Outpatient synacthen testing in a large metropolitan region: a clinical audit.

AIM: To audit short synacthen tests (SSTs) performed at a single laboratory within the greater Auckland area. METHODS: Two hundred and eighty-seven SSTs conducted in 286 individuals between September 2016 and September 2019 were assessed. Test requests were not triaged. We assessed source of referrals, indications for testing, adequacy of pre-test information and test outcomes. RESULTS: Seventy-one percent of referrals were for women. Fifty-six percent were from primary care and 18% from rheumatology. One-hundred and fifteen (40%) of those referred had been taking corticosteroids within the previous three months: this information was only provided in 49 referrals. In 32% of referrals, no serum cortisol measurement had been undertaken within the previous six months. In 20% of referrals, no indication was provided. Thirty-three (11%) SSTs were abnormal. Of these, 29 were in patients taking corticosteroids. No SSTs were abnormal among 64 patients with pre-test serum cortisol >300nmol/L or >400nmol/L according to the cortisol assay in use. CONCLUSIONS: Referrals for SSTs often lack important information, such as the indication for testing and recent corticosteroid exposure. Up to one quarter of SSTs could be avoided if a serum cortisol was routinely measured prior to referral. Adopting a structured referral form that mandates provision of important clinical and biochemical data might reduce unnecessary testing.

Cap polyposis mistaken for Crohn's disease: case report and review of literature.

We report the case of a 19-year old male who presented with collapse and hypoglycemia associated with two weeks of frequent hard stools, abdominal pain relieved by defecation, postprandial vomiting and significant weight loss. Radiologically and endoscopically a diagnosis of Crohn's colitis was made and the patient was treated with steroids and immunosuppression. Following several hospital admissions treatment had to be escalated to include anti-TNF-α agents. Despite maximum therapy the patient continued to deteriorate symptomatically and biochemically with severe hypoalbuminemia and persistent anemia and a total colectomy was performed. Intra-operative finding was that of an inflamed large intestine and pseudo-polyposis but histology was reported as cap polyposis. The specimen was compared with the biopsies obtained from the earlier colonoscopies and it was felt that the previous samples were taken from areas of severely inflamed polypoid mucosa with histology mimicking colitis in inflammatory bowel disease.