Cases

Question 1

A 60yo M has had alternating cycles of diarrhoea and constipation for the last few months. he has noticed that, even when he passes formed stool, it is often covered in mucus. He also reports feeling that he has never completely emptied his rectum, even immediately after opening bowels. What condition can this be?

Answer 1

Colorectal cancer.

A fluctuating bowel habit with the passage of mucus per rectum is highly suspicious of malignancy. The feeling of incomplete emptying is tenesmus, which is common in irritable bowel syndrome but can also be caused by a tumour.

Question 2

A 64yo F feels that for the past couple of years, her bowel motions have been either far too loose or far too infrequent. She also has intermittent left-sided abdominal pain. It feels like a cramp and is relieved temporarily by bending over and more definitely by defaecating. It is associated with nausea and the frequent passage of wind.

Answer 2

Diverticulosis.

This is the presence of outpouchings of the gut wall. It is often asymptomatic but can present with non-specific abdominal pain and the feeling of bloating.

Question 3

A 66yo M has been passing loose stools for the past 2 weeks. They are light in colour and resistant to being flush away. He also has generalised abdominal pain that has never really improved since its onset some years ago and has continued to lose weight.
Choose:
1. Inflammatory bowel disease
2. Conversion disorder
3. Chronic pancreatitis
4. Porphyria

Answer 3

Chronic pancreatitis.

This man has steatorrhoea - indicative of fat malabsorption - and acute on chronic abdominal pain. Continued weight loss is also caused by general malabsorption due to an atrophic pancreas, which is caused in more than 70% of cases by alcohol.

Question 4

A 62yo F has had recurrent cycles of diarrhoea alternating between constipation over many years. She suffers with intermittent lower abdominal pain. It is usually eased by opening her bowels, but has been generally worse since her partner dies unexpectedly last month. Choose:

1. Autonomic neuropathy
2. Lymphoma
3. Colorectal Cancer
4. Irritable bowel syndrome

Answer 4

Irritable bowel syndrome.

She is showing chronic intermittent symptoms that are exacerbated by stress.

Question 5

A 60yo M has had profuse watery diarrhoea for the last 72 hours. He feels generally unwell, with abdominal pain, sore joints, and gritty eyes. He has been prone to similar such episodes in the past. He suspects he has lost weight recently and has not traveled abroad.
Choose:
1. Systemic sclerosis
2. Inflammatory bowel disease
3. Coeliac disease
4. Lymphoma

Answer 5

Inflammatory bowel disease.

Arthritis and conjunctivitis in the setting of abdominal pain and diarrhoea is suggestive of inflammatory bowel disease and would need urgent investigation via a sigmoidoscopy.

Question 6

A 65yo F has had difficulty swallowing both solids and liquids for 3 months. She has non-insulin-dependent diabetes, has had 2 strokes, and has a BMI of 45kg/m2. A barium swallow diagnoses the cause of her symptoms but she is deemed by a gastroenterologist to be a high-risk surgical candidate and instead is offered therapy with botulinum toxin.

Answer 6

Achalasia.

This occurs due to failure of relaxation of her lower oesophageal sphincter as a result of degeneration of the myenteric plexus, although the cause is unknown. Dysphagia and regurgitation of undigested food are the commonest symptoms.

Question 7

A 70yo M has sudden severe chest pain while at rest. he reports having had the pain before, always during meals. Rather than being accompanied by shortness of breath, it is associated with difficulty swallowing. After having a normal ECG, the man is discharged with an appointment for a barium swallow as an outpatient.

Answer 7

Oesophageal spasm.

Loss of the normal oesophageal propulsive motiltiy is responsible for the chest pain, regurgitation, and dysphagia experienced. It is often treated with calcium-channel blockers or nitrates.

Question 8

A 75yo F has recently developed difficulty in making the swallowing movement and has weakness in all 4 limbs. She has spent 4 weeks on a surgical ward recovering after a complicated anterior resection of a rectal tumour. Earlier in the week, she had severe hyponatraemia, rapidly corrected by the on-call house officer.

Answer 8

Bulbar palsy.

Rapid correction of hyponatraemia can lead to bulbar palsy and central pontine myelinolysis. This is severe damage to pontine nerve cell myelin sheaths, leading to limb weakness and difficulty speaking and swallowing. The signs are of a lower motor neurone lesion.

Question 9

A 58yo F has had pain on swallowing that has developed over the past few months. Prior to this, she suffered from pain in the centre of her chest, especially when lying down or bending over. She has osteoarthritis but is otherwise fit and well.
Choose:
1. Retrosternal goitre
2. Oesophagitis
3. Syringobulbia
4. GORD

Answer 9

Oesophagitis.

It is the pain on swallowing that suggests that this has developed from GORD to actual oesophageal inflammation. However, it may also indicate cancer and this woman will need an oesophagogastroduodenoscopy.

Question 10

A 66yo M feels pain on swallowing solid food. He can still tolerate fluids without any discomfort. He has lost 5kg since the start of this pain 2 years ago. He attributes the onset of these symptoms to his quitting smoking.

Answer 10

Oesophageal cancer.

Dysphagia, weight loss, and retrosternal chest pain should prompt immediate referral for investigations TRO this diagnosis.