IBD, diarrhoea, ischaemic colitis, coeliac

Question 1

Likely diagnosis for acute diarrhoea

Answer 1

Infection, constipation with overflow, dietary, pseudomembranous colitis

Question 2

Likely diagnosis for chronic diarrhoea

Answer 2

Chronic IBD or IBS
Coeliac disease
Colon or pancreatic cancer
Whipples disease (Tropheryma whippelii bacterial disease of the gut causing weight loss,
diarrhoea, abdominal and joint pain)
Infection (C diff)
Cystic fibrosis 
Medications e.g. laxatives

Question 3

Investigations for common causes of diarrhoea

Answer 3

Red flag symptoms - weight loss, antibiotics, travel, stress, pain, lifestyle
PR exam
Stool specimen
Bloods - FBC, ESR, LFTs, CRP, Vit b12, ferritin, calcium, anti-TTG

Question 4

Most common cause of infectious diarrhoea in UK

Answer 4

Campylobacter
Symptoms 2-5 days after ingestion
Malaise, bloody diarrhoea and abdo pain
Erythromycin or ciprofloxacin

Question 5

Coeliac disease:

Answer 5

Autoimmune response to gliadin peptide antigen in what, rue, barley and other grains.
Genetic predisposition - HLA-DQ2 or DQ8 mutation
Proteins resistant to human proteases and can enter intestinal mucosa, activate IL15

Question 6

Pathophys of IBD:

Answer 6

Mucosal immune system (IgA) exerts inappropriate response

possibly due to deficient bacterial clearance by neutrophils.

Question 7

Differentials for Crohn’s disease:

Answer 7

 Ulcerative colitis - Colonoscopy differentiates UC always involves the rectum, is continuous and doesn’t go past the colon.
 Infectious colitis - Stool testing reveals the infection
 Pseudomembranous colitis - History of recent Abx use, C. difficile toxin is diagnostic.
 Ischaemic colitis - Colonoscopy show mucosal friability in the watershed areas of the left colon
 Radiation colitis - History of exposure to external beam radiotherapy. Patients may have bleeding angioectatic vessels
 Yersinia enterocolitica - Y enterolitica can cause an acute ileitis with a clinical picture resembling an acute flare-up of
CD. Stool cultures and serological tests confirm the diagnosis
 Colorectal cancer - CT may show primary or secondary disease, colonoscopy provides tissue for histological diagnosis
 Diverticular disease - Commonly presents with left-sided abdominal pain in patients aged 50 years and older. CT scan
shows evidence of diverticular disease.
 Acute appendicitis - Younger patients, CT scan shows inflammation of appendix only.
 IBS -Colonoscopy is normal.

Question 8

What is ischaemic colitis?

Answer 8

Typically large bowel and multifactorial
RF- Age, AF, CVD, Cocaine
Acute but transient symptoms - bloody diarrhoea, inflammation, ulceration
Occurs in watershed areas like splenic flexure
‘Thumbprinting’ seen on X-ray due to oedema/haemorrhage
Conservative management

Question 9

What is acute mesenteric ischaemia?

Answer 9

Caused by embolism occluding artery supply of SMALL BOWEL
RF= AF
Severe abdo pain, sudden onset
Urgent surgery required and high mortality

Question 10

Which organism causes vomiting within hours of eating?

Answer 10

Bacillus Cereus

Found in contaminated food
Incubation 1-6 hours after eating
Rapid resolution

Question 11

What is the most commonly reported cause of food poisoning?

Answer 11

Campylobacter jejuni

Question 12

What is an important cause of acute kidney injury associated with bloody diarrhoea?

Answer 12

E. coli 0157

Associated with haemolytic uraemic syndrome

Is a severe illness in infancy

Question 13

What is the most likely cause for diarrhoea and vomiting 2 hours after eating a meal?

Answer 13

Staphylococcus aureus

E. coli and salmonella dont cause vomiting as a predominant symptom

Question 14

What are the symptoms associated with IBS?

Answer 14

Abdominal bloating

Diarrhoea for several months

Question 15

First line treatment for Moderate IBD to induce remission:

Answer 15

Topical 5-ASA (rectally)

Question 16

Second line treatment for Moderate IBD to induce remission:

Second line if intolerant to aminosalicylates:

Answer 16

Oral 5-ASA

Rectal corticosteroid (budesonide, hydrocortisone, prednosolone) or oral prednisolone

Question 17

What is the first line treatment for IDS related diarrhoea?

Answer 17

Loperamide (imodium)

Question 18

What is the Truelove and Witts’ severity index?

What is the criteria for classifying the flare-up as Severe?

Answer 18

NICE recommendation for the severity of UC

‘Severe’ when the patient has blood in their stool, or is passing more than 6 stools per day plus at least one of the following features:
Temperature greater than 37.8°C
Heart rate greater than 90 beats per minute
Anaemia (Hb less than 105g/ L)
Erythrocyte sedimentation rate greater than 30 mm/hour

Question 19

What is the criteria for classifying the flare-up as mild?

Answer 19

Fewer than four stools daily, with or without blood

No systemic disturbance

Normal erythrocyte sedimentation rate and C-reactive protein values

Question 20

What is the criteria for classifying the flare-up as moderate?

Answer 20

Four to six stools a day, with minimal systemic disturbance

Question 21

What is the first line investigation when suspecting coeliac disease?

Answer 21

IgA and IgA tTG antibody

Question 22

What is the least invasive way to diagnose gallstones?

Answer 22

Abdominal ultrasound

Question 23

Which IBD can lead to terminal ileitis making people prone to gallstones?

Answer 23

Crohn’s disease

Question 24

Which hormone is excessively produced in Zollinger- Ellison syndrome

Answer 24

Gastrin causes increased acid release

Question 25

NICE advise using what investigation in primary care to differentiate between IBS and IBD?

Answer 25

Faecal Calprotectin