MICA cases

Question 1

A patient presenting with painless rectal bleeding, do they need investigation?

Answer 1

Rectal bleeding must be investigated unless there is a good evidence clinically for haemorrhoids

Question 2

What other things should be asked about with rectal bleeding?

Answer 2

weight loss, change in bowel habit, tenesmus and the presence of mucus in the stool

Question 3

What are the top differential for painless rectal bleeding?

Answer 3

Carcinoma of the colon

Haemorrhoids

Question 4

What conditions are associated with an increased risk of colorectal carinoma?

Answer 4

Peutz-Jeghers syndrome

Familial adenomatous polyposis (FAP)

Ulcerative colitis

Question 5

What is FAP?

Answer 5

Hundreds to thousands of adenomatous polyps lining the colon

Autosomal dominant

Question 6

When might you do a CXR in a gastro pt?

Answer 6

Staging after confirmed GI tumor

Question 7

What are dukes criteria for staging?

Answer 7

Dukes A – tumour confined to bowel wall

Dukes B – tumour has gone through wall but not into nodes

Dukes C – tumour involving regional nodes

Dukes D – distant metastases are present

Dukes stage histologically affects prognosis – i.e. 90% alive at 5 years Dukes A, reducing to 10% for Dukes D.

Question 8

In who should a diagnosis of IBS be considered?

Answer 8

patients who have either abdominal pain or bloating or change in bowel habit for a minimum of six months

Question 9

What initial tests should be done to exclude other differentials other than IBS?

Answer 9

FBC
ESR
CRP
Coeliac serology

Question 10

What dietary advice is give to those with IBS?

Answer 10

Regular meals
Restrict carbonated drinks
Increase water intake
Reduce caffeine intake
Discourage use of sweetners in IBS with diarrhoea
Increase oats and linseeds

Question 11

What are some treatments for IBS?

Answer 11

CBT
low dose TCA for abdo pain
Loperamide for dirrhoea
Hypnotherapy
Antispasmodic agents

Question 12

PR bleeding, weightloss and diarrhoea - apart from bloods what investigations?

Answer 12

AXR
Stool cultures
Flexible sigmoidoscopy

Question 13

What are some extra-intestinal manifestations of UC related to colitis?

Answer 13

Erythema nodosum
Aphthous ulcers
Episcleritis
Anterior uveitis
Acute arthropathy

Question 14

What are some extra-intestinal manifestations of UC not related to colitis?

Answer 14

Sacroiliiitis /Ankylosing spondylitis

Primary sclerosing cholangitis

Question 15

Which of the following tests may help diagnosis of the lower back pain?

Answer 15

85-95% Caucasian patients with axial spondyloarthropathy are positive for HLA-B27

Lower back and sacro-iliac XR

MRI lumbar spine and sacro-iliac joints

Question 16

What is first line management of acute sever colitis?

Answer 16

IV Hydrocortisone

Question 17

What is next management if unresponsive to initial UC treatment?

Answer 17

IV ciclosporin

Infliximab

Question 18

What is infliximab?

Answer 18

biologic which suppresses the TNF-alpha and should only be considered if intravenous ciclosporin is contra-indicated or inappropriate

Question 19

What are contraindications to ciclosporin?

Answer 19

hypertension and renal impairment

Question 20

How is mild UC defined?

Answer 20

fewer than 4 stools a day with no systemic disturbance and normal CRP and ESR

Question 21

How is moderate UC defined?

Answer 21

4-6 stools a day with minimal systemic disturbance

Question 22

How is severe US defined?

Answer 22

more than 6 stools a day and evidence of systemic disturbance

Question 23

What is used to induce remission in sever UC?

Answer 23

IV corticosteriods

Oral in mild/moderate

Question 24

Young female with diarrhoea at weight loss - differentials?

Answer 24

Coeliac
Hyperthyroidism
Crohn’s

Question 25

How is a diagnosis of coeliac disease confirmed?

Answer 25

Small bowel biopsy, which is most easily obtained during an OGD

IgA tTG serology is reasonably accurate (>95%), it is not sufficient

Question 26

When is HLA genotyping used to diagnosis coeliac?

Answer 26

patients who have put themselves onto a gluten free diet before small bowel biopsies were obtained

Question 27

What happens when a GF diet is adhered to?

Answer 27

Small bowel changes completely resolve

Question 28

Why is a bone density scan recommended in pts. with coeliac disease?

Answer 28

osteopenia / osteoporosis is very common in patients who are newly diagnosed with coeliac disease

Question 29

Why is first degree relative screening recommended in coeliac?

Answer 29

10% of their relatives will have / develop coeliac disease