recover with no specific treatment. However, fever can also be the presenting feature of serious illness, which may be life threatening if not diagnosed and treated appropriately. It is important to establish whether the temperature has been measured and, if so, how. The height of the temperature should be recorded, and always enquire what device has been used, as a reading from a forehead thermometer may not be accurate. While many families will use a thermometer the impression of the child being hot to touch without formal measurement should still be taken seriously. Check whether the child is still feeding or taking fluids adequately. Any child may be irritable when their temperature is high, but a constantly irritable or inconsolable child, or one who is extremely lethargic, drowsy or difficult to rouse is a cause for concern. Ask about any skin changes or rashes the parent may have noticed. Find out what measures the parent may already have taken to manage the fever, and in particular, whether, and at what time, antipyretics have been given. Enquire about contact with infectious illnesses, and foreign travel. Other vital signs, including heart rate, respiratory rate and capillary refill time should also be recorded. The child should be examined for focal signs indicating the site of infection, and hydration should be assessed. Posture, tone, fontanelle (if patent), presence of a rash, neck stiffness and level of consciousness should also be assessed. If the diagnosis is unclear, potentially serious, and specific treatment may be needed to prevent deterioration, the child should be referred.
Bronchiolitis shows a seasonal pattern with peak incidence occurring in the winter. Around 2-3% of children require admission to hospital. Admission rates are highest in infants less than three months old and those with...Bronchiolitis shows a seasonal pattern with peak incidence occurring in the winter. Around 2-3% of children require admission to hospital. Admission rates are highest in infants less than three months old and those with underlying comorbidities. It typically affects children in the first year of life peaking between three and six months of age. Infants will have a coryzal prodrome lasting one to three days before developing a persistent cough. Fever and reduced feeding are common and very young infants may present with apnoeic episodes. Symptoms normally peak between days three to five of the illness. There will be evidence of increased work of breathing such as tachypnoea, in drawing/recession, head bobbing, grunting, nasal flaring or tracheal tug. Auscultation typically reveals wheeze and/or crepitations throughout both lung fields. Most children with bronchiolitis do not need to be referred to secondary care and can be managed safely at home. Immediate referral to hospital should be arranged if there is: apnoea (observed or reported), the child looks seriously unwell, severe respiratory distress, marked chest recession or a respiratory rate >70 breaths/minute, central cyanosis or persistent oxygen saturation < 92% when breathing room air.
The incidence of acute kidney injury (AKI) is rising reflecting an increasingly elderly at-risk population, with multiple comorbidities, coupled with improved detection of AKI following introduction of clinical chemistry...The incidence of acute kidney injury (AKI) is rising reflecting an increasingly elderly at-risk population, with multiple comorbidities, coupled with improved detection of AKI following introduction of clinical chemistry laboratory algorithms. AKI is potentially reversible so improvements in its recognition and early interventions could have a major impact on patient outcomes. AKI occurs when there is a rapid decrease in GFR within hours to days. The loss of kidney function results in the retention of urea and creatinine and subsequent dysregulation of electrolytes and fluid balance. Individuals in the community with pre-existing CKD and/or patients treated with an ACE inhibitor or angiotensin receptor blocker are at increased risk of AKI if they develop an illness associated with hypovolaemia or hypotension. Potential clues in the history for AKI include reduced fluid intake and/or increased fluid losses, urinary tract symptoms and recent drug ingestion. Postural changes in pulse and BP are more sensitive indicators of hypovolaemia than supine observations. Once an unexplained raised serum creatinine is identified this should trigger a careful review of the patient's history including the common AKI risk factors, medication record, baseline renal function and clinical examination. The severity of the AKI should be considered by evaluating the extent of rise of serum creatinine from baseline. Reagent strip urinalysis should be performed, if possible, on any patient with suspected AKI. Positive protein and blood indicators of 2+ to 4+ on urinalysis suggest intrinsic glomerular disease and should trigger more urgent referral to hospital. The focus of AKI management is correcting the conditions causing or contributing to it.
The classic symptoms of irritable bowel syndrome (IBS) are abdominal pain, bloating and some form of bowel dysfunction. The pain is typically colicky in nature and can occur at any site although most commonly it is on th...The classic symptoms of irritable bowel syndrome (IBS) are abdominal pain, bloating and some form of bowel dysfunction. The pain is typically colicky in nature and can occur at any site although most commonly it is on the left side. The abdomen feels flat in the morning and then gradually becomes more bloated as the day progresses reaching a peak by late afternoon or evening. It then subsides again over night. Traditionally IBS is divided into diarrhoea, constipation or alternating subtypes. IBS patients frequently complain of one or more non-colonic symptoms, these include constant lethargy, low backache, nausea, bladder symptoms suggestive of an irritable bladder, chest pain and dyspareunia in women. The traditional view that IBS is a largely psychological condition is no longer tenable. Rectal bleeding, a family history of malignancy and a short history in IBS should always be treated with suspicion. Both pain and bowel dysfunction are often made worse by eating. It is recommended that a coeliac screening test is undertaken to rule out this condition. Other routine tests should include inflammatory markers such as CRP or ESR. Calprotectin is a marker for leukocytes in the stools and detects gastrointestinal inflammation. A negative test almost certainly rules out inflammatory bowel disease, especially in conjunction with a normal CRP. Fermentable carbohydrates can have a detrimental effect on IBS and this has led to the introduction of the low FODMAP diet.
Gallstones form when there is an imbalance in the composition of bile resulting in precipitation of one or more of its components. Between 37 and 86% of gallstones are cholesterol-rich stones, 2-27% are pigment stones an...Gallstones form when there is an imbalance in the composition of bile resulting in precipitation of one or more of its components. Between 37 and 86% of gallstones are cholesterol-rich stones, 2-27% are pigment stones and 4-16% are mixed. Cholesterol-rich gallstones are more common in Europe and North America. This has been attributed to obesity and diets containing a high proportion of refined carbohydrates and fat. Low-calorie diets and rapid weight loss are also associated with cholesterol-rich gallstones. Gallstone disease increases with age. Women have a higher prevalence of gallstones than men, which is attributed to exposure to oestrogen and progesterone. Of those with gallstones, around 1 to 4% will develop symptoms annually. Most patients (> 80%) will remain asymptomatic throughout their lifetime and the likelihood of developing symptoms diminishes with time. Liver function tests and an abdominal ultrasound should be offered to patients with symptoms suggestive of gallstone disease (e.g. abdominal pain, jaundice, fever). They should also be considered in patients with less typical but chronic abdominal or gastrointestinal symptoms. In patients with acute pancreatitis and evidence of ongoing bile duct obstruction and/or cholangitis, endoscopic retrograde cholangio-pancreatography and biliary sphincterotomy is recommended within 24-72 hours of the onset of symptoms. Patients with acute cholecystitis should be referred for laparoscopic cholecystectomy.