EMRCS PATHO 6 Flashcards
A 30 year old male presents with gynaecomastia. Clinically, he is noted to have a nodule in the left testis. What is the most likely diagnosis?
Oestrogen abuse Seminoma with syncytiotrophoblast giant cells Teratoma Choriocarcinoma Leydig cell tumour
Leydig cell tumours are rare testicular sex cord stromal tumours (which also include sertoli cell tumours) which are associated with hormonal activity.
Patients with Leydig cell tumours may present with gynaecomastia before they notice testicular enlargement.
Majority are benign
Histology: eosinophilic cells in columns
What is the most common cause of osteolytic bone metastasis in children?
Osteosarcoma Neuroblastoma Leukaemia Rhabdomyosarcoma Nephroblastoma
Neuroblastomas are a relatively common childhood tumour and have a strong tendency to developing widespread lytic metastasis.
Which of the following features are not typical of Crohns disease?
Complex fistula in ano Small bowel strictures Skip lesions 'Rose thorn ulcers' on barium studies Pseudopolyps on colonoscopy
Pseudopolyps are a feature of ulcerative colitis and occur when there is severe mucosal ulceration. The remaining islands of mucosa may then appear to be isolated and almost polypoidal.
At which of the following sites is the development of diverticulosis least likely?
Caecum Ascending colon Transverse colon Sigmoid colon Rectum
Because the rectum has a longitudinal muscle coat (blending of of the tenia marks the recto-sigmoid junction), diverticular disease almost never occurs here. Right sided colonic diverticular disease is well recognised (though less common than left sided).
A 32 year old lady presents with a 1.5cm pigmented lesion on her back. The surgeon is concerned that this may be a melanoma. What is the most appropriate course of action?
2mm punch biopsy from the centre of the lesion 4mm punch biopsy from the centre of the lesion Wide excision of the lesion with 3cm margins Excisional biopsy of the lesion Wide excision of the lesion with 1cm margins
Excisional biopsy of the lesion
Lesions that are suspicious for melanoma should be excised with complete margins. Radical excision is not routinely undertaken for diagnostic purposes and therefore if subsequent histopathological assessment determines that the lesion is a melanoma a re-exicision of margins may be required. Incisional punch biopsies of potential melanomas makes histological interpretation difficult and is best avoided.
A 50 year old male presents with painless frank haematuria. Clinical examination is unremarkable. Routine blood tests reveal a haemoglobin of 18g/dl but are otherwise normal. What is the most likely underlying diagnosis?
Squamous cell carcinoma of the bladder Adenocarcinoma of the prostate Adenocarcinoma of the kidney Wilms tumour Transitional cell carcinoma of the renal pelvis
Polycythaemia is a recognised feature of renal cell carcinoma. Wilms tumours most commonly occur in children.
Which of these lesions is most closely associated with Barretts oesophagus?
Squamous cell carcinoma Gastro intestinal stromal tumours Carcinoid tumours Leiomyosarcoma Adenocarcinoma
Barretts oesophagus is most closely associated with adenocarcinoma, and it confers a 30 fold increased risk of developing the condition.
A 56 year old man presents with epigastric discomfort and episodes of migratory thrombophlebitis. On examination he is mildly jaundiced. A CT scan shows lymphadenopathy at the porta hepatis and a mass in the pancreatic head. Which of the following is the most likely underlying diagnosis?
Squamous cell carcinoma of the pancreas Adenocarcinoma of the pancreas Insulinoma Glucagonoma Gastrinoma
Adenocarcinoma of the pancreas is the most likely diagnosis and migratory thrombophlebitis is associated with the condition. Squamous cells carcinoma is extremely uncommon in the pancreas. Gastrinoma are extremely rare and thus not the most likely diagnosis.
A 45 year old man undergoes a surgical excision of a carotid body tumour. Histological analysis is most likely to demonstrate which of the following?
Paraganglionoma Fibromatosis colli Schwannoma Lipoma Neuroma
Carotid body tumours are the commonest type of head and neck paraganglionoma.
A 22 year old man is having a blood transfusion after losing blood from a peptic ulcer. He is normally fit and well. Four hours after the transfusion; he complains of sudden onset shortness of breath and chest pain. On examination his temperature is 37.2, saturations are 88% on air, blood pressure 100/55 mmHg and HR 110 bpm. He has crepitations bilaterally up to the midzones. He is given IV furosemide, but deteriorates and is admitted to ITU. Invasive monitoring shows normal right heart pressures. What is the most likely underlying process?
Acute haemolytic transfusion reaction Delayed haemolytic transfusion reaction Fluid overload Transfusion associated lung injury Graft versus host disease
The normal right heart pressures indicate this is not fluid overload. Transfusion associated lung injury is a rare reaction causing neutrophilic mediated allergic pulmonary oedema. Patient’s have antibodies to donor leukocytes. It is important to consider this as a diagnosis when patients don’t respond to treatment for pulmonary oedema. Patients normally respond to supportive therapy including fluids and oxygen.
A 56 year old man with long standing ulcerative colitis and a DALM lesion in the rectum is admitted with jaundice. On CT scanning the liver has 3 nodules in the right lobe and 1 nodule in the left lobe. Carcinoembryonic antigen levels are elevated. What is the most likely diagnosis?
Yolk sac tumour Hepatocellular carcinoma Metastatic lesion Cholangiocarcinoma Rhabdomyosarcoma
This is likely to be due to metastatic lesions from a colonic primary. DALM lesions should be excised by oncological colectomy for this reason. This burden of metastatic disease is unlikely to precipitate jaundice directly and nodal disease at the porta hepatis is the most likely cause in this case.
A 22 year old man presents with symptoms of headache, lethargy and confusion. On examination, he is febrile and has a right sided weakness. A CT scan shows a ring enhancing lesion affecting the left motor cortex. Which of the following is the most likely diagnosis?
Arteriovenous malformation Cerebral abscess Herpes simplex encephalitis Metastatic renal adenocarcinoma Glioblastoma multiforme
The combination of rapidly progressive neurology, fever and headache is highly suggestive of cerebral abscess. CT scanning will show a ring enhancing lesion because the intravenous contrast cannot penetrate the centre of the abscess cavity. HSV encephalitis does not produce ring enhancing lesions.
A 56 year old man from Egypt has suffered from recurrent attacks of haematuria for many years. He presents with suprapubic discomfort and at cystoscopy is found to have a mass lesion within the bladder. What is the most likely diagnosis?
Squamous cell carcinoma Transitional cell papilloma Adenocarcinoma Leiomyosarcoma Rhabdomyosarcoma
In Egypt, Schistosomiasis is more common than in the UK and may cause recurrent episodes of haematuria. In those affected with the condition who develop a bladder neoplasm, an SCC is the most common type.
A newborn infant is noted to have a unilateral cleft lip only. What is the most likely explanation for this process?
Incomplete fusion of the second branchial arch Incomplete fusion of the nasolabial muscle rings Incomplete fusion of the first branchial arch Incomplete fusion of the third branchial arch Incomplete fusion of the secondary palate
Unilateral isolated cleft lip represents a failure of nasolabial ring fusion. It is not related to branchial arch fusion. Arch disorders have a far more profound phenotype and malformation sequences.
A 72 year old woman with back pain and chronic renal failure has the following blood test results:
Reference range
Ca2+ 2.03 2.15-2.55 mmol/l
Parathyroid hormone 10.4 1-6.5 pmol/l
Phosphate 0.80 0.6-1.25 mmol/l
What is the most likely diagnosis?
Hypoparathyroidism Primary hyperparathyroidism Secondary hyperparathyroidism Tertiary hyperparathyroidism Pseudohypoparathyroidism
In relation to secondary hyperparathyroidism; there is a HIGH PTH and the Ca2+ is NORMAL or LOW. In secondary hyperparathyroidism there is hyperplasia of the parathyroid glands in response to chronic hypocalcaemia (or hyperphosphataemia) and is a normal physiological response. Calcium is released from bone, kidneys and the gastrointestinal system.
A 4 year old boy is brought to the clinic by his mother who has noticed a small lesion at the external angle of his eye. On examination there is a small cystic structure which has obviously been recently infected. On removal of the scab, there is hair visible within the lesion. What is the most likely diagnosis?
Dermoid cyst Desmoid cyst Sebaceous cyst Epidermoid cyst Keratoacanthoma
Dermoid cysts occur at sites of embryonic fusion and may contain multiple cell types. They occur most often in children.
The lesion is unlikely to be a desmoid cyst as these are seldom located either at this site or in this age group. In addition they do not contain hair. Sebaceous cysts will usually have a punctum and contain a cheesy material. Epidermoid cysts contain keratin plugs.
Which of the following tumours are most likely to give rise to para-aortic nodal metastasis early?
Ovarian Bladder Rectal Caecal Cervical
Ovarian tumours are supplied by the ovarian vessels, these branch directly from the aorta. The cervix drains to the internal and external iliac nodes.
Which of the following statements relating to malignant mesothelioma is false?
It may be treated by extrapleural pneumonectomy. It is linked to asbestos exposure. It is linked to cigarette smoking independent of asbestos exposure. It may occur intra abdominally. It is relatively resistant to radiotherapy
It is not linked to cigarette smoking. When identified at an early stage a radical resection is the favored option. Radiotherapy is often given perioperatively. However, it is not a particularly radiosensitive tumour. Combination chemotherapy gives some of the best results and most regimes are cisplatin based.
Which of the following conditions is least likely to exhibit the Koebner phenomenon?
Vitiligo Molluscum contagiosum Lichen planus Psoriasis Lupus vulgaris
Lupus vulgaris
Koebner phenomenon The Koebner phenomenon describes skin lesions which appear at the site of injury. It is seen in: Psoriasis Vitiligo Warts Lichen planus Lichen sclerosus Molluscum contagiosum
Which of the tumour types listed below is found most frequently in a person with aggressive fibromatosis?
Medullary thyroid cancer Basal cell carcinoma of the skin Desmoid tumours Dermoid tumours Malignant melanoma
Aggressive fibromatosis is a disorder consisting of desmoid tumours, which behave in a locally aggressive manner. Desmoid tumours may be identified in both abdominal and extra-abdominal locations. Metastatic disease is rare. The main risk factor (for abdominal desmoids) is having APC variant of familial adenomatous polyposis coli. Most cases are sporadic.
Treatment is by surgical excision.
A 69 year old male presents with haematuria. He worked in the textile industry. He has a left flank mass. A CT IVU shows a lesion of the left renal pelvis. What is the most likely lesion?
Adenocarcinoma Transitional cell carcinoma Nephroblastoma Neuroblastoma Angiomyolipoma
TCC is a rare form of renal cancer, accounting for approximately 7% of all renal tumours. Risk factors include exposure to chemicals in the textile, plastic and rubber industry.
A 20 year old man is suspected of having an inflamed Meckels diverticulum. At which of the following locations is it most likely to be found?
Approximately 60 cm distal to the ileo-caecal valve Approximately 60 cm proximal to the ileocaecal valve Approximately 200cm distal to the ileocaecal valve Approximately 200cm proximal to the ileocaecal valve 50cm distal to the DJ flexure
They are typically found 2 feet proximal to the ileocaecal valve (or approximately 60cm).
A 43 year old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?
Endovascular stent Medical therapy with beta blockers Medical therapy with ACE inhibitors Sutured aortic repair Aortic root replacement
Proximal aortic dissections are generally managed with surgical aortic root replacement. The proximal origin of the dissection together with chest pain (which may occur in all types of aortic dissection) raises concerns about the possibility of coronary ostial involvement (which precludes stenting). There is no role for attempted suture repair in this situation.
A 56 year old man is investigated for anaemia and a large exophytic growth is identified in the distal stomach. What pathological finding is most likely?
Squamous cell carcinoma Adenocarcinoma Lymphoma Leiomyosarcoma Rhadomyosarcoma
Most gastric malignancies are adenocarcinomas
A 45 year old lady presents with a pathological fracture of her femoral shaft. She is a poor historian, but it transpires that she underwent a thyroidectomy 1 year previously. She has no other illness or co-morbidities. What is the most likely underlying diagnosis?
Hyperparathyroidism Metastatic papillary carcinoma of the thyroid Metastatic medullary carcinoma of the thyroid Metastatic follicular carcinoma of the thyroid None of the above
Follicular carcinomas are a recognised cause of bone metastasis. Papillary lesions typically spread via the lymphatics.
A 55 year old lady presents with discomfort in the right breast. On clinical examination a small lesion is identified and clinical appearances suggest fibroadenoma. Imaging confirms the presence of a fibroadenoma alone. A core biopsy is taken, this confirms the presence of the fibroadenoma. However, the pathologist notices that a small area of lobular carcinoma in situ is also present in the biopsy. What is the best management?
Whole breast irradiation Simple mastectomy Mastectomy and sentinal lymph node biopsy Wide local excision and sentinel lymph node biopsy Breast MRI scan
Lobular carcinoma in situ has a low association with invasive malignancy. It is seldom associated with microcalcification and therefore MRI is the best tool for determining disease extent. Resection of in situ disease is not generally recommended and most surgeons would simply pursue a policy of close clinical and radiological follow up.
A 78 year old man presents with symptoms of headaches and deteriorating vision. He notices that there is marked pain on the right hand side of his face when he combs his hair. What is the most likely diagnosis?
Giant cell arteritis Wegeners granulomatosis Polyarteritis nodosa Takayasu's arteritis Buergers disease
Temporal arteritis may present acutely with symptoms of headache and visual loss, or with a less acute clinical picture. Sight may be threatened and treatment with immunosuppressants should be started promptly. The often requested temporal artery biopsy (which can be the bane of many surgeons) is often non diagnostic and unhelpful.
Which one of the following may be associated with an increased risk of venous thromboembolism?
Diabetes Cannula Hyperthyroidism Tamoxifen Amiodarone
Consider thromboembolism in breast cancer patients on tamoxifen!
A 42 year old lady is investigated for symptoms of irritability and altered bowel habit. On examination she is noted to have a smooth enlargement of the thyroid gland. As part of her investigations thyroid function tests are requested, these are as follows:
TSH 0.1 mug/l
Free T4 35 pmol/l
The most likely underlying diagnosis is:
Multinodular goitre Follicular carcinoma of the thyroid gland Graves disease Pregnancy None of the above
TSH receptor antibodies will cause stimulation of the thyroid to synthesise T4. However, this will have a negative feedback effect on the pituitary causing decrease in TSH levels.
Where hyperthyroidism occurs secondary to pregnancy the TSH is typically elevated.
Which of the following is not a risk factor for developing tuberculosis?
Gastrectomy Solid organ transplantation with immunosupression Intravenous drug use Haematological malignancy Amiodarone
Amiodarone
Risk factors for developing active tuberculosis include: silicosis chronic renal failure HIV positive solid organ transplantation with immunosuppression intravenous drug use haematological malignancy anti-TNF treatment previous gastrectomy
A 75 year old lady is investigated for episodes of painless haematuria. Apart from COPD from long term smoking she is otherwise well. She has no other urinary symptoms. What is the most likely cause?
Transitional cell bladder cancer Squamous cell bladder cancer Adenocarcinoma of the bladder Stone disease Arteriovenous malformation of the bladder
TCC commonly presents with painless haematuria that may be detected during testing carried out for other reasons. Bladder AVM are very rare.
A 2 week infant has foul smelling material discharging from the umbilicus. What is the underlying problem?
Proximal enterocutaneous fistula Distal enterocutaneous fistula Entero-enteric fistula Colo-cutaneous fistula Vesico cutaneous fistula
Distal enterocutaneous fistula
This baby has an enterocutaneous fistula at the umbilicus due to complete failure of the omphalomesenteric duct to obliterate. This is treated with resection. Remember that vitello intestinal duct anomalies are common and these are always distal.
Which of the following is not true of gastric cancer?
There is an association with blood group A Adenocarcinoma is the most common subtype Individuals with histological evidence of signet ring cells have a lower incidence of lymph node metastasis Lymphomas account for 5% cases In Western Countries a more proximal disease distribution has been noted
Signet ring cells are features of poorly differentiated gastric cancer associated with a increased risk of metastatic disease.
What is the most common presentation of a parotid gland tumour?
Parapharyngeal mass Mass at anterior border of masseter Mass inferior to the angle of the mandible Mass posterior to the angle of the mandible Mass anterior to the ear
Mass posterior to the angle of the mandible
A 52 year old male is referred to urology clinic with impotence. He is known to have hypertension. He does not have any morning erections. On further questioning the patient reports pain in his buttocks, this worsens on mobilising. On examination there is some muscle atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
Leriche syndrome S3-S4 cord lesion Pudendal nerve lesion Psychological impotence Beta blocker induced impotence
Leriche syndrome
Classically, it is described in male patients as a triad of symptoms:
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries. Management involves correcting underlying risk factors such as hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.
A patient presents with a facial nerve palsy. This occurred following repeat excision of a facial lump. The histology report remarks on the biphasic appearance of the lesion and mucinous connective tissue. What is the most likely underlying lesion?
Pleomorphic adenoma Adenolymphoma Anaplastic carcinoma Adenoid cystic carcinoma Schwannoma
Pleomorphic adenoma
The histological features are as described with a classic biphasic (mixed stromal and epithelial elements), although benign local recurrence can complicate incomplete excision. As this is a benign lesion direct extension into the facial nerve is unlikely to occur. Facial nerve injury can happen during repeat parotid surgery.
A 23 year old man presents with diarrhoea and passage of mucous. He is suspected of having ulcerative colitis. Which of the following is least likely to be associated with this condition?
Superficial mucosal inflammation in the colon Significant risk of dysplasia in long standing disease Epsiodes of large bowel obstruction during acute attacks Haemorrhage Disease sparing the anal canal
Large bowel obstruction is not a feature of UC, patients may develop megacolon. However, this is a different entity both diagnostically and clinically. Ulcerative colitis does not affect the anal canal and the anal transitional zone. Inflammation is superficial. Dysplasia can occur in 2% overall, but increases significantly if disease has been present over 20 years duration. Granulomas are features of crohn’s disease.
A 23 year old lady undergoes a total thyroidectomy as treatment for a papillary carcinoma of the thyroid. The pathologist examines histological sections of the thyroid gland and identifies a psammoma body. What are these primarily composed of?
Clusters of calcification Aggregations of neutrophils Aggregations of macrophages Giant cells surrounding the tumour Clusters of oxalate crystals
Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in papillary carcinomas.
A 52 year old woman attends clinic for investigation of abdominal pain and constipation. On examination, you note blue lines on the gum margin. She mentions that her legs have become weak in the past few days. What is the most likely diagnosis?
Acute intermittent porphyria Lead poisoning Constipation Guillan Barre syndrome Rectal carcinoma
This would be an impressive diagnosis to make in the surgical out patient department! The combination of abdominal pain and a motor periperal neuropathy, should indicate this diagnosis. The blue line along the gum margin can occur in up to 20% patients with lead poisoning.
A 28 year old man presents with right upper quadrant pain and hydatid disease is suspected. Which of the following statements relating to the disease is untrue?
First line treatment is with pentavalent antimony. Peritoneal contamination with active daughter cysts may complicate surgery. CT scanning of the liver may show a floating membrane. Biliary communication with the cysts may occur. It is caused by Echinococcus granulosus.
First line treatment is with pentavalent antimony.
Drug treatment is with albendazole or mebendazole. Praziquantzel may be used in the pre operative stages.
A 33 year old man is involved in a road traffic accident. He is initially stable and transferred to the accident and emergency department. On arrival he is catheterised. One minute later he becomes hypotensive, with evidence of angioedema surrounding his penis. What is the most likely explanation for this event?
Type V latex hypersensitivity reaction Type IV latex hypersensitivity reaction Type III latex hypersensitivity reaction Type I latex hypersensitivity reaction Type II latex hypersensitivity reaction
Sudden collapse and angioedema following exposure to latex (of which most urinary catheters are manufactured) suggests a type I hypersensitivity reaction.
A 48 year old lady with chronic hepatitis B infection is noted to have worsening liver function tests and progressive jaundice. Her alpha feto protein levels are grossly elevated. What is the most likely diagnosis?
Hepatocellular carcinoma Metastatic cancer Cholangiocarcinoma Yolk sac tumour Liver cell adenoma
Hepatocellular carcinoma
A 43 year old female develops severe chest wall cellulitis following a mastectomy. On examination, the skin is markedly erythematous. Which of the acute inflammatory mediators listed below is least likely to produce vasodilation at this site?
Complement component C5a Lysosomal compounds Histamine Serotonin Prostaglandins
Erythema is a classical feature of acute inflammation. Potent mediators of vascular dilatation include; histamine, prostaglandins, nitric oxide, platelet activating factor, complement C5a (and C3a) and lysosomal compounds. Although serotonin is associated with acute inflammation it is a vasoconstrictor.
A 43 year old man presents with a 3 week history of malaise, sore throat, odynophagia and dysphagia. On examination he is found to have patchy white spots in his oropharynx. An upper GI endoscopy is performed and similar lesions are identified in the oesophagus. Which investigation is most likely to identify the underlying pathology in this case?
Serum urea and electrolytes Oesophageal biopsy for culture Oesophageal biopsy for histology Glucose tolerance testing Viral serology
Viral serology
Oesophageal candidiasis is associated with immunosupression; mainly in patients on chemotherapy, with haematological malignancy, HIV or inhaled steroids. In patients with HIV, oesophageal candidiasis is part of the spectrum of AIDS defining illnesses and usually occurs when the CD4 count is less than 200. Others include PCP pneumonia and CMV infections.
A 52 year old man with dyspepsia is found to have a duodenal ulcer. A CLO test is taken and is positive. Which statement relating to the likely causative organism is false?
It is a gram negative organism It preferentially colonises gastric type mucosa It may occupy areas of ectopic gastric metaplasia In patients who are colonised there is commonly evidence of fundal gastritis on endoscopy It produces a powerful urease that forms the basis of the Clo test
In patients who are colonised there is commonly evidence of fundal gastritis on endoscopy
Helicobacter pylori rarely produces any typical features on endoscopy. Where infection is suspected the easiest course of action is to take an antral biopsy for Clo testing in the endoscopy suite.
A 34 year old male presents with painful rectal bleeding and a fissure in ano is suspected. On examination he has an epithelial defect at the mucocutaenous junction that is located anteriorly. Approximately what proportion of patients with fissure in ano will present with this pattern of disease?
90% 10% 50% 25% 100%
Only a minority of patients with fissure in ano will have an anteriorly sited fissure. They are particularly rare in males and an anterior fissure in a man should prompt a search for an underlying cause.
The pathogenesis of osteopetrosis is best explained by a defect in which of the following?
Osteoclast function PTH receptors Osteoblast function Calcium resorption in proximal tubule Calcium absorption
Also known as marble bone disease
Rare disorder of defective osteoclast function resulting in failure of normal bone resorption
Stem cell transplant and interferon-gamma have been used for treatment
A 2 year old boy presents with a right renal mass. On examination, he has an irregular mass arising from the right flank and is hypertensive. A CT scan shows a non calcified irregular lesion affecting the apex of the right kidney and the right adrenal gland. What is the most likely diagnosis?
Neuroblastoma Nephroblastoma Renal cell carcinoma Transitional cell carcinoma Lymphoma
Wilm’s tumour of the kidney is the most common renal tumour in children. Both nephroblastoma and neuroblastoma may occupy the adrenal and apex of the kidney. In the case of neuroblastoma the lesion will have arisen from the adrenal, in the case of nephroblastoma the lesion will have arisen from the kidney. Hypertension is more commonly associated with nephroblastoma. Neuroblastomas are usually calcified, whereas nephroblastomas are not and this may be of diagnostic usefulness pre operatively.
A 13 month old boy is brought to the surgical clinic by his mother because his left testicle is not located in the scrotum. At which of the following sites would the testicle be located if it were an ectopic testis?
Canalicular Inguinal External inguinal ring Superficial inguinal pouch High scrotal
Ectopic testes are those that come to lie outside the normal range of embryological descent (i.e. in the superficial inguinal pouch). Other sites of ectopic testes include; base of penis, femoral triangle and perineum.
Which of the following is seen more commonly with Crohns disease rather than ulcerative colitis?
Mucosal islands at endoscopy Goblet cell depletion on biopsy Fat wrapping of the terminal ileum Attenuated symptoms in smokers Toxic megacolon
Fat wrapping of the terminal ileum is commonly seen in patients with ileal disease (the commonest disease site). The mesenteric fat in patients with IBD is often dense, hard and prone to considerable haemorrhage during surgery. At endoscopy, the mucosa in patients with Crohns disease is said to resemble cobblestones, mucosal islands (pseudopolyps) are seen in ulcerative colitis.
