Short cases

Question 1

Small Bowel Obstruction aetiology

definition

classification

Answer 1

Defined as blocked passage of bowel contents through the small bowel. Fluid and gas can build up proximal to the obstruction, leading to fl uid and electrolyte
imbalances and signifi cant abdominal discomfort.

The obstruction can be complete or partial,

and ischemia or necrosis of the bowel may occur.

SBO may arise from:

1. adhesions from: a prior abdominal surgery (60% of cases),
2. hernias
3. (10–20%),
4. neoplasms (10–20%)
5. intussusception
6. gallstone ileus
7. stricture due to IBD volvulus.

Question 2

Ileus

definition

aetiology

Answer 2

Loss of peristalsis without structural obstruction.

Risk factors include

1. recent surgery/GI procedures,
2. severe medical illness,
3. immobility,
4. hypokalemia or
5. other electrolyte imbalances,
6. hypothyroidism,
7. DM,
8. medications that slow
9. GI motility (e.g., anticholinergics, opioids).

Question 3

Hx of Presentation

in

SBO

vs

LBO

Answer 3

SBO

• Moderate to severe acute abdominal pain;
• copious emesis.
• Cramping pain with distal SBO.
• Fever, signs of dehydration, and hypotension may be seen.

LBO

• Constipation/obstipation, deep and cramping
• abdominal pain (less intense than SBO),
• nausea/vomiting (less than SBO but more commonly feculent).

Question 4

LBO

aetiology

Answer 4

1. Colon cancer
2. diverticulitis
3. volvulus
4. fecal impaction
5. benign tumors.

Assume colon cancer until proven otherwise.

Question 5

Site of

ulcerative colitis

Answer 5

The rectum is always involved.

Limited to colon

May extend
proximally in a continuous fashion.

Inflammation and ulceration are limited to the
mucosa and submucosa

Question 6

site
of

Chron’s

Answer 6

May involve any portion of the GI tract, particularly
the ileocecal region,

in a discontinuous pattern
(“skip lesions”).

The rectum is often spared.

Transmural inflammation is seen.

Question 7

Ulcerative colitis

and chorn’s

extraintestinal manifestations

Answer 7

BOTH

• Aphthous stomatitis
• episcleritis/uveitis
• arthritis,
• primary sclerosing cholangitis
• erythema nodosum
• pyoderma gangrenosum.

Unique to chron’s

gallstones,
nephrolithiasis, and fi stulas to the skin, bladder, or
between bowel loops.

Question 8

Treatment for ulcerative colitis

Answer 8

5-ASA agents (e.g., sulfasalazine, mesalamine),
topical or oral;

corticosteroids and
immunomodulating agents (e.g., azathioprine)
for refractory disease.

Total proctocolectomy is curative for longstanding
or fulminant colitis or toxic megacolon;
it also ↓ cancer risk.

Question 9

treatment for chron’s

Answer 9

5-ASA agents; corticosteroids and
immunomodulating agents (e.g., azathioprine,
infl iximab) are indicated if no improvement is
seen.
Surgical resection may be necessary for suspected
perforation, stricture, fi stula, or abscess; may
recur anywhere in the GI tract

Question 10

ulcerative colitis and chron’s

associated risk of malignancy?

Answer 10

Ulcerative colitis: Markedly ↑ risk of colorectal cancer in longstanding cases (monitor with frequent fecal occult
blood screening and yearly colonoscopy with
multiple biopsies after eight years of disease).

\

With Chron’s, Incidence of 2° malignancy is lower than in
ulcerative colitis, but greater than the general
population.

Question 11

Cholelithiasis and Biliary Colic

definition

and Hx

diagnosis

treatment

Answer 11

Colic results from transient cystic duct blockage from impacted stones.

Although risk factors include the 4 F’s—Female, Fat, Fertile, and Forty—the disorder is common and can occur in any patient

HISTORY/PE
■ postprandial abdominal pain (usually in the RUQ) that radiates to the right subscapular area or the epigastrium.
■ Pain is abrupt; is followed by gradual relief; and is often associated with nausea and vomiting, fatty food intolerance, dyspepsia, and flatulence.
■ Gallstones may be asymptomatic in up to 80% of patients.

Exam may reveal RUQ tenderness and a palpable gallbladder

DIAGNOSIS

RUQ ultrasound is the imaging modality of choice (85–90% sensitive).

TREATMENT

■ Cholecystectomy is curative and can be performed electively for symptomatic gallstones. It is generally performed laparoscopically. Asymptomatic
gallstones do not require any intervention.
■ Patients may require preoperative endoscopic retrograde cholangiopancreatography
(ERCP) for common bile duct stones.
■ Treat nonsurgical candidates with dietary modifi cation (avoid triggers
such as fatty foods).

Question 12

Acute Cholecystitis

definition

Hx

Dx

Answer 12

Prolonged blockage of the cystic duct, usually by an impacted stone, that leads to o_bstructive distention, inflammation, superinfection, and possibly gangrene of the gallbladder_ (acute gangrenous cholecystitis).

HISTORY/PE
■ Patients present with RUQ pain, nausea, vomiting, and fever.

Symptoms are typically more severe and of longer duration than those of biliary colic.
■ RUQ tenderness, inspiratory arrest during deep palpation of the RUQ (Murphy’s sign), low-grade fever, mild icterus, and possibly guarding or rebound tenderness may be present on exam.

Fever is often present, and CBC shows leukocytosis

TREATMENT
■ Hospitalize patients, administer broad-spectrum IV antibiotics and IV fl uids, and replete electrolytes.
■ If diagnosed soon after onset, early cholecystectomy is indicated.

Question 13

Choledocholithiasis

definition

Answer 13

Gallstones in the common bile duct. Symptoms vary according to the degree of obstruction, the duration of the obstruction, and the extent of bacterial
infection.

Hx/PE: Although sometimes asymptomatic, it often presents with biliary colic, jaundice, fever, and pancreatitis.
■ Dx: The hallmark is ↑ alkaline phosphatase and total bilirubin, which may be the only abnormal lab values
■ Tx: Management generally consists of ERCP with sphincterotomy followed by semielective cholecystectomy. Common bile duct exploration
may be necessary.

Question 14

Ascending Cholangitis

Answer 14

An acute bacterial infection of the biliary tree that commonly occurs 2° to obstruction, usually from gallstones (choledocholithiasis) or primary sclerosing cholangitis (progressive inflammation of the biliary tree associated with ulcerative colitis).

Other etiologies include bile duct stricture and malignancy (biliary or pancreatic).

Gram- enterics (e.g., E. coli, Enterobacter, Pseudomonas) are commonly identifi ed pathogens.

HISTORY/PE
■ Charcot’s triad—RUQ pain, jaundice, and fever/chills—is classic and seen
in 50–70% of cases.
■ Reynolds’ pentad—Charcot’s triad plus septic shock and altered mental status—may be present in acute suppurative cholangitis and suggests sepsis.

Question 15

Primary Sclerosing Cholangitis

Answer 15

An idiopathic disorder characterized by infl ammation, fibrosis, and strictures of extra- and intrahepatic bile ducts. The disease usually presents in young men with IBD (most often ulcerative colitis).

■ Hx/PE: Presents with progressive jaundice, pruritus, and fatigue.
■ Dx:
■ Laboratory findings include ↑ alkaline phosphatase and ↑ bilirubin.
■ MRCP/ERCP show multiple bile duct strictures with dilatations between strictures.
■ Liver biopsy reveals periductal sclerosis (“onion skinning”).
■ Tx: High-dose ursodeoxycholic acid; endoscopic dilation and short-term stenting of bile duct strictures; liver transplantation.

Patients are at ↑ risk for cholangiocarcinoma.

Question 16

Primary Biliary Cirrhosis

Answer 16

■ An autoimmune disorder characterized by destruction of intrahepatic bile ducts. The disease most commonly presents in middle-aged women
with other autoimmune conditions.
■ Hx/PE: Presents with progressive jaundice, pruritus, and malabsorption of the fat-soluble vitamins (A, D, E, K).
■ Dx: Laboratory findings include ↑ alkaline phosphatase, ↑ bilirubin, antimitochondrial antibody, and ↑ cholesterol.
■ Tx: Ursodeoxycholic acid (slows progression of disease); cholestyramine for
pruritus; liver transplantation.