Abdominal pain- core conditions 3

Question 1

The criteria for a two week referral for colorectal cancer

Answer 1

• They are aged 40 and over with unexplained weight loss and abdominal pain
• They are aged 50 and over with unexplained rectal bleeding
• They are aged 60 and over with: iron‑deficiency anaemia or changes in their bowel habit
• Tests show occult blood in their faeces.

Question 2

When should you consider a suspected cancer referral

Answer 2

In adults with a rectal or abdominal mass.

In adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings:
• Abdominal pain
• Change in bowel habit
• Weight loss
• Iron‑deficiency anaemia.

Question 3

Right colon tumours

Answer 3

• Altered (dark) blood per rectum
• More likely than left sided tumours to be occult and symptomless
• Symptoms of obstruction in advanced tumours

Question 4

Left colon tumour

Answer 4

• Constipation and obstruction
• Abdominal pain and perforation
• More overt bleeding and bleeding per rectum

Question 5

Rectal tumours

Answer 5

• Bleeding is the main complaint
• Change of bowel habits
• Tenesmus (spasms)
• Palpable rectal mass

Question 6

Bowel screening test

Answer 6

Faecal immunochemical test (FIT) tests for occult blood in the stool

Question 7

National bowel cancer screening programme

Answer 7

• At 55 you are invited for a colonoscopy screening, which has high sensitivity, and can remove polyps but it is expensive , with lower patient acceptability, and associated with a degree of risk
• Between 60 and 74 years, FIT home screening sample. If the results are positive then the patient will be invited to undergo a colonoscopy. FIT has lower sensitivity (it fails to detect 20%-50% of cancers), and lower specificity (false positive are yielded by other conditions such as haemorrhoids, peptic ulcer and anal fissure) than colonoscopy, but it is cheaper and has no associated morbidity.

Question 8

Investigations for bowel cancer

Answer 8

• CEA- tumour marker in bowel cancer, limited value in diagnosis but is useful for prognosis as high levels indicate metastasis or advanced disease
• Colonoscopy: diagnoses bowel cancer, enables biopsies to be taken
• FBC- in rectal bleeding you need to see if the haemoglobin is critically low as they may require a blood transfusion
• CT- shows local spread and the precense of distant metastases in the chest, abdomen and pelvis. Creatine and U&E must be done before the CT scan as it determines whether a contrast agent can be used

Question 9

Risk factors for colorectal cancer

Answer 9

• Lack of fibre: it is thought that reduced speed of transit exposes gut mucosa to potential carcinogens
• High fat Diet: thought to favour bacterial flora which can degrade bile salts into carcinogens
• Obesity (especially in men)
• Inflammatory bowel disease: chronic ulcerative, Crohn’s disease
• Family history of benign/malignant colorectal tumour
• Pelvic irradiation
• Colon polyps

Question 10

Enhanced recovery

Answer 10

• Helps people recover more quickly after having major surgery
• Used in breast, colorectal, gynaecological, musculoskeletal and urological sugrey
• Stay active- maybe walk to the operating theatre
• Drink fluids till 2 hours before your operation
• Become active as soon as possible after surgery
• Eat a healthy diet after surgery

Question 11

Inflammatory bowel disease- tests

Answer 11

Patients with inflammatory bowel disease may have anaemia or other signs of inflammation which can be determined by a blood or stool test. There are tests for antibodies in the blood which suggests they have inflammatory bowel disease but alone these cant diagnose Crohn’s disease or UC.
Abdominal x-ray can give you information about: dilated loops of bowel, signs of colitis, faecal loading, perforation

Question 12

Differential diagnosis for diarrhoea

Answer 12

• Colitis
• Gastroenteritis
• STI’s affecting the rectum
• Coeliac disease
• Haemorrhoids
• IBS
• Lymphoma

Question 13

Colitis

Answer 13

Colitis- inflammation of the colon wall. The causes of colitis can be inflammatory bowel disease, infective gastroenteritis etc.
CT abdomen pelvis for colitis- thickening of the sigmoid colon and rectum

Question 14

Flexible sigmoidoscopy vs colonoscopy

Answer 14

Flexible sigmoidoscopy is less risky than a colonscopy especially when the patient has active colitis which increased perforation risk. Patients can have a full colonoscopy when the disease is more stable or after hospital discharge

Question 15

Clinical features and treatment for UC

Answer 15

• Crypt abscesses
• Increased inflammatory cells in the lamina propria
• Neutrophilic infiltration of the surface epithelium
• Presence of ulcers
• Features suggestive of ulcerative colitis

Standard treatment for UC: Iv steroids, oral steroids with topical steroid enemas

Question 16

Symptoms of crohns disease

Answer 16

• Intermittent right iliac fossa pain/ache followed by diarrhoea
• There are flare ups
• Ulcers in her mouth
• Low grade fever
• Rash over her shins- Erythema nodosum

Question 17

Crohns tests

Answer 17

• Stool culture to rule out infective cause
• Faecal calprotectin
• Blood tests= FBC, U&E’s, CRP, LFT, ESR, Autoantibodies
• Immunoglobulins and coeliac antibodies
• AXR

Question 18

IBD

Answer 18

An inflammatory conditions which affects multisystem including GI, skin, fever. History of diarrhoea with abdominal pain is chronic but with recent exacerbations

Question 19

Investigations for crohns

Answer 19

• CT abdomen pelvis: to see if there is any other underlying collection in the abdomen causing persistently elevated inflammation
• Colonoscopy: biopsies can be obtained

Question 20

Histology of crohns disease

Answer 20

• Areas of chronic inflammation, with increased lamina propria plasma cells and lymphocytes in association with chronic architectural distortion with patchy, mild to severe neutrophilic inflammation, including neutrophilic cryptitis, crypt abscesses or erosions/ulcers
• Skin lesions comprising focal, patchy erosions or ulcers, vertical fissures and fistulas
• Transmural inflammation with multiple lymphoid aggregates
• Granulomas

Question 21

Crohns

Answer 21

• Mean age of onset: 26
• Higher incidence if patients who have a relative who have IBD
• Higher incidence in smokers

Question 22

Ulcerative colitis

Answer 22

• Mean age of onset: 42
• Similar incidence M:F
• Higher incidence if you have a relative with IBD
• More common in non smokers

Question 23

Pathophysiology of crohns and UC

Answer 23

• Bacterial antigens are taken up by M cells in the gut and pass through leaky gaps between cells into the lamina propria
• The antigens are picked up by antigen presenting cells, triggering the release of pro-inflammatory cytokine TNF-alpha, IL-12 and IL-18
• T-cells are activated and these and the cytokines build up to cause a full inflammatory response. This included oedema and vascular adhesions which leads to ulceration and strictures
• Causes on-going inflammation

Question 24

Crohns disease location

Answer 24

Affects any part of the GI tract from mouth to anus, most commonly the distal ileum. Affects deeper mucosa layers with ‘skip lesions’ of unaffected tissue

Question 25

Ulcerative colitis location

Answer 25

Confined to the colon, worst distally with the rectum almost always involved. Inflammation is confined to the mucosa and submucosa. May have crypt abscesses, mucosal ulcers and depleted goblet cells

Question 26

Signs and symptoms of crohns and UC

Answer 26

• Crohns: perianal abscesses, fistulas and skin tags, fatty liver disease, conjunctivitis, renal stones
• UC: Iritis, cholangitis
• Both: Diarrhoea, abdominal pain, fever, malaise, pyoderma gangrenosum, weight loss, erythema nodosum, nail clubbing, arthralgia/arthritis

Question 27

In an acute attack of UC and Crohns

Answer 27

• Fever
• Tachycardia
• Anaemia
• Diarrhoea with blood/mucus
• As many as 20 motions a day

Question 28

Investigations- Crohns

Answer 28

• Blood tests- check for signs of raised inflammatory markers, low albumin and anaemia. Due to risk of upper GI involvement with anaemia in crohns always check B12 and folate. Antibody testing usually shows pANCA as negative
• Stool sample- to rule out infective causes of diarrhoea
• MRE (MRI with small bowel enterography): uses neutral dye contrast to distend the small bowel and highlights inflammation, fistulas etc. Has comparable accuracy to CT and avoids radiation exposure
• Colonoscopy- direct viewing of the colon and can take biopsies

Question 29

Investigations- UC

Answer 29

• Blood tests- check for signs of raised inflammatory markers, low albumin and anaemia. Antibody testing usually shows pANCA as positive
• Stool sample- to rule out infective causes of diarrhoea
• CT scan- used acutely to rule out collections and perforation
• Right sigmoidoscopy: to view the distal colon and take biopsies

Question 30

Conservative management of IBD

Answer 30

• Smoking cessation is important to improve symptoms
• Monitoring nutrition to avoid vitamin deficiencies i.e. B12, folate and fat soluble vitamins A,D,E,K

Question 31

Medical management of IBD

Answer 31

• Steroids: given orally, IV or via enema. Help to induce but not maintain remission
• 5-ASA’s (Aminosalicylates) i.e. Mesalazine. These are steroid spring agents which induce and maintain remission
• Immunosuppressants i.e. Azathioprine, Cyclosporin. Used in severe cases which have not responded to other treatment. Care needed due to side effects including increased risk of serious infections due to a suppressed immune system
• Biologics i.e. Adalimumad, Infliximab, used when steroids and 5-ASA’s have failed. Used to induce and maintain remission. Do not use anti-diarrhoeal due to the risk of developing toxic megacolon

Question 32

Surgical management of IBD

Answer 32

• Involves removal of the bowel
• UC tends to remove the whole colon as healthy parts will later become diseased, leads to stoma formation
• In Crohns only the diseased segments are resected then anastomoses formed. Patients are likely to need further resections and too many can cause short gut syndrome so surgery is only tried when medical treatment fails. Local surgery can be used to drain abscesses, repair fistulas etc

Question 33

Diagnosing diabetic acidosis

Answer 33

Diagnosed using a capillary blood glucose with a random plasma glucose more than 11mol/L
You need to test for capillary ketones to rule out diabetic ketoacidosis.
Venous blood gas- acidaemia needs to be performed in a patient with established ketonaemia. If they have acidaemia then the patient will have diabetic ketoacidosis.

Question 34

Risk factors for type 1 diabetes

Answer 34

• Ketosis.
• Rapid weight loss.
• Age of onset younger than 50 years.
• Body mass index (BMI) below 25 kg/m2.
• Personal and/or family history of autoimmune disease.

Question 35

Diabetic ketoacidosis (DKA)

Answer 35

• Metabolic disorder characterised by hyperglycaemia, acidosis and ketonemia
• Usually due to insulin deficiency and an increase in counter regulatory hormones i.e. glucagon, cortisol, growth hormone, epinephrine
• Enhances hepatic gluconeogenesis and glycogenolysis causing severe hyperglycaemia
• Enhanced lipolysis increases serum free fatty acids which are metabolised as an alternative energy source in ketogenesis
• Results in large quantities of ketone bodies and subsequent metabolic acidosis

Question 36

Symptoms of diabetic ketoacidosis

Answer 36

• General features: Nausea, vomiting, abdominal pain, confusion/agitation, Kussmaul breathing
• Features of hyperglycaemia: polyuria, polydipsia, blurred vision
• Features of dehydration: Lying/standing deficit, reduced skin turgor, dry warm skin, severe shock (hypovolaemic shock)

Question 37

Diagnosis of diabetic ketoacidosis (DKA)

Answer 37

• Ketonaemia 3 mmol/L and over or significant ketonuria (more than 2+ on standard urine sticks)
• Blood glucose over 11 mmol/L or known diabetes mellitus
• Bicarbonate (HCO3-) below 15 mmol/L and/or venous pH less than 7.3

Question 38

Potential causes of diabetic ketoacidosis

Answer 38

• Missing an insulin dose- can be due to poor concordance
• Lack of education: Nausea/vomiting/ reduced appetite- patient should never omit long acting insulin
• Sick day rules: Stressors, like infections increase the bodys insulin requirements
• Infection and sepsis: due to an increase in counterregulatory hormone
• Coma and general anesthesia: due to increased usage of ketones by the brain

Question 39

Treatment of DKA

Answer 39

• Fluids: restoration of circulatory volume, clearance of ketones, normalisation of electrolytes
• Insulin: inhibition of further ketogenesis, normalisation of electrolytes
• Potassium: normalisation of electrolytes

Question 40

Hormones involved in blood glucose

Answer 40

• Hormones which lower your blood glucose: Insulin
• Hormones which increase your blood glucose: Glucagon, Cortisol, Thyroid hormone, Epinephrine and Norepinephrine, Growth hormone

Question 41

Counter regulatory hormones in blood glucose

Answer 41

• Glucagon- acts immediately
• Adrenaline and noradrenaline- acts immediately
• Cortisol- acts after several hours
• Growth hormone- long term
• Thyroid hormone- long term

Question 42

Diagnosing diabetes mellitus

Answer 42

• Characteristics of Diabetes Mellitus AND 1 of:
• Random Blood Glucose >11.0mmol/L
• Fasting blood Glucose >7.0 mmol/L
• HbA1c >48mmol/mol

Question 43

Why do you get polyuria with diabetes

Answer 43

As blood sugar rises, the renal threshold for reabsorption is exceeded leading to loss of glucose in the urine and due to its osmotic effect water

Question 44

Symptoms of hypoglycaemia

Answer 44

• Adrenergic: Sweating, Palpitations, Shaking, Hunger
• Neuroglycopenic: Confusion, Drowsiness, Odd behaviour, Speech difficulty, Stroke like symptoms, Incoordination
• The adrenergic symptoms occur first, at glucose levels 3.6-3.9 mmol/L. The Neuroglycopenic symptoms occur at <2.8mmol/L

Adrenergic symptoms do not occur whilst sleeping

Question 45

Hypoglycaemia is caused by

Answer 45

• Glucose entering the bloodstream at a lower rate. (e.g. congenital enzyme deficiencies)
• Glucose leaving the bloodstream at a higher rate.

Question 46

Overnight hypoglycaemic events

Answer 46

Overnight hypoglycaemic events (‘overnight hypos’) can be dangerous and have significant morbidity and mortality; including hypoxic brain injury and death. The vast majority of patients, however, wake up and the risk is greatest in those who have lost their counter regulatory response and have hypoglycaemia unawareness.

Question 47

Different categories of hypoglycaemia

Answer 47

• Mild: adults who are conscious, orientated and able to swallow
• Moderate: patient conscious and able to swallow but confused, disorientated or aggressive
• Severe: patient unconscious/fitting or very aggressive or nil by mouth

Question 48

Mild hypoglycaemia

Answer 48

• Give 15-20g of quick acting carbohydrate, such as 5-7 Dextrosol® tablets or 4-5 Glucotabs® or 150-200ml pure fruit juice
• Test blood glucose level after 15 minutes and if still less than 4.0mmol/L repeat up to 3 times. If still hypoglycaemic, call doctor and consider IV 10% glucose at 100 ml/hr or 1mg glucagon IM

Question 49

Moderate hypoglycaemia

Answer 49

• If capable and cooperative, treat as for mild hypoglycaemia
• If not capable and cooperative but can swallow give 1.5-2 tubes of 40% glucose gel (squeezed into mouth between teeth and gums). If ineffective, use 1mg glucagon IM
• Test blood glucose level after 10-15 minutes and if still less than 4.0mmol/L repeat above up to 3 times. If still hypoglycaemic, call doctor and consider IV 10% glucose at 100 ml/hr

Question 50

Severe hypoglycaemia

Answer 50

• Check ABC, stop IV insulin, contact doctor urgently
• Give IV glucose over 15 minutes as 75ml 20% glucose or 150ml 10% glucose or 30ml 50% glucose (risk of extravasation injury) or 1mg Glucagon IM
• Recheck glucose after 10 minutes and if still less than 4.0mmol/L, repeat treatment

Question 51

Gallstones treatment

Answer 51

ERCP- is an invasive procedure used choledocholithuasis and acute cholangitis
Extracorporeal shock wave lithotripsy- breaks stones stones into small particles but doesn’t prevent stone recurrence
Oral ursodeoxyxhlorix acid- used for symptomatic patients with contraindications in definitive treatment

Question 52

Diverticulitis

Answer 52

An elderly patient presenting with large amounts of painless bright red blood per rectum, especially with a history of constipation

Question 53

Diagnosis of diabetes Melkite’s

Answer 53

• Hba1C >48mmol/mol
• Symptoms plus positive glucose (fasting >7mmol/L or random glucose >11.1 moll/L)
• No symptoms plus 2 positive glucose (fasting >7mmol/L or random glucose >11.1mmol/L) samples must be separate

Question 54

Different pathologies caused by gallstones

Answer 54

Biliary colic- presents with right upper abdominal pain, wouldn’t expect jaundice or rigours
Cholangitis- stone in the CBD, causes jaundice due to back pressure on the liver. Infection on top of this, hence the Tigris
Cholecystitis- RUQ pain, with fever but no jaundice
Pancreatic cancer- painless jaundice, no fever
Pancreatitis- central abdominal pain, radiating to the back. Jaundice is not expectwd

Question 55

Diagnosing coeliac disease

Answer 55

Refer to a gastroenterologist for an intestinal biopsy. Don’t get the patient to stop eating gluten before you do this