Bowel

Question 1

What are the presenting features of small bowel disease?

Answer 1

Diarrhoea (sometimes steatorrhea)
Abdo pain and discomfort
Weight loss
Nutritional deficiencies (iron, B12, folate) (ankle oedema-hypoalbuminaemia) (bruising, vit k) (osteomalacia vit d)

Question 2

What are the characteristics of steatorrhoea?

Answer 2

Pale, bulky, offensive, fat >17mmol/day, float in the toilet, difficult to flush away

Question 3

What are the investigations needed for small bowel disease?

Answer 3

Full blood count (anaemia macro/micro) (dimorphic) (MCV low= ferritin and transferrin receptor) (MCV high= B12, folate) (MCV low in coeliac and crohn’s)
Albumin
Low calcium and high ALP (osteomalacia)
Autoantibodies (tissue transglutaminase, reticulin, gliadin= coeliac)

Question 4

When are B12 absorption studies used?

Answer 4

Pernicious anaemia 
Ileal disease (when oral vitamin B12 given with intrinsic factor will show malabsorption)
Bacterial overgrowth (measurement of vitamin B12 plus intrinsic factor absorption is repeated after antibiotics)

Question 5

What are diseases of the small intestine which cause malabsorption?

Answer 5

Coaliac disease
Dermatitis herpetiformis 
Tropic sprue
Bacterial overgrowth 
Intestinal resection 
Whipples disease 
Radiation enteritis 
Parasite infestation (guardia intestinalis)

Question 6

What is coeliac disease?

Answer 6

Inflammation of the jejunal mucosa decreasing in severity towards the ileum that improves when patient doesn’t eat gluten
Pure oats aren’t harmful
Absence of villi, crypt hyperplasia with chronic inflammatory cells in the lamina propria
Can present at any age
Tiredness, malaise, associated anaemia
Diarrhoea, steatorrhea, bloating, weight loss
Mouth ulcers and angular stomatitis
Infertility and neuropsychiatric problems
Associated diseases include- IBD, chronic liver disease, epilepsy, fibrosing allergic alveolitis

Question 7

What investigations are done for coeliacs disease?

Answer 7

EMA, tissue transglutaminas (tTg) antibodies (IgA)
Anti-reticulin antibodies (ARA)- less sensitive also used for crohn’s
Duodenal/jejunal biopsy (smoothness of mucosa)
Haematology- anaemia, folate deficiency,
Radiology- dilation of the small bowel with a change in fold pattern
Bone densitometry
Bone chemistry

Question 8

What complications can occur in coeliacs?

Answer 8

Intestinal lymphoma 
Ulcerative jejunitis (fever, abdo pain, perforation)

Question 9

What occurs with ileal resection?

Answer 9

Malabsorption of water and electrolytes leading to diarrhoea
Steatorrhoea, lithogenic bile and gallstone formation
Renal oxalate stones
Low serum B12 and macrocytosis
Low GLP-2

Question 10

What is Meckel’s diverticulum?

Answer 10

Most common congenital abnormality of the Gi tract
Usually symptomless
Peptic ulcers can bleed and perforate as 50% secrete HCL
Acute inflammation

Question 11

What are the most common causes of small bowel obstruction?

Answer 11

Adhesions

Hernias

Question 12

What are the features of small bowel obstruction?

Answer 12

central abdominal pain
nausea and vomiting
‘constipation’ with complete obstruction
abdominal distension may be apparent, particularly with lower levels of obstruction

Question 13

What is Murphy’s sign associated with?

Answer 13

Inspiratory arrest upon palpation of the RUQ
Cholecystitis
Ascending cholangitis comes with high fever, altered mental state hypotension

Question 14

What is pernicious anaemia?

Answer 14

Autoimmune parietal cell destruction 
More common in females 
Middle to old age 
More common in blood group A
results in vitamin B12 deficiency
associated with thyroid disease, diabetes, Addison's, rheumatoid and vitiligo
predisposes to gastric carcinoma

Question 15

What are the features of pernicious anaemia?

Answer 15

Lethargy, weakness
dyspnoea
paraesthesia
also: mild jaundice, diarrhoea, sore tongue
possible signs: retinal haemorrhages, mild splenomegaly, retrobulbar neuritis

Question 16

What is suggestive fo mesenteric ischameia?

Answer 16

Low bicarbonate

Metabolic acidosis

Question 17

What are the conditions that cause ischameia to the GI tract?

Answer 17

acute mesenteric ischaemia
chronic mesenteric ischaemia
ischaemic colitis

Question 18

What are common predisposing factors for bowel ischaemia?

Answer 18

increasing age
atrial fibrillation - particularly for mesenteric ischaemia
other causes of emboli: endocarditis, malignancy
cardiovascular disease risk factors: smoking, hypertension, diabetes
cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

Question 19

What are common features of bowel ischaemia?

Answer 19

abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis

Question 20

What immunisations do patients with coeliac disease require?

Answer 20

Have a degree of functional hyposplenism
For this reason, all patients with coeliac disease are offered the pneumococcal vaccine
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
Currrent guidelines suggest giving the influenza vaccine on an individual basis.