Lower GI

Question 1

IBS

• Symptoms
• Tests

Answer 1

Abdominal pain/bloating/change in bowel habit for 6 months.
Pain relieved by defecation or altered stool form.
Symptoms made worse by eating.
+/- mucus in stools.
Others: lethargy, nausea, backache, bladder symptoms.

FBC, ESR and CRP, TTG antibodies for coeliac disease.

Question 2

IBS

-Management

Answer 2

Pain- anti spasmodic.
Constipation- laxatives
Diarrhoea- loperamide.

2nd line: low dose TCAs Amitriptyline 5-10mg
3rd line: SSRI

Dietary advice: regular meals, stay hydrated, restrict tea and coffee, limit alcohol and fizzy drinks, oats, linseeds.

Question 3

Crohn’s disease
Where is affected
Histology

Answer 3

IBD, can effect anywhere mouth-anus but most commonly the terminal ileum.

Inflammation in all layers down to serosa- prone to strictures, fistulas and adhesions. ++ Goblet cells and granulomas.

Question 4

Crohn’s symptoms and tests

Answer 4

Early adulthood
Weight loss, lethargy
Diarrhoea + blood if Crohn's colitis.
Abdominal pain. Mouth ulcers.
Extra-intestinal features: arthritis, erythema nodosum, episcleritis, pyoderma gangrenousum.

Raised CRP, increased faecal calprotectin, anaemia, low B12 and vitamin D.

Colonoscopy- deep ulcers and skip lesions.

Question 5

Crohn’s management

Answer 5

Stop smoking

Induce remission- glucocorticoids. Enteral feeding. 5-ASA drugs e.g. mesalazine are 2nd line.

Acathioprine/methotrexate or mercaptopurine add on therapies to maintain remission.
Metronidazole for isolated peri-anal disease.

80% have surgery- ileocecal resection. Subtotal colectomy, pan proctocolectomy, staged subtotal colectomy and proctectomy.

Question 6

Ulcerative colitis
Where is affected
Histology

Answer 6

Continuous inflammation starts at rectum and spreads proximally, never beyond ileocecal valve.

Red raw bleeding mucosa. Ulceration, pseudo polyps.
No inflammation beyond submucosa.
See crypt abscesses.
Loss of haustral markings in colon.

Question 7

UC symptoms

Answer 7

Bloody diarrhoea, urgency, tenesmus, abdominal pain in LIF, extra intestinal features: arthritis, erythema nodosum, pyoderma gangerenosum, uveitis, primary sclerosing cholangitis.

Question 8

UC management

Answer 8

Mild < 4 stools/day, minimal blood
Moderate 4-6/day, varying blood.
Severe > 6 bloody stools / day, systemic upset.

Mild/moderate- topical rectal aminosalicylate e.g. mesalazine for proctitis.
2nd line add oral mesalazine then oral/topical steroids.

Severe- IV steroids, consider IV ciclosporin. Consider surgery- colectomy and ileostomy formation. +/- ileoanal pouch.

Question 9

UC flare ups causes

Answer 9

Stress, medications, NSAIDs and antibiotics, smoking cessation.

Question 10

Coeliac disease
Histology
Symptoms

Answer 10

Autoimmune sensitivity to gluten.
Villous atrophy -> malabsorption.

Chronic/intermittent diarrhoea, failure to thrive in children, unexplained nausea and vomiting, fatigue, cramping pains, weight loss, anaemia.

Question 11

Coeliac disease- associated conditions

Answer 11

Autoimmune thyroid disease
Dermatitis herpetiformis
IBS
T1 diabetes
Screen 1st degree relatives.

Question 12

Coeliac diagnosis

Answer 12

Immunology:
TTG IgA antibodies
Anti-casein antibodies

Duodenal biopsy- villous atrophy, crypt hyperplasia, lymphocyte infiltration (must eat gluten for 6 weeks prior)

Question 13

Coeliac management

Answer 13

Gluten dree diet

Often see functional hypersplenism so patients offered the pneumococcal vaccine.

Question 14

Appendicitis

• symptoms
• signs
• management

Answer 14

Peri-umbilical pain (visceral stretching) radiating to RIF (parietal peritoneum inflammation).
+/- vomiting, diarrhoea, mild pyrexia, no appetite.

Peritonitis if perforated- Rebound and percussion tenderness, guarding and rigidity.

Appendicectomy laparoscopic or open. Prophylactic antibiotics. Perforated- copious abdominal lavage.

Question 15

Volvulus

• what is it
• symptoms
• management

Answer 15

Torsion of colon around mesenteric axis- compromised blood flow, closed loop obstruction.
Sigmoid volvulus- 80%. Older patients, chronic constipation.

Constipation, bloating, pain, n+v
XR- large bowel obstruction
Rigid sigmoidoscopy for sigmoid, right hemicolectomy often needed for caecal volvulus.

Question 16

Diverticulosis

Answer 16

Outpouchings of colonic mucosa though muscular bowel wall. Altered bowel habit, bleeding and pain.
Can lead to diverticulitis, haemorrhage, fistula, perforation, abscess formation.

Question 17

Diverticulitis

Answer 17

Infection of outpouchings.
LIF pain, anorexia, nausea and vomiting, constipation or diarrhoea, pyrexia, raised WCC and CRP.
Oral antibiotics, liquid diet and analgesia. Serve- IV antibiotics.
Co-amoxiclav.

Question 18

Haemorrhoids

• what are they
• symptoms
• types and grades
• treatment

Answer 18

Enlarged, congested, symptomatic vascular cushions.
Painless rectal bleeding, pain.

External- painful, below dentate line
Internal- painless, above dentate line
Grade I- no prolapse
Grade II- prolapse of defecation
Grade III- manually reduced
Grade IV- cannot be reduced

Soft stools, local anaesthetics, steroids, rubber band ligation.

Question 19

Abdominal hernia types

Answer 19

Direct inguinal-protrudes though Hesselback triangle, passes superior and medial to inferior epigastic artery. Due to weakness in transversalis fascia.
Seen in adult males.

Indirect inguinal- protrudes through inguinal ring, lateral to inferior epigastric artery. Due to failure of processus vaginalis to close. Seen in infant males.

Femoral- protrude below inguinal ligament and below and lateral to pubic tubercle, lateral to pubic tubercle. High risk of strangulation. Most common in adult females.

Question 20

Congenital hernias

Answer 20

Congenital inguinal hernia- indirect inguinal from patent processus vaginalis. 60% R. sided. Should be surgically repaired due to risk of incarceration.

Infantile umbilical hernia- symmetrical bulge under umbilicus. Most resolve before ages 4-5.