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Five-minute Practitioner: December 2006

Only got five minutes? Then just read these key points on: colorectal cancer, bipolar disorder and whiplash

Only got five minutes? Then just read these key points on: colorectal cancer, bipolar disorder and whiplash

Colorectal cancer

The classic symptoms of colorectal carcinoma?(CRC)?are:
• Rectal bleeding
• Change in bowel habit
• Weight loss
• Abdominal pain

Rectal bleeding with a change of bowel habit to a looser stool and/or weight loss, and absence of anal symptoms, are associated with an increased risk of colorectal carcinoma.

Predictive signs of CRC are:
• Anaemia
• A right side abdominal mass
• A rectal mass on digital rectal examination

Virtual colonoscopy involves a CT scan and 3D image reconstruction of the colon. Virtual colonoscopy has been found to be comparable with colonoscopy in detecting colorectal polyps in asymptomatic adults . However, it gives a large radiation dose, and its place in screening has not been clarified.

The five-year survival rate remains below 50 per cent. The stage at which bowel cancer is diagnosed is the most important determinant of outcome.

Bipolar disorder

Bipolar affective disorder is equally common in both genders. it is characterised by episodes of mania or hypomania. It is a lifelong condition that can have serious effects on social and occupational functioning.

Mania is the descriptive term for a syndrome of emotional, cognitive and behavioural symptoms whereby the patient experiences irritability or elation in mood, racing thoughts, grandiosity, overactivity, pressured speech and disinhibition as well as decreased need for sleep. Bipolar disorder requires long-term treatment to minimise the risk of recurrence of acute episodes. Lithium, olanzapine or valproate are recommended for long-term treatment.

Treatment of bipolar disorder as unipolar depression with antidepressants can destabilise the illness. Patients require an antimanic drug as well as an antidepressant to prevent a hypomanic or manic switch.

In pregnancy, lithium leads to an increased risk of a congenital cardiac anomaly (Ebstein's anomaly) in the fetus, which occurs in one to two babies in every 1,000.

Valproate is associated with neural tube defects in five to nine per cent of pregnancies. NICE recommends that valproate should not be used in women of childbearing potential unless absolutely necessary.

Patients on lithium should have levels monitored every three months and urea, creatinine and thyroid function every six months.

Whiplash

Whiplash typically follows low-velocity car accidents. it is a diagnosis of exclusion that does not encompass fractures or subluxations. It follows a sudden acceleration or deceleration of the head relative to the trunk in any plane.

There is little correlation between visible vehicle damage and reported injury. One possible explanation for this is a change in bumper design.

Seatbelts may worsen whiplash by increasing hyperflexion. The head restraint is the most useful device to limit injury, but is often positioned incorrectly.

MRI scanning has shown several abnormalities in whiplash patients, including ligament tears and disc herniations. However, the correlation with symptoms is poor.

Early mobilisation and exercises to prevent stiffness are advantageous. Soft collars should not be used.

Litigation is independently associated with poorer outcomes, irrespective of the financial award, and evidence exists that patients with resistant cases are better served by cognitive behavioural therapy than further physical treatments with diminishing returns.

Most patients have a favourable outlook and recover fully within two months. Mild cases may resolve without treatment in a few days.

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