Constipation

Question 1

Physiological elements needed for an effective, soft stool

Answer 1

Neurological input for defecation and the urge to push intact (no pain)
Effective peristalsis
Soft stool

Think of a tube with a head on the end

Question 2

Red flags of constipation

Answer 2

Acute change in bowel habit 
Blood
No flatus
FLAWS
Severe, persistent constipation

Question 3

Is constipation more likely to be serious if acute or chronic?

Answer 3

Acute

Chronic is usually dehydration or lifestyle

Question 4

What is tenesmus and what may it indicate?

Answer 4

It’s the feeling of incomplete emptying. May indicate a persistent mass in the rectum, e.g. a tumour

Question 5

If the patient reports bleeding PR, what important questions need asking?

Answer 5

Colour
When you noticed
How much
On the tissue?

Question 6

FH of bowel cancer conditions

Answer 6

FAP

HNPCC

Question 7

Which drugs can cause constipation?

Answer 7

Opiates, anticholinergics, TCA antidepressants, CCB, iron supplements

Question 8

In all abdominal pathology, which lymph node should you check?

Answer 8

Virchows

Question 9

If constipated, what examination should you consider?

Answer 9

DRE, checking for impacted faeces

Question 10

If you find lax anal tone on DRE, what may it indicate?

Answer 10

Neuropathy, e.g. diabetic neuropathy or MS

Question 11

Which cancer marker is indicated in bowel cancer?

Answer 11

CEA

Question 12

Which cancer marker is indicated in ?ovarian cancer?

Answer 12

CA125

Question 13

Which electrolyte disturbances can cause constipation

Answer 13

Hypercalcaemia

Hypokalaemia

Question 14

What may you find on FBC in cancer?

Answer 14

Micro cystic anaemia (Fe deficiency from blood loss)

Question 15

What investigations are available to look at the colon?

Answer 15

Protoscopy 
Rigid sigmoidoscopy 
Flexible sigmoidoscopy
Colonoscopy
CT colonography 
OGD for the top bit

Question 16

How can we treat chronic constipation?

Answer 16

Lifestyle changes, e.g. more fluid, exercise, fibre.
Can give bulk producers such as fibre supplements
Stool softeners
Laxatives

Question 17

Patient with long standing constipation, heavy periods, fatigued, positive talen test. Likely diagnosis?

Answer 17

Hypothyroidism

Question 18

Likely cause of hypothyroidism in a young woman

Answer 18

Autoimmune = Hashimoto’s thyroiditis

Question 19

Which antibodies are present in Hashimoto’s?

Answer 19

Anti TPO

Question 20

Patient with constipation, aches and pains all over his body, polyuria, polydipsia, normal capillary glucose, lethargy and low mood.
Likely diagnosis

Answer 20

Hypercalcaemia

Moans, bones, groans and stones

Question 21

A patient is found to have hypercalcaemia, how do we find a cause?

Answer 21

Blood tests
ALP, PTH, phosphate
Calcium profile

Bone cancer increases turnover of bones -> raised ALP and phosphate
Hyper parathyroidism, high ALP. High calcium should inhibit ALL PTH! So normal is still high.

Question 22

In metastatic breast cancer, what drug can you take to protect your bones?

Answer 22

Alendronate or pamidronate

Question 23

What drug can you give for nausea from morphine?

Answer 23

Cyclizine

Question 24

Neurological cause of constipation?

Answer 24

Cauda equina or other cord compression

Question 25

What drug can you give for morphine induced constipation?

Answer 25

Methylnaltrexone

Question 26

Coffee bean sign =

Answer 26

Sigmoid volvulus

Question 27

Management of sigmoid volvulus

Answer 27

Drip and suck = IV fluids and an NG tube

Referral to surgeons for removal of obstruction

Question 28

TNM classification

Answer 28

T = 1-4 local invasion and size 
N = nodes 1-3 (3 being distant nodes)
M = 0/1 if metastasised

Question 29

Dukes classification

Answer 29

A= muscularis propria
B = beyond 
C = lymph nodes
D = other organs

Question 30

The sigmoid colon derives its arterial supply from which branch of the abdominal aorta?

Answer 30

Inferior mesenteric artery