Hormonal evaluation includes:
1-mg overnight dexamethasone suppression test
24-hour urinary specimen for measurement of fractionated metanephrines and catecholamines
Blood plasma aldosterone concentration and plasma renin activity, if hypertension is presentOn CT scan, benign adenomas typically are of low radiodensity (due to fat content). A radiodensity equal to or below 10 Hounsfield units (HU) is considered diagnostic of an adenoma. An adenoma also shows rapid radiocontrast washout (50% or more of the contrast medium washes out at 10 minutes). If the hormonal evaluation is negative and imaging suggests benign lesion, follow up may be considered. Imaging at 6, 12, and 24 months and repeat hormonal evaluation yearly for 4 years is often recommended, but there exists controversy about harm/benefit of such screening as there is a high subsequent false-positive rate (about 50:1) and overall low incidence of adrenal carcinoma. Brain
Autopsy series have suggested that pituitary incidentalomas may be quite common. It has been estimated that perhaps 10% of the adult population may harbor such endocrinologically inert lesions. Most of these lesions, especially those which are small, will not grow. However, some form of long-term surveillance has been recommended based on the size and presentation of the lesion. With pituitary adenomas larger than 1cm, a baseline pituitary hormonal function test should be done, including measurements of serum levels of TSH, prolactin, IGF-1 (as a test of growth hormone activity), adrenal function (i.e. 24 hour urine cortisol, dexamethasone suppression test), testosterone in men, and estradiol in amenorrheic women.
Signs and symptoms
Symptoms of pouchitis include increased stool frequency, urgency, incontinence, nocturnal seepage, abdominal cramping, pelvic discomfort, and arthralgia.Symptom severity does not always correlate with severity of endoscopically or histologically evaluated pouch inflammation. Additionally, these symptoms are not necessarily specific for pouchitis, as they may arise from other inflammatory or functional pouch disorders such as Crohns disease of the pouch, cuffitis, pouch sinus, or irritable pouch syndrome. The most reliable tool for diagnosis is endoscopy combined with histologic features (derived from tissue biopsies obtained during endoscopy). Diagnosis
Classification
Once a diagnosis of pouchitis is made, the condition is further classified. The activity of pouchitis is stratified as:
Remission (no active pouchitis)
Mild to moderately active (increased stool frequency, urgency, infrequent incontinence)
Severely active (hospitalised for dehydration, frequent incontinence)The duration of pouchitis is defined as acute (less than or equal to four weeks) or chronic (four weeks or more) and the pattern classified as infrequent (1–2 acute episodes), relapsing (three or fewer episodes) or continuous. Finally, the response to medical treatment as labelled as treatment responsive or treatment refractory, with the medication for either case being specified. Treatment
First line treatment is usually with antibiotics, specifically with ciprofloxacin and metronidazole. Ampicillin or piperacillin can also be considered as alternatives to empiric ciprofloxacin and metronidazole. Administration of metronidazole at a high daily dose of 20 mg/kg can cause symptomatic peripheral neuropathology in up to 85% of patients.