Abdo + Colorectal

Question 1

List the differentials of acute abdo pain

Answer 1

Abdo viscera:
Appendicitis/Pancreatitis/Cholangitis/Cholcystitis/Diverticulitis
SBO/LBO/Perf
IBD
Renal calculi
Scrotal

Vascular:
AAA
Ischaemic colitis

Other:
Mesenteric adenitis
TB/Typhoid/Herpes Zoster

Medical:
Lower lobe pneumonia / MI referred
GORD
UTI/Pyelo

Gynae:
Ectopic
Ov cyst (ruptured/torsion)
PID

Question 2

What are the indications for urgent laparotomy in acute abdo?

Answer 2

Ruptured organ (spleen/ao/ectopic)
Peritonitis (perforation)

NB stabilise before theatre UNLESS losing blood fast than can replace

Question 3

If suspecting appendicitis, what Ix should be done to exclude DDx? (5+2)

Answer 3

Bloods: FBC/UEs/CRP-ESR
Pregnancy test (female)
Pelvic exam (female)
Urinalysis
PR

AXR/CXR (?Perf)
USS/CT (Dx uncertain)

Question 4

What Abx used in confirmed appendicitis?

Answer 4

Ceph + Met

Question 5

What are some early (2) + late (2) complications of appendicitis?

Answer 5

Early:
Haematoma
Wound infection

Late:
SBO (adhesions)
Incisional hernia

Question 6

Give DDx for a RIF mass (5)

Answer 6

Inflamm mass (appendix/ abscess post-perf)
Lymphoma
Tumour (caecal/carcinoid)
Pelvic kidney
Crohn's

Question 7

What is a carcinoid tumour?

How does it present?

Answer 7

Usually from appendix tip
10% assoc w. MEN1
Secrete active substances e.g. serotonin/prostaglandins
Good prog, resectable

Pt >40
Diarrhoea
Facial flushing

Question 8

List the different presentations of Meckels diverticulum (6)

Answer 8

Only 2% develop sx (present in 2% pop)

Asymp
Caecal volvulus
Peptic ulceration (periumbilical)
Appendicitis
Intussusception
Sinus tract of patent vitellointestinal duct

Question 9

What would be seen on microscopy in Crohn’s VS UC

Answer 9

Crohn’s:
Transmural
Granulomas (non-caseating)
Lymphoid hyperplasia

UC:
Mucosal
Crypt abscesses
Goblet cell depletion

Question 10

Indications for surgery in UC (7)

Answer 10

Severe UC flare:

(Systemically unwell)
CRP >45
Albumin low
Temp raised
HR raised
HB low

Colonic dilation
>8 stools/day

Question 11

List some complications of Crohn’s (4)

+ of UC (4)

Answer 11

Crohn's:
Fistulas (10%)
Abscesses 
SBO
B12/Fol/Fe defc

UC:
Lower GI haemorrhage
Perforation
Toxic megacolon
Colon carcinoma

Question 12

What are the features of toxic megacolon (4)

Answer 12

Persistent fever / tachy
Bloody diarrhoea
Falling Albumin / K+
AXR: dilated >6cm w. mucosal islands

Question 13

What are some SPECIFIC signs you may seen O/E in acute appendicitis (4)

Answer 13

Obturator sign (pain on R int. rotation – pelvic appendix)
Rovsing’s sign (more RIF pain when press LIF)
Psoas sign (pain on hip ext – retrocaecal appendix)
DRE painful on R side (pelvic appendix)

Question 14

How is an appendix mass managed?

Answer 14

Dx by USS/CT
IV ceph/met
Toxic/Non-resolving –> percutaneous abscess drain
Once resolved –> Interval appendectomy (3m)

Question 15

What red flags should be excluded when ?IBS case? (7)

Answer 15

Rectal bleeding
Unintentional wt loss
Faecal incontinence
Frequently opening bowels at night
Anaemia

Bowel habit change >60
FH Bowel/Ovarian cancer

Question 16

Outline the drug management in IBS

Answer 16

1st line – mebeverine ± laxative/loperamide
2nd line – TCAs
3rd – SSRIs

Question 17

What Ix are done into IBD (4321)

Answer 17

Bloods:
FBC (Fe/B12/Fol)
CRP-ESR (monitoring)
U+Es (dehydration)
LFTs (drugs + comps + albumin in inflamm)

Stool studies:
Stool chart
Faecal calprotectin (–ve excludes)
Stool MCS x3 (exclude infection)

Imaging:
AXR/CXR (acute)
CT (crohn’s comps)

Endoscopy:
Colonscopy (or sigmoid) ± biopsy

Question 18

Outline the management for Crohn’s:
Acute flare
Maintenance

Answer 18

Acute: 
Mild – steroids/clinic
Severe (sys unwell):
Admit / NBM + TPM / Close monitor
• 1st: IV hydrocortisone 
• 2nd: thiopurine
• 3rd: infliximab

Maintenance:
1st – thiopurine (aza/mercapto)
2nd – MTX
± Metronidazole for anal disease

Question 19

What are the hallmarks of ‘systemically well/unwell’ in IBD flare ups?

Answer 19

CATH is well

CRP-ESR (high)
Albumin (low)
Temp
HR