lower GI Flashcards
A 22 y/o female presents to her GP with a two year history of intermittent diarrhoea and constipation. She complains of bloating and abdominal pain, which eases with defecation. Which condition is she likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
B. Ulcerative colitis
A 26 y/o male presents to his GP with weight loss, abdominal pain and watery diarrhoea. On examination he looks pale and you notice ulcers in his mouth. Which condition is he likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
C. Crohn’s disease
A 23 y/o female presents to her GP with a limp. On further questioning she reveals she has recently lost weight and has had bloody, mucoid diarrhoea. On examination her right knee is tender and swollen, and her eyes are red. Which condition is she likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
E. Infectious diarrhoea
A 27 y/o male presents with a history of mucoid, bloody diarrhoea and weight loss. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
A. IV corticosteroid B. Oral prednisolone C. Topical mesalazine D. Oral azathioprine E. IV cyclosporin
C. Topical mesalazine
A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin
B. Oral prednisolone
which is a corticosteroid
A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
After starting treatment, his symptoms improve. Which additional treatment would you start him on to maintain his remission?
A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin
D. Oral azathioprine
A 55 y/o female presents to her GP with an itchy rash on her forearms. On further questioning she reveals she has recently lost weight and has had mucoid diarrhoea. Which test will best confirm her diagnosis?
A. Endoscopy with duodenal biopsy B. Serum antibodies to tissue-transglutaminase C. Serum anti-endomysial antibodies D. Colonoscopy E. Endoscopy with ileal biopsy
A. Endoscopy with duodenal biopsy
Crohn’s:
- Gut layer
- Regions most common site
- Inflammation
- Abscess/fissure
- symptoms
- Flare patterns
- surgery
- All
- mouth to anus (although terminal ileum is common)
- patchy - skip lesions
- common
- Diarrhoea +/- blood (mixed in)
- systemically unwell
- NOT curative
Ulcerative Colitis
- Gut layer
- Regions most common site
- Inflammation
- Abscess/fissure
- symptoms
- Flare patterns
- surgery
- Mucosa and submucosa
- Colon and rectum
- continuous
- uncommon
- bloody +/- mucus diarrhoea (mixed in)
- well between attacks
- curative
What are other important features of Crohn’s
- mouth ulcer
- fever
- perianal lesions
- RIF pain (from ileitis)
What are other important features of UC
- Abdominal pain
2. relapsing-remitting
What are extra-intestinal manifestations of IBD
A PILE SAC
A = aphthos
What are extra-intestinal manifestations of IBD
A PILE SAC A = aphthos (mouth) ulcers [CD>UC] P = pyoderma gangrenosum I = (eye) iritis, uveitis, episcleritis [CD>UC] E = erythema nodosum S = sclerosing cholangitis [UC] A = arthritis C = clubbing fingers [CD>UC]
What is the first line investigation for inflammatory bowel disease
Stool sample
What are the investigations used to diagnose Crohn’s
- stool sample
- Blood tests
- CT/MRI
- (colonoscopy and biopsy)
What are the investigations used to diagnose ulcerative colitis
- stool sample
- blood tests
- AXR
- colonoscopy/flexible sigmoidoscopy and biopsy
What are the radiological signs of inflammatory bowel disease
- lead pipe sign
- thumb printing
- toxic megacolon (IBD is serious enough to cause inflammatory colitis)
What drug is used to induce remission in Crohn’s
corticosteroids
What drug is used to induce remission in ulcerative colitis
Aminosalycilates
- topical
- oral (low dose)
- oral (high dose)
What drugs are used to maintain remission in Crohn’s
- Azathioprine
- methotrexate
- cyclosporin
- infliximab
What drugs are used to maintain remission in ulcerative colitis
- Azathioprine
- methotrexate
- cyclosporin
What is coeliac disease
chronic autoimmune disease of the small intestine, categorised by gluten intolerance in genetically susceptible individuals
What is the aetiology behind coeliac disease
autoimmune damage to intestinal mucosa leads to villous atrophy WBC infiltration cryptal hyperplasia = malabsorption
What are the risk factors for coeliac disease
- female
- autoimmune background
T1DM
Thyroid disease - Family history
What are the symptoms of coeliac disease
- diarrhoea
which is difficult to flush
What are the symptoms of coeliac disease
1. diarrhoea which is difficult to flush 2. Bloating 3. Abdo pain after eating gluten 4. fatigue
What are the signs of coeliac disease
- IgA deficiency
- anaemia
- dermatitis herpetiformis
What is the first line management for coeliac disease
stool sample
What is the gold standard investigation for coeliac disease
Endoscopy + duodenal biopsy
What are the investigations for coeliac disease
- Stool sample
- serum anti-body tests:
antibodies to tissue transglutaminase (TTG)
anti-
What are the investigations for coeliac disease
- Stool sample
- serum anti-body tests:
antibodies to tissue transglutaminase (TTG)
anti-endomysial antibodies - Gold standard: endoscopy + duodenal biopsy
What is the management of coeliac disease
- guten-free diet
2. vitamin D supplementation
What are the complications of coeliac disease
- upper GI lymphomas and carcinoma
- osteoporosis due to lack of vitamin D
- Chronic dermatitis herpetiformis
A 67 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He is otherwise fit and well. What is the next appropriate step to take?
A. Colonoscopy B. Faecal occult blood test C. Abdominal exam D. Digital rectal exam E. Sigmoidoscopy
C. Abdominal exam
A 35 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He adds that he is very sore ‘down there’ and it is agony to defecate. Which condition is he likely to have?
A. Haemorrhoids B. Anal fissure C. Crohn’s disease D. Ulcerative colitis E. Colorectal carcinoma
B. Anal fissure
A 67 y/o male presents to his GP complaining of rectal bleeding. Over the last few months he has noticed blood mixed in with his stool. He sometimes feels like he hasn’t completely emptied his bowels after defecating, and is more tired than usual. What is the next step to take?
A. Routine referral to colorectal surgeons
B. Urgent referral to colorectal surgeons
C. FBC
D. Abdominal exam
E. Faecal occult blood test
D. Abdominal exam
What is an anal fissure
It is a split in the skin of the distal anal canal
What are the risk factors for anal fissure
- young, white males
2. can be linked to previous constipation
What are the symptoms of an anal fissure
- pain
tearing sensation - Blood on paper
What are the investigations for an anal fissure
purely clinical diagnosis
What is the treatment of anal fissures
- fluids and fibre
- topical analgesia
- can add topical GTN or diltiazem
- surgery in severe, chronic cases
What are the complications of anal fissures
- chronicity
2. incontinence from surgery
What are haemorrhoids
haemorrhoidal cushions are normal anatomical structures located within the anal canal. As they enlarge, they van protrude outside the anal canal causing symptoms
What are the risk factors for haemorrhoids
Increased intra-abdominal pressure
What are the symptoms of haemorrhoids
- rectal bleeding
bright red
sides of the pan - rectal pain
What are the signs of haemorrhoids
- Lump on DRE
2. 3rd/4th type may be visible on inspection
What are the investigations for haemorrhoids
- DRE
2. Colonoscopy
What is the management for haemorrhoids
- fluid and fibre, topical analgesia
- 2nd or 3rd degree: non-surgical removal
- 4th: excision
What is the most common type of colorectal cancer
adenocarcinoma
What are the risk factors for colorectal cancer
- alcohol/smoking/high red meant diet
- polyps
- Genetic conditions:
FAP/HNPCC
Features of a right sided tumour (colorectal cancer)
- weight loss
- anaemia
- abdominal pain
- obstruction less likely
- harder to detect, presents later
Features of left sided tumour (colorectal cancer)
- bleeding/mucus PR
- Altered bowel habit
- tenesmus
- obstruction
- Mass PR
- Easier to detect, presents earlier
What are the investigations for colorectal cancer
1. Bloods: FBC (anaemia) LFTs (baseline) Renal function (baseline) 2. colonoscopy/barium enema/ CT colonography (to find and stage the tumour) 3. biopsy (to grade tumour
