Constipation

Question 1

How to opioids lead to constipation? What other drugs can do this

Answer 1

Cause abnormal bowel peristalsis

Iron supplements and CCBs do the same

Question 2

What is sigmoid volvulus

Answer 2

a condition in which the sigmoid colon wraps around itself and its own mesentery, causing a closed-loop obstruction

Rare but important intestinal obstruction

Question 3

What non-GI structures may cause constipation due to bowel obstruction?

Answer 3

pelvic masses
(e.g. uterine fibroids,
ovarian tumour)

Question 4

Causes of colonic stricture

Answer 4

radiotherapy, Crohn’s
disease, diverticular
disease

Question 5

Why are you asking about bone pain in the context of constipation

Answer 5

Could suggest bone metastases, which would lead to hypercalcaemia that can cause constipation

Question 6

What could Intermittent diarrhoea and constipation suggest

Answer 6

irritable
bowel syndrome (in younger patients), colorectal cancer (in patients >45
years, especially if the diarrhoea is mucoid), or diverticular disease (in patients
>60 years, especially if they have had episodes of left iliac fossa pain).

Question 7

What could blood on faeces, per rectum or when wiping indicate

Answer 7

May suggest haemorrhoids,

anal fi ssure, diverticular disease, or colorectal cancer

Question 8

Most common aetiology of constipation & management

Answer 8

A combination of lack of fibre in the diet, dehydration, and a degree of immobility.

1. Drink lots
2. Eat fibre-rich cereal/wholemeal bread
3. Osmotic laxatives (only accutely as they cause dehydration)
4. Stool softeners (liquid parrafin and arachis oil enemas)
5. Peristalsis stimulants
6. Phosphate enemas (last resort)

Question 9

How does fibre help constipation

Answer 9

fi bre helps constipation by providing bulk (which activates stretch receptors in the bowel and triggers peristalsis) and by retaining water (which makes faeces softer).

Question 10

What can be given if patient cannot achieve significant bulk by diet alone

Answer 10

methylcellulose tablets, ispaghula husk

Question 11

Examples of peristalsis stimulatnts

Answer 11

glycerol suppositories, bisacodyl, or senna

Question 12

What is a +phalens sign

Answer 12

prolonged wrist hyperfl exion reproduces the hand symptoms of numbing, tingling feeling

Suggests carpal tunnel syndrome

Question 13

Most common cause of hypothyroidism in 22 year old female

Answer 13

Th e most likely cause for hypothyroidism in a woman of this age is chronic autoimmune thyroiditis, also known as Hashimoto’s hypothyroidism.

Question 14

How do you confirm hypothyroidism, how do you show something is specifically hashimotos

Answer 14

Hypothyroidism is easily confi rmed by a blood test revealing a high TSH level, which is due to the lack of suffi cient thyroxine to negatively feed back on its production. If this is Hashimoto’s hypothyroidism, one will also find high antithyroid peroxidase antibodies.

Question 15

Hypercalcaemia symptoms are commonly described as

Answer 15

‘moans, groans, bones, and stones’ referring to the depression, aches and pains, and renal stones often found in this condition. Polidipsia and polyuria are also common, with the classic (but rarely seen) hypercalcaemia patient waking up at night to down a glass or two of water

Question 16

Causes of hypercalcaemia

Answer 16

Bone mets, myeloma, primary/tertiary hyperparathyroidism, vit D overdose

Question 17

What happens to bone cells in myeloma and thus what happens to ALP

Answer 17

In myeloma, osteoclasts are activated and osteoblasts are inhibited. As ALP comes from osteoblasts, it remains normal.

Question 18

Calcium is high and PTH is normal, could this be hyperparathyroidism?

Answer 18

Yes, Note that PTH levels are often in the ‘normal range’ but that this is actually abnormal as they should be low in the presence of high calcium (remember that PTH release is normally inhibited by high calcium levels). •

Question 19

Causes of primary hyperparathyroidism

Answer 19

Th is is usually caused by a solitary, benign parathyroid adenoma, although parathyroid hyperplasia, parathyroid carcinoma, or PTH-secreting ectopic tumours also occur

Question 20

Which drug has been specifically deveoped to deal with opioid induced constipation

Answer 20

Methylnaltrexone

Question 21

Best way to confirm bowel obstruction?

Answer 21

Th e best way to confi rm bowel obstruction is a plain abdominal radiograph. Small bowel loops with a diameter >3 cm, or large bowel loops with a diameter >6 cm, indicate bowel obstruction.

Question 22

Coffee-bean sign is what? What does it indicate

Answer 22

an enormous, dilated loop of bowel, shaped like a coff ee bean and extending from the pelvis up to the diaphragm), caused by the sigmoid portion of the bowel twisting on itself

Indicates sigmoid volvulus

Question 23

How do you remove the obstruction in:

i. sigmoid voluvulus
ii. colorectal cancer
iii. Diverticulitis

Answer 23

i. In sigmoid volvulus, this is done using a sigmoidoscope with a long, soft flatus tube to untwist the bowel, or surgery if this is unsuccessful or the patient is peritonitic.
ii. In colorectal cancer, a metallic stent can be used to relieve the obstruction until the tumour is removed surgically
iii. can be used to relieve the obstruction until the tumour is removed surgically. In diverticulitis, reduction of the infl ammation with bowel rest and antibiotics may be enough to reduce the obstruction, although surgical resection is occasionally necessary.