Question 1

A computed tomography scan of kidneys, ureters and bladder (CT-KUB) is performed (see below). A right renal tract calculus is observed.

What is the most common location for renal tract calculi?

CT-KUB is the first line imaging modality in most centres for patients with renal colic, although intravenous urography (IVU) is still used in some hospitals. A plain abdominal radiograph is of limited use in acute renal colic, but may be used to monitor a known radio-opaque calculus.

Renal calculi come in various types (see box)

The 3 most common locations for renal calculi (from proximal to distal) within the renal tract are:

• Pelvico-ureteric junction
• Within the ureter at the pelvic brim
• Vesico-ureteric junction (the commonest)

Question 2

Which of the following blood results would be in keeping with this information?

Some drugs including gold can cause an acquired immunodeficiency leading to low levels of immunoglobulins. This in turns predisposes to repeated infections. Recurrent respiratory tract infections can eventually lead to scarring and dilatation of distal airways. This eventually causes them to fill with mucous which subsequently becomes infected - this is bronchiectasis.

Bence Jones protein is a urine test useful in the diagnosis of multiple myeloma. Anti-double stranded DNA antibody is a very specific test for systemic lupus erythematosus. Anti-nuclear antibody is positive in several immunological conditions.

Question 3

What diagnosis is he most worried about?

Colorectal malignancy is one of the commonest malignancies in the UK population.

In terms of presentation they can be divided into LEFT and RIGHT sided tumours.

The presenting symptoms differ, with some overlap, as shown in the boxes.

On a barium enema, caecal carcinoma is observed as a filling defect within the bowel (the barium contrast being unable to fill the luminal part of the caecum occupied by the tumour mass).

The commonest part of the large bowel to be affected by Crohn's disease is the ileo-caecal segment.

Question 4

Whilst observing the procedure, the consultant in charge asks you the location of the Ampulla of Vater.

Where does the ampulla of Vater enter the bowel?

The small intestine is composed of the duodenum, jejunum and ileum.

The duodenum is divided into 4 parts: ascending, descending, inferior and superior. The duodenum is C-shaped the first part often being referred to as the duodenal cap.

The confluence of the common bile duct and pancreatic duct enters the descending (second part) of the duodenum as the Ampulla of Vater (major duodenal papilla).

The side viewing aspect of the ERCP endoscope is used to cannulate the Ampulla of Vater allowing access to the biliary tree.

Question 5

What is the most appropriate initial course of action?

Introducing infection is a serious complication of intra-articular steroid injection. This is why it is very important to use aseptic technique. Septic arthritis needs prompt treatment with intravenous antibiotics to reduce long term damage to the joint.