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core curriculum > 8. Lower GI > Flashcards

8. Lower GI Flashcards

1
Q

A 22 y/o female presents to her GP with a two year history of intermittent diarrhoea and constipation. She complains of bloating and abdominal pain, which eases with defecation. Which condition is she likely to have?

A. 	Coeliac disease
B. 	Ulcerative colitis
C. 	Crohn’s disease
D. 	Irritable bowel syndrome
E. 	Infectious diarrhoea
A

D. Irritable bowel syndrome

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2
Q

A 26 y/o male presents to his GP with weight loss, abdominal pain and watery diarrhoea. On examination he looks pale and you notice ulcers in his mouth. Which condition is he likely to have?

A. 	Coeliac disease
B. 	Ulcerative colitis
C. 	Crohn’s disease
D. 	Irritable bowel syndrome
E. 	Infectious diarrhoea
A

C. Crohn’s disease

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3
Q

A 23 y/o female presents to her GP with a limp. On further questioning she reveals she has recently lost weight and has had bloody, mucoid diarrhoea. On examination her right knee is tender and swollen, and her eyes are red. Which condition is she likely to have?

A. 	Coeliac disease
B. 	Ulcerative colitis
C. 	Crohn’s disease
D. 	Irritable bowel syndrome
E. 	Infectious diarrhoea
A

B. Ulcerative colitis

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4
Q

A 27 y/o male presents with a history of mucoid, bloody diarrhoea and weight loss. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?

A. 	IV corticosteroid
B. 	Oral prednisolone
C. 	Topical mesalazine
D. 	Oral azathioprine
E. 	IV cyclosporin
A

C. Topical mesalazine

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5
Q

A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?

A. 	IV corticosteroid
B. 	Oral prednisolone
C. 	Oral mesalazine
D. 	Oral azathioprine
E. 	IV cyclosporin
A

B. Oral prednisolone

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6
Q

After starting treatment, his symptoms improve. Which additional treatment would you start him on to maintain his remission?

A. 	IV corticosteroid
B. 	Oral prednisolone
C. 	Oral mesalazine
D. 	Oral azathioprine
E. 	IV cyclosporin
A

D. Oral azathioprine

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7
Q

A 55 y/o female presents to her GP with an itchy rash on her forearms. On further questioning she reveals she has recently lost weight and has had mucoid diarrhoea. Which test will best confirm her diagnosis?

A. 	Endoscopy with duodenal biopsy
B. 	Serum antibodies to tissue-transglutaminase
C. 	Serum anti-endomysial antibodies
D. 	Colonoscopy
E. 	Endoscopy with ileal biopsy
A

A. Endoscopy with duodenal biopsy

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8
Q

UC Signs and Symptoms

A

Diarrhoea - With blood fresher and redder than upper GI bleeding; Mixed in (unlike anal fissure and haemorrhoids) + mucus
Abdominal pain
Relapsing-remitting

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9
Q

Extra-intestinal manifestations of IBD

A

A PIE SAC:

  • Aphthous (mouth) ulcers [CD>UC]
  • Pyoderma gangrenosum
  • I (eye) – iritis, uveitis, episcleritis [CD>UC]
  • Erythema nodosum - raised red marks
  • Sclerosing cholangitis (primary) [UC]
  • Arthritis
  • Clubbing fingers [CD>UC]

CAI is more CD than UC

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10
Q

Invx for CD

A
  • Stool sample (first line)
  • Blood tests
  • CT/MRI abdomen
  • (Colonoscopy and biopsy)
    Biopsy = confirmatory not diagnostic - crypt architectual changes
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11
Q

Invx for UC

A
  • Stool sample (first-line)
  • Blood tests - WBC, CRP, ESR, (inflam baseline) LFT (PSC)
  • AXR: toxic megacolon, lead pipe
  • Colonoscopy/flexible sigmoidoscopy and biopsy - necessary: mucin depletion, diffuse mucosal atrophy, continuous from the rectum with anal sparing.
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12
Q

Radiology signs in IBD

Where are they found?

A

Lead pipe sign: loss ofhaustral markings in the diseased section of colon; organ appears smooth-walled and cylindrical.Due to inflammation.
Thumbprinting (projections into aerated lumen) - large bowel wall (haustra) thickening at regular intervals, usually caused by oedema, related to an infective or inflammatory process (colitis).

In UC these signs will be focused near the rectum, in Crohn’s focused in terminal ileum.

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13
Q

Toxic megacolon
Definition
Symptoms
Mx

A

When IBD/C. diff is serious enough to cause inflammatory colitis.

Symptoms: extreme vomit, abdo pain and abdo distention (think obstructive symptoms). EMERGENCY!

§Treat with resuscitation (fluids, adrenaline etc, likely to be in shock), nasogastric decompression and corticosteroids in the case of IBD complication.

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14
Q

CD Management

A

Inducing remission: Corticosteroids

Maintaining remission:
Azathioprine
Methotrexate
Cyclosporin
Infliximab (TNFa)

Surgery: NOT curative

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15
Q

UC Management

A 
Inducing remission: 
Aminosalycilates
-Topical
-Oral (low dose)
-Oral (high dose)
Maintaining remission:
Azathioprine
Methotrexate
Cyclosporin
-

Surgery: Curative

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16
Q

Prognosis and Complications of IBD

A

Crohn’s: Increased mortality.
(Duration of the disease) higher comorbidity score increase this.

UC: Mortality not affected
But toxic megacolon is a concern

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17
Q

Coeliac disease: Definition and Epidemiology

A

Chronic autoimmune disease of the small intestine, characterised by gluten intolerance in genetically susceptible individuals.

Higher prevalence in Europeans.
Peaks at infancy and 50-60 years.

18
Q

Aetiology of Coeliac’s

A 
Autoimmune damage to the intestinal mucosa leads to:
Villous atrophy
WBC infiltration
Cryptal hyperplasia
= malabsorption
19
Q

Risk factors of Coeliacs

A

Female sex (2:1)
Autoimmune background - T1DM, Thyroid disease
Family history

20
Q

Symptoms of Coeliacs

A

Diarrhoea - Difficult to flush
Bloating
Abdo pain (After eating gluten)
Fatigue

21
Q

Signs of Coeliacs

A

IgA deficiency (coming up as an incidental finding can indicate silent coeliac disease- still important due to complications)
Anaemia
Dermatitis herpetiformis

22
Q

Coeliac disease: investigations

A

Stool sample

Serum antibody tests:

  • Anti-tissue transglutaminase (TTG)
  • Anti-endomysial

Endoscopy + duodenal biopsy (gold-standard)

  • Villous atrophy
  • Cryptal hyperplasia
  • Intraepithelial WBCs
23
Q

Coeliac disease: Mx

A

Gluten-free diet

Vitamin D supplementation

24
Q

Coeliac disease: Prognosis and complications

A

Up to 90% will have complete and lasting resolution of symptoms on a gluten-free diet alone.

Complications:

  • Upper GI lymphomas and carcinomas
  • Osteoporosis (Vit D)
  • Chronic dermatitis herpetiformis
25
Q

Coeliac disease: Prognosis and complications

A

Up to 90% will have complete and lasting resolution of symptoms on a gluten-free diet alone.

Complications:

  • Upper GI lymphomas and carcinomas
  • Osteoporosis (Vit D)
  • Chronic dermatitis herpetiformis
26
Q

IBS: Diagnosis of Exclusion - Criteria

What has it been linked to?
What can be used for Mx?

A 
Rome IV criteria:
Recurrent abdo pain at least 1d/wk, on average, in the past 3 months a/w 2 or more of:
- Defacation
- Change in stool frequency
- Change in form of stool

Symptom onset should occur at least 6 months prior to diagnosis; should be present during the past 3 months

Links to stress and inflammation - SSRIs can form part of treatment plan.

27
Q 
A 67 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He is otherwise fit and well. What is the next appropriate step to take?
A. 	Colonoscopy
B. 	Faecal occult blood test
C. 	Abdominal exam
D. 	Digital rectal exam
E. 	Sigmoidoscopy
A

C. Abdominal exam

But likely to be haemorrhoids

28
Q

A 35 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He adds that he is very sore ‘down there’ and it is agony to defecate. Which condition is he likely to have?

A. 	Haemorrhoids
B. 	Anal fissure
C. 	Crohn’s disease
D. 	Ulcerative colitis
E. 	Colorectal carcinoma
A

B. Anal fissure

29
Q

A 67 y/o male presents to his GP complaining of rectal bleeding. Over the last few months he has noticed blood mixed in with his stool. He sometimes feels like he hasn’t completely emptied his bowels after defecating, and is more tired than usual. What is the next step to take?

A. Routine referral to colorectal surgeons
B. Urgent referral to colorectal surgeons
C. FBC
D. Abdominal exam
E. Faecal occult blood test

A

D. Abdominal exam

But this likely to be CRC

30
Q

Anal fissure: Definition and Aetiology.

Epidemiology

A

Anal fissure = split in the skin of the distal anal canal.

Can be linked to previous constipation/Ischaemia (90% occur along the posterior midline of the anal canal, where there is the poorest circulation.)

Common in young, white males.

31
Q

Anal Fissure Symptoms:

Invx

A

Pain (Tearing sensation)
Blood (Small amounts - on paper)
Purely clinical Dx

32
Q

Anal Fissure Management:

A

Fluids and fibre
Topical Analgesia
Can add topical GTN or diltiazem (relaxes musculature and blood vessels surrounding, to promote adequate blood flow for healing.)
Surgery in severe, chronic cases (avoid - incontinence risk - bigger QoL impact)

33
Q

Anal Fissure Prognosis and Complications

A

80% heal with treatment.
60% heal after 6-8 weeks with fluids and fibre.
A further 20% heal with the addition of diltiazem.

Complications:

  • Chronicity
  • Incontinence from surgery.
34
Q

Haemorrhoids (Haemorrhoidal cushions)

Haemorrhoids: Definition, Epidemiology and Aetiology

A

Normal anatomical structures located within the anal canal. As they get inflamed/enlarge, they can protrude outside the anal canal causing symptoms.

4% of population, peak between 45-65 years.

Main risk factor: increased intra-abdominal pressure (Straining - constipation, chronic cough, pregnancy, obesity, ascites, SOL)

35
Q

Haemorrhoids classification

A

1st Degree: No Prolapse, Just prominent blood vessels

2nd: Prolapse upon bearing down, reduces spontaneously
3rd: Prolapse upon bearing down, requires manual reduction
4th: Prolapsed and cannot be manually reduced

36
Q

Haemorrhoids: Symptoms, Signs, Invx

A

Symptoms:
Rectal bleeding (always) - Bright red, Sides of the pan
Rectal pain (may be present)
NB CR carcinoma - darker

Signs/Invx
Abdo exam
Lump on DRE 
3/4th may be visible on inspection
Colonoscopy (for painful 1st or 2nd degree)
37
Q

Haemorrhoids: Management

A

1st degree: fluid and fibre, topical analgesics, stool softener, topical steroids (min time)

2nd or 3rd degree: non-operative
Rubber band ligation
Infra-red coagulation
Cryotherapy

4th: Excisional haemorrhoidectomy

38
Q

Haemorrhoids: Complications and Prognosis

A

Complications (rare):Anaemia, thrombosis, incarceration.

Prognosis: generally good
Surgery has lowest recurrence rates: around 20%.

39
Q

Colorectal cancer: Definition, Epi and RF

A 
Colorectal cancer (CRC) is 3rd commonest cancer in UK
Mostly adenocarcinoma (glandular tissue origin)
Mostly >60yrs
Risk factors:
Alcohol / Smoking / High red meat diet
Polyps
Genetic conditions
 (FAP/HNPCC)
40
Q

Colorectal cancer: Signs and Symptoms

A 
R-sided tumour:
- Weight loss
- Anaemia
- Abdominal pain
- Obstruction less likely
Harder to detect, presents later
L-sided tumour
- Bleeding/mucus PR
- Altered bowel habit
- Tenesmus
- Obstruction
- Mass PR
Easier to detect, presents earlier

Both has abdo mass
Symptoms can be heterogenous so in exam questions look out for FLAWS first, coupled with some risk factors and abdo symtpoms.

41
Q

Colorectal cancer: Investigations

A

Bloods

  • FBC (anaemia)
  • LFTS (baseline)
  • Renal function (baseline)

Colonoscopy/ barium enema/CT colonography
- To find and stage the tumour

Biopsy (may be concurrent with complete surgical excision)
- To grade the tumour

42
Q

Differentiators for CD, UC, Coeliac, Anal Fissure, Haemorrhoids, CRC

A

Crohns: Diarrhoea AND systemically unwell, mouth ulcers

Ulcerative Colitis: Diarrhoea with mixed blood

Coeliac: Other autoimmune conditions
Anal fissure: TEARING pain

Haemorrhoids: Bright red blood splashes the pan

Colorectal cancer: FLAWS, presence of risk factors (AGE)

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