Small Intestine and Appendix

Question 1

Tx Acute diarrhoea

Answer 1

Oral rehydration therapy is the main treatment as the majority of acute diarrhoea is self-limiting
KCl
NaCl
Dissociate hydrogen citrate with glucose

Often just a solute packet dissolved in water

This + adequate fluid intake tends to be enough

Somtimes loperamide is useful for rapid control of symptoms

Question 2

Tx confirmed appendicitis

Answer 2

A-E resus

IV Metronidazole/cephalosporin

Laporoscopic appendectomy

Early complications are haematoma/wound infections

Later complications are incisional herniae or small bowel adhesions

Question 3

complication of perforated appendix

Answer 3

Peritonitis and sepsis

Appendix mass

Inflamed appendix becomes covered in omentum

Appendix abscess
Local/pelvic/subhepatic/subphrenic abscesses develop if the appendix mass fails to resolve

Adhesions

Infertility
Due to tubal obstruction after pelvic infection

Question 4

complications of bowel obstruction

Answer 4

Bowel wall becomes oedematous and distends

Bacteria proliferate in the obstructed bowel

Bowel distends and blood supply is stretched, eventually leading to ischaemia and strangulation (ischaemia and necrosis)

Eventually bowel perforates

Symptoms develop more gradually in large bowel obstruction as there is more room to expand, even longer if the iliocaecal valve is competent

Question 5

Tx of small bowel obstruction

Answer 5

A-E resus

NBM + NG decompression of stomach

No strangulation = delay operative procedure for 48 hours

50% of adhesion based SBO resolves with conservative management after 4 days

Strangulation/severe symptoms = theatre management

Antibiotic therapy commenced if there are signs of strangulation

Question 6

Tx large bowel obstruction

Answer 6

Usually operative – hartmanns procedure

End colostomy with closure of the anorectal stump and resection of the difficult area – usually sigmoid

If it is due to faecal impaction, enemas or manual evacuation will be tried

Question 7

Tx of coeliacs

Answer 7

Lifelong gluten free diet
Only wheat, barley, rye,
Rice/potatoes/corn/oats are fine

Verify that it is working with endomysial antibody tests

Question 8

Complication of coeliacs

Answer 8

malnutrition

small bowel lymphoma/adenocarcinoma

Question 9

what skin rash is associated with coeliacs

Answer 9

dermatitis herpetiformis

Question 10

Tx chronic pancreatitis

Answer 10

Analgesia (pain management is a vital part of management)

Creon (lipase) and multivite (fat soluble vitamins)

Monitoring of blood sugars

Treatment of alcohol abuse if required

Low fat diet

Partial pancreatectomy/pancreaticojejunostomy may be required if there is unremitting pain, narcotic use or weight loss

Question 11

Tx of IBS-C

Answer 11

1st line - laxative + lifestyle +antispasmodic if bloating/cramping
ispagula

2nd line for constipation - linaclotide/plecanatide/tenapanor (only if constipation for 12 months and on max dose of initial laxative)

3rd line - SSRI +/- hypnotherapy or CBT

avoid lactulose as it causes

Question 12

Tx of IBS-D

Answer 12

1st line - loperamide + antispasmodic if painful

2nd line - TCAs +/- hypnotherapy or CBT

Question 13

Tx of IBS-M

Answer 13

No pain/bloating ​
Lifestyle/dietary modifications​
+/- Laxatives​
+/- Loperamide ​

Pain/bloating ​
1st line ​
Lifestyle/dietary modifications​
\+/- Laxatives​
\+/- Loperamide ​
Antispasmodic ​

2nd line ​
Lifestyle/dietary modifications​
TCA or SSRI ​
CBT/hypnotherapy

Question 14

Tx acute crohns

Answer 14

Mild attack – but systemically well
Oral prenisolone
Tapered steroids and clinic review

Severe attack –symptoms + systemic upset
Admit if: raised temp/pulse/ESR/CRP/low albumin
IV steroids – hydrocortisone 100mg/6hrs
NBM + parenteral nutrition or elemental diet
High level monitoring is required

2nd line pharmacological
Thiopurines
Azathioprine
6-mercaptopurine

Before prescribing the TMPT gene needs to be tested for as a deficiency of the gene can cause severe acute myelosuppression when thiopurines are given

3rd line
Biological agents - Infliximab

On improvement transfer to oral prednisolone as per mild attack

If unable to control surgical advice should be given

Antibiotics are considered if there are septic signs

Question 15

Tx maintenance of Crohns

Answer 15

Thiopurines first line
Azathioprine/6-mercaptopurine

Methotrexate second line
When thiopurines are contraindicted (TMPT)
Thiopurines unsuccessful
if methotrexate has been used previously successfully

Oral metronidazole is useful for anal disease

Question 16

Tx acute UC

Answer 16

Mild/moderate (less than 6 motions per day, systemically well)
Proctitis/proctosigmoiditis
Topical aminosalicylate (e.g. mesalazine)
+/- oral mesalazine

more extensive disease
Loading dose oral mesalazine
+/- oral beclometosone
Topical mesalazine

2nd line
If these aren’t effective after 4 weeks add oral prednisolone

3rd line
Tacrolimus after 2-4 weeks of inadequate control

4th line
Biological agents
Considered by a specialist

Question 17

Tx acute fulminating severe UC

Answer 17

MDT management

Start with IV corticosteroids

Assess the patient with regard to surgical intervention

SC heparin

Avoid any antimotility drugs – including opioids

2nd line
IV ciclosporin
Escalate to this if there is 72 hours of no improvement/worsening on oral corticosteroids

3rd line
Biological agents
Considered by specialist

Question 18

indications of surgery in UC

Answer 18

> 8 motions a day

Pyrexia

Tachycardia

Colonic dilatation

low albumin

Anaemia

CRP >45

Question 19

complications of IBD

Answer 19

Bowel perforation

Lower GI haemorrhgae

Toxic dilatation (more common in UC)

Colonic carcinoma - Risk is raised in crohns but barely raised in UC

pancolitis = These patients require 2 yearly colonoscopies

Crohns specific complications  
Small bowel obstruction  
Fistulae (10%) 
Abscess formation 
B12/folate/iron deficiencies 
Terminal ileum is where B12 is absorbed

Question 20

UC maintenance

Answer 20

5- ASA derivatives
Sulfasalazine
Mesalazine

Oral thiopurines are second line

Maintenance is lifelong