Gastrointestinal: Colorectal

Question 1

RIF pain that started at umbilicus with fever and some vomiting is indicative of what condition?

Answer 1

Acute appendicitis

Question 2

What are two ‘classic’ exam signs for appendicitis?

Answer 2

Pressing LIF to induce RIF pain (Rovsing’s sign)

Hip extension induces RIF pain (Psoas sign)

Question 3

What is diagnostic for appendicitis?

What two tests should you do to ensure no other differentials?

Answer 3

Clinical features + Raised WCC

Urine negative for B-HCG (pregnancy), nitrites (renal colic)

Question 4

What is the treatment for acute appendicitis?

Answer 4

Prophylactic antibiotics

Laparoscopic appendectomy

Question 5

What does ‘generalised abdominal pain associated with green, bilious vomiting. Also complete constipation, abdominal distention and tinkling bowel sounds.’ describe?

Answer 5

Bowel obstruction

Features

Green, bilious vomiting

General abdominal pain

Constipation incl. no farts

Abdominal distention

Tinkling bowel sounds

Question 6

What is ‘third spacing’?

Answer 6

Backlog of fluid due to lack of colonic reuptake

Question 7

What findings help distinguish an ileus from a volvulus?

Answer 7

Ileus: absent rather than ‘tinkling’ bowel sounds

Volvulus: ‘coffee bean’ sign on AXR

Question 8

What is the gold standard investigation for suspected bowel obstruction?

Answer 8

CT: Confirm +/- identify perforation

Question 9

What AXR signs suggest bowel obstruction?

Answer 9

Distended bowel loops (loss of haustra)

lines across small bowel (valvulae conniventes)

Question 10

What blood gases are present in bowel obstruction management?

Answer 10

Metabolic alkalosis (vomiting)

Raised lactate (ischaemia)

Question 11

What is the treatment for bowel obstruction?

Answer 11

Conservative if stable or volvulus

Surgical correction if not

Stent if palliative

Question 12

How do Crohn’s and Ulcerative colitis differ in a) symptoms b) GI involvement and c) extra-intestinal involvement?

Answer 12

Crohn’s // UC

a) Weight loss prominent, perianal pain, RIF mass // PR bleeding prominent, LIF pain, tenesmus
b) Skip lesions in terminal ileum (but anywhere potentially) // continous Rectum –> ileocaecal valve
c) Gallstones // Primary sclerosing cholangitis

Question 13

Crohn’s vs UC: submucosa inflammation, increased goblet cells and granulomas?

Answer 13

Crohn’s

UC: Mucosal inflammation, reduced gobelt cells and crypt abscesses

Question 14

Crohn’s vs UC: enema shows haustral loss, pseudopolyps and superficial ulceration

Answer 14

UC

Crohn’s: strictures, proximal bowel dilation, rose thorn uclers, fistulae

UC: ‘thumbprinting’

Crohn’s: String sign

Question 15

What are the 1st, 2nd and adjunctive treatments used to induce remission in Crohn’s

Answer 15

1st line: Glucocorticoids

2nd line: Mesalazine (5-ASA)

+ azathioprine/mercaptopurine

Question 16

What is mild-moderate vs severe ulcerative colitis?

Answer 16

Mild-moderate: 4-6 stools, small blood, no systemic

Severe: >6 stools, blood, systemic

Question 17

How do you induce remission in mild-moderate UC?

Answer 17

1st line: topical aminosalicylate

if proctitis: + oral aminosalicylate /corticosteroids

Question 18

How do you induce remission in severe UC?

Answer 18

IV steroids

+ ciclosporin if no improvement

Question 19

How is maintenance done in Crohn’s?

Answer 19

Stop smoking

1st line: Azathioprine/mercaptopurine

Question 20

How is mild-moderate UC remission maintained?

Answer 20

Aminosalicylate: Topical/oral/both

Question 21

How is severe UC remission maintained?

Answer 21

Azathioprine / mercaptopurine

Question 22

What clinical findings help discern coeliac disease from irritable bowel?

Answer 22

Coeliac // irritable bowel

Crampy abdo pain // pain worse on eating, relieved by opening bowels

Diarrhoea // constipation +/- diarrhoea

Mouth ulcers // PR mucus

Question 23

What conditions is coeliac associated with?

Answer 23

Dermatitis herpetiformis

T1DM

Autoimmune thyroid disease

Question 24

What blood antibodies confirm coeliac?

Answer 24

Anti-tTG, Anti-EMA

Question 25

What tests confirm irritable bowel syndrome?

Answer 25

NONE

Negative inflammation, coeliac serology and faecal calprotectin

Question 26

How is coeliac disease managed?

Answer 26

Lifelong gluten free diet

Question 27

What is the first, second and third line medical management for IBS?

Answer 27

1st: Loperamide for diarrhoea, laxatives for constipation (not lactulose)
2nd: Tricyclics
3rd: SSRIs