Change In Bowel Habit

Question 1

Name the main arterial blood supply associated with each embryological region of the GI tract. (3)

Answer 1

Foregut - coeliac trunk
Midgut - superior mesenteric artery
Hindgut - inferior mesenteric artery

Question 2

What are the primary functions of the large intestine? (3)

Answer 2

Absorbing water and electrolytes
Producing and absorbing vitamins
Forming and propelling faeces toward the rectum

Question 3

Where does the large majority of food digestion and absorption take place?

Answer 3

The small intestine

Question 4

What is the main function of the small intestine? (1)

Answer 4

Absorption of nutrients and minerals from food.

Question 5

Give one autoimmune cause of diarrhoea.

Answer 5

Coeliac disease

Question 6

What are two neoplastic causes of diarrhoea?

Answer 6

Bowel cancer
Ovarian cancer

Question 7

Give one endocrine cause of diarrhoea.

Answer 7

Thyrotoxicosis

Question 8

What are some of the main early warning signs in colorectal cancer? (6)

Answer 8

-Rectal bleeding, either bright/dark red in colour
- Tenesmus (feeling that you have to empty your bowel but nothing passes)
- Anaemia caused by iron deficiency
- Persistent abdominal pain/distension
- Unexplained weight loss
- Unexplained appetite changes

Question 9

What are diverticulae?

Answer 9

Small outpouches of the mucosa of the colon, through its muscular wall.

Question 10

What is the difference between diverticulosis, diverticular disease and diverticulitis?

Answer 10

Diverticulosis —> asymptomatic presence of diverticulae
Diverticular disease —> patients with diverticulosis who become symptomatic (most commonly with abdominal pain)
Diverticulitis —> complication of diverticulosis where inflammation and/or infection occur.

Question 11

What symptoms effectively rule out Inflammatory Bowel Syndrome (IBS)? (2)

Answer 11

Weight loss
Rectal bleeding

Question 12

What population demographic are most commonly affected by Irritable Bowel Syndrome (IBS)?

Answer 12

Females between 20 and 30 years old.

Question 13

What tests should be undertaken to exclude other diagnoses in people who meet the NICE Inflammatory Bowel Disease (IBD) Diagnostic Criteria? (4)

Answer 13

-Full blood count
-Erythrocyte sedimentation rate (ESR) or plasma viscosity
-C-reactive protein (CRP)
-Antibody testing for coeliac disease (EMA or TTG testing)

Question 14

What pharmacological therapies are available for Irritable Bowel Syndrome (IBS)? (6)

Answer 14

-Antispasmodic agents taken as required
-Laxatives for constipation (NOT lactulose)
-Linaclotide if previous laxatives haven’t worked
-Loperamide (antimotility agent for diarrhoea)
-Tricyclic antidepressants (second line if none of above have helped)
-Selective serotonin reuptake inhibitors (if TCAs ineffective)

Question 15

What is the first line investigation for suspected colorectal cancer in adults, used to guide subsequent referral?

Answer 15

Quantitative Faecal Immunochemical Testing (FIT)

Question 16

What Faecal Immunochemical Testing (FIT) result would trigger referral of an individual using the 2 week wait suspected colorectal cancer pathway?

Answer 16

FIT Test result of at least 10 micrograms of haemoglobin per gram of faeces.

Question 17

What is mesenteric ischaemia?

Answer 17

An acute or chronic problem where blood supply to the bowel is disturbed by arterial thrombosis or embolism.

Question 18

Describe the nature of the pain seen in mesenteric ischaemia.

Answer 18

Severe pain, out of proportion with any physical examination findings, and associated with eating.

Question 19

How can you differentiate between mechanical and functional bowel obstruction on auscultation?

Answer 19

Mechanical bowel obstruction —> bowel sounds become high pitched or ‘tinkling’
Functional bowel obstruction —> bowel sounds are absent

Question 20

What are the NICE criteria for offering FIT tests to investigate bowel cancer? (3)

Answer 20

EITHER
-adult without rectal bleeding, aged >=50 with unexplained abdominal pain or weight loss
-adult aged <60 with changes in bowel habit or iron deficiency anaemia
-adult aged >=60 with anaemia without iron deficiency

Question 21

In which half of the colon are more tumours diagnosed?

Answer 21

More tumours are diagnosed in the left half of the colon than in the right side.

Question 22

Where is the most frequent site for colon tumours to be found?

Answer 22

The recto-sigmoid colon.

Question 23

Which types of staging criteria are used for bowel cancer? (2)

Answer 23

TNM Staging and Dukes’ Criteria

Question 24

What is the Dukes’ Staging System? (4)

Answer 24

Four groups of cancer features used to categorise the stage of bowel cancer an individual has, where A is an early stage and D is advanced:
A - cancer only in innermost bowel lining or slightly growing into muscle layer
B - cancer has grown through muscle layer of bowel
C - cancer has spread to at least one lymph node in area close to the bowel
D - cancer has spread to somewhere else in the body (such as liver or lungs)

Question 25

What is synchronous metastatic disease?

Answer 25

Metastatic disease found at the time of diagnosis of the primary tumour.

Question 26

How can a DRE exam discern between mechanical (physical) bowel obstruction and functional obstruction (where there is no bowel peristalsis)?

Answer 26

Mechanical obstruction - collapsed rectum on DRE (all bowel distal to obstruction will be collapsed)
Functional obstruction - entirety of bowel will be distended and capacious, including the rectum

Question 27

What type of bowel obstruction may acute pancreatitis cause?

Answer 27

Functional bowel obstruction (ileus)

Question 28

What are the main three potential causes of bowel obstruction?

Answer 28

Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)

Question 29

What is the initial management of bowel obstruction? (3)

Answer 29

‘Drip and suck’:
-Nil by mouth
-IV fluids to hydrate and correct electrolyte imbalances (‘drip’)
-NG tube with free drainage to allow stomach contents to freely drain and reduce risk of vomiting and aspiration (‘suck’)

Question 30

What is the screening eligibility criteria for bowel cancer in the UK?

Answer 30

Everyone aged 60-74 years, every 2 years.

Question 31

Which tests are used for screening as part of the national bowel screening programme?

Answer 31

FIT or faecal occult blood (FOB) test (depending on region of UK)

Question 32

What are the two main types of Inflammatory Bowel Disease (IBD)?

Answer 32

Ulcerative colitis
Crohn’s disease

Question 33

What are the general presenting features of Inflammatory Bowel Disease (IBD)? (5)

Answer 33

Diarrhoea
Abdominal pain
Rectal bleeding
Fatigue
Weight loss

Question 34

What features differentiate Crohn’s Disease from Ulcerative Colitis? (5)

Answer 34

NESTS:
-No blood or mucus (PR bleeding less common)
-Entire GI tract affected
-‘Skip lesions’ on endoscopy
-Terminal ileum most affected and Transmural (full thickness) inflammation
-Smoking (as a risk factor)