Abdominal pain- IBS

Question 1

IBS: who gets it

Answer 1

Presents in young adults 20-30s
Females more then males
Runs in families

Question 2

IBS- mechanism and risk factors

Answer 2

Mechanism- Hypersensitive viscera, abnormalities to the GI immune function, colonic microbiota, autonomic activity and GI motility
Risk factors- Genetic, previous inflammation/infection of the gut, dietary factors, medication, psychological factors

Question 3

Symptoms of IBS

Answer 3

Abdominal pain/bloating or changes in bowel habit- tend to have the symptoms for over 6 months

Associated symptoms: altered stool passage, abdominal bloating, distension, hardness, symptoms worsened by eating, passage of rectal mucus

Question 4

Diagnosis of IBS

Answer 4

Normally a diagnosis of exclusion, you will find nothing on examination but distension of the abdomen and generalised tenderness

Question 5

Red flags for IBS symptoms

Answer 5

Unexplained weight loss, new onset of symptoms over 50, bleeding per rectum, fevers, night sweats, localised tenderness/rigidity

Question 6

Investigating IBS

Answer 6

Bedside examinations- digital rectal examination, body mass index
Other tests- FBC, inflammatory markers i.e. CRP/ESR, stool sample id suspect infection, coeliac screening

Question 7

Management of IBS

Answer 7

May be useful to keep a food diary to identify triggers. Avoid short-chain fermentable carbohydrates (see FODMAP diet), eat regular balanced meals, limit alcohol, coffee, foods high in insoluble fibre, and sugar-free products.

Medications- if constipation is the main symptoms then take soluble fibre supplements i.e. ispaghula husk or anti-spasmodic agents like mebevarine or buscopan. Tricyclic antidepressants and SSRI can also be considered

Question 8

Management of Crohns- inducing remission

Answer 8

First line: steroids i.e. oral prednisiolone or IV hydrocortisione
Second line: Azathioprine, Mercaptopurine, Methotrexate, Infliximab, Adalimumab

Question 9

Management of Crohns- maintaining remission

Answer 9

First line: Azatthioprine, Mercaptopurine
Second line: Methotrexate, Infliximab, Adalimumab

Question 10

Crohns surgery

Answer 10

When the disease only affects the distal ileum it is possible to surgically resect this area and prevent further flares of the disease. Crohns typically involves the entire GI tract

Surgery can also be used to treat strictures and fistulas secondary to Crohns disease.

Question 11

Management of UC- inducing remission

Answer 11

Mild to moderate disease

First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)

Severe disease

First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin

Question 12

Management of UC: maintaining remission

Answer 12

Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine

Question 13

Management of UC- surgery

Answer 13

Ulcerative colitis typically only affects the colon and rectum. Therefore, removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.

Question 14

Biliary colic

Answer 14

Is caused by an impacted stone at the neck of the gallbladder and typically presents with crampy abdominal pain in the absence of infective features (e.g. fever/raised inflammatory markers). Biliary colic is typically triggered by the consumption of fatty foods.

Question 15

Cholecystitis

Answer 15

Typically presents with constant RUQ pain, fever and raised inflammatory markers. However, jaundice is absent in most cases as there is no associated biliary obstruction (except if the gallbladder is compressing the common bile duct, as in Mirizzi syndrome). Inflammation of the gallbladder, usually due to a gallstone blocking the cystic duct

Question 16

Macroscopic and Microscopic changes with Ulcerative colitis

Answer 16

Macroscopic findings:

Continuous, uniformly inflamed mucosa
Erythematous, friable mucosa
Abnormal vascular pattern
Ulceration
Inflammatory polyps (‘pseudopolyps’)

Microscopic findings (biopsy):

Crypt abscesses
Decreased goblet cell abundance

Question 17

UC summary

Answer 17

UC is the most common type of inflammatory bowel disease and has a relapsing-remitting course.
Common symptoms of UC include episodic diarrhoea with urgency, rectal bleeding and abdominal pain.
Extra-intestinal manifestations include; erythema nodosum, uveitis and joint pain.
Topical and oral aminosalicylates are the mainstay therapies used in UC.
Surgical intervention should not be delayed for urgent indications and usually involves partial or complete resection of the colon.
UC increases the lifetime risk of colorectal cancer and thromboembolic events.

Question 18

General examination findings for uc

Answer 18

Features of anaemia (e.g. pallor, fatigue)
Joint pain
Clubbing
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Episcleritis

Question 19

UC: classification

Answer 19

Proctitis: rectum
Proctosigmoiditis: rectum and sigmoid colon
Left-sided colitis: rectum, sigmoid colon and descending colon
Extensive colitis: rectum, sigmoid colon, descending colon and transverse colon
Pancolitis: rectum and entire colon

Question 20

Diabetic ketoacidosis

Answer 20

• Associated with type 1 diabetes mellitus
• Ketone bodies are generated in excess of clearance. Ketone bodies are produced when there is scarcity of glucose

Question 21

Appearance of diabetic ketoacidosis

Answer 21

Acute deterioration – abdominal pain, nausea, vomiting

Examination – Hypotension, Tachycardia, fever, reduced GCS

Causes: Missed insulin dose(s), Sepsis, Myocardial Ischaemia, Alcohol

Question 22

Investigations into diabetic ketoacidosis

Answer 22

Blood glucose (>11 mmol/L)
Blood Ketones (>3 mol/L) or Urine Ketones (2+)
Arterial or Venous blood gas – Metabolic Acidosis (pH < 7.3, HCO3 <15 mmol/L)

Other tests – raised inflammatory markers, Urea and Electrolytes, ECG, septic screen

Question 23

Treatment of diabetic ketoacidosis

Answer 23

Aim of treatment is to correct underlying abnormal physiology

Intravenous insulin

Intravenous Rehydration= 500ml of IVT STAT if BP is low i.e. <90mmHg

Correction of electrolyte abnormalities – Potassium, Sodium

Treat underlying cause!!!!

Question 24

Hypoglycaemia symptoms

Answer 24

Autonomic response (BG < 3.3 mmol/L) – Hunger, tremor, sweats, anxiety, palpitations, nausea

Severe hypoglycaemia (BG < 2.8 mmol/L) – Neuroglycopaenia: weakness, confusion, lethargy, change in behaviour. can lead to convulsions, coma and death

Question 25

Hyperosmolar Hyperglycaemic state (HHS)

Answer 25

Occurs in Type 2 Diabetics Hyperglycaemia (>30 mmol/L) Hyperosmolar (>320 mosmol/L) Treatment: Intravenous fluid +/- intravenous insulin Cautious correction to prevent fluid shifts e.g. cerebral oedema

Question 26

Primary, secondary and tertiary disease of the Thyroid

Answer 26

Primary – disease of thyroid gland Secondary – disease of pituitary Tertiary – disease of hypothalamus (rare e.g. craniopharyngioma)

Question 27

Synthesis of thyroid hormones

Answer 27

- Tyrosine attaches to Thyroglobulin - It is then Iodinated to MIT and DIT - MIT and DIT are coupled together - Through Proteolysis and secretion Thyroxine (T4) is released

Question 28

Metabolic functions of T3

Answer 28

Thermogenesis Basal metabolic rate Lipid metabolism Salt and water balance Reflex times & muscle strength Heart rate and contraction time

Question 29

Hyperthyroidism

Answer 29

Core symptoms: Weight loss, heat intolerance, palpitations, goitre Other symptoms: anxiety, temor, fatigue, weakness, menstrual change, breathlessness, eye signs, sweating, hyperkinesia, diarrhoea

Question 30

Hyperthyroidism- Examination

Answer 30

Tachycardia Palmar erythema Tremor Proximal myopathy Hyper-reflexia Eye signs Goitre

Question 31

Hyperthyroidism- eyes

Answer 31

Exclusively associated with Grave’s Disease (Autoimmune) Early signs: Lid lag, lid retraction, stare (note can occur with any cause of hyperthyroidism – adrenergic stimulation) Conjunctival erythema and swelling Proptosis, Exopthalmos Opthalmoplegia Optic nerve compression

Question 32

Hyperthyroidism: hands

Answer 32

Dermopathy – glycosaminoglycan deposition (skin of hands, or pretibial myxoedema!) Thyroid acropachy – clubbing, skin tightness, soft tissue oedema and periosteal reaction

Question 33

Aetiology of Hyperthyroidism

Answer 33

Primary Disease Autoimmune (Grave’s disease) Toxic adenoma- raised T3, normal FT4, often large palpable nodules in one lobe Toxic multinodular goitre- elderly patients generally, raised FT3, relatively normal FT4 Thyroiditis (viral/postpartum/drug-induced e.g. Amiodarone) Secondary Disease TSH-oma Thyroid Hormone Resistance

Question 34

How the Thyroid hormones interacr

Answer 34

Raised TRH- causes increased TSH Raised TSH- causes increased T3 and T4 T3 and T4- causes decreased TSH

Question 35

Investigations into Hyperthyroidism

Answer 35

Thyroid Function Tests: ↓TSH, ↑FT3/FT4 Autoantibodies: TPO, Thyroglobulin, TSH-Receptor antibody Thyroid Uptake scan

Question 36

Treatment for hyperthyroidism

Answer 36

Carbimazole, Propylthiouracil (PTU) Propranolol Radio-Iodine Thyroid Surgery

Question 37

Hypothyroidism symptoms

Answer 37

Symptoms: weight gain, constipation, goitre Other symptoms: cold intolerance, depression, fatigue, weakness, dry skin, puffy face, menorrhagia, Paraesthesia,Hoarse voice, yellow skin, bradycardia, bradykinesia

Question 38

Causes of Hypothyroidism

Answer 38

Primary Hypothyroidism - Hashimoto’s Thyroiditis (Autoimmune) - Thyroiditis (Viral, Postpartum) - Post-treatment for Hyperthyroidism Drug-induced - Iodine deficiency or excess - Dyshormonogenesis (inborn errors of hormone synthesis) Secondary Hypothyroidism - Pituitary Disease

Question 39

Hypothyroidism- investigations

Answer 39

Tests - Thyroid Function Tests: ↑TSH, ↓FT3/FT4 - Autoantibodies: TPO, Thyroglobulin, TSH-Receptor blocker Treatment - Replacement T4 (Levothyroxine once daily) - Regular monitoring of Thyroid function every 6 – 12 months

Question 40

X-ray: Abdominal structures and density

Answer 40

High density(white)-bone,stones,metal,NG tubes. Medium density(grey)-soft tissue -liver,spleen,kidneys,psoas muscles. Low density(black)-air and fat-bowel gas,subcutaneous fat

Question 41

What to look for in an abdominal x-ray

Answer 41

Personal details Film details Adequacy Gas pattern Organs Bones- blood vessels Calcification Review area Objects

Question 42

Abdominal x-ray specialist procedures

Answer 42

Small bowel study: patient drink barium and an x-ray is taken, valvulae conniventes will be seen in small bowel obstruction Barium meal: visualisation of the stomach Barium enema: visualisation of the colon, there is an 'apple core' stricture in colonic cancer

Question 43

Ultrasound (transabdominal)

Answer 43

Non-invasive Cheap Widely available Safe (no radiation) Good at looking at soft tissues Images available in real-time (can be combined with biopsies) First-line investigation in patients with hepatobiliary or pancreatic disease Measure size of AAA avoiding the need for CT However: Operator dependant, Images can be difficult to obtain eg obesity

Question 44

Abdomen: Computed Tomography

Answer 44

Fast Non-invasive Accurate Usually requires IV contrast Good views of the organs of upper abdomen However: Significant radiation

Question 45

What do you use CT to diagnose in the abdomen

Answer 45

- infections such as appendicitis, pyelonephritis and abscesses. - inflammatory bowel disease, pancreatitis (including complications) and liver cirrhosis. - cancers of the liver, kidneys, pancreas, ovaries and bladder. kidney and bladder stones. - abdominal aortic aneurysms (AAA), injuries to abdominal organs such as the spleen, liver, kidneys or other internal organs in cases of trauma

Question 46

Systematic approach to AXR

Answer 46

1) Projection: normally AP with patient supine 2) Patient details 3) Technical adequacy- the entre abdomen should be included 4) Obvious abnormalities- i.e. small bowel dilation 5) Systematic review: large and small bowel, diameter of the bowel, bowel wall thickness. The large bowel should be no wider then 6cm and the sall bowel no more than 3cm 6) Other- foreign bodies, bones etc

Question 47

Small bowel obstruction

Answer 47

- Dilated loops of small bowel proximal to obstruction - Often multiple and centrally located - Dilatation over 3cm in at least 3 places - Valvulae Conniventes are visible - More common than large bowel obstruction - AXR 50% sensitive for SBO

Question 48

Causes and presentation of small bowel obstruction

Answer 48

- Presentation: abdominal pain, abdominal distension, vomiting, abslute constipation, lack of bowel sounds/tinckling bowel sounds - Causes: congenital causes, extrinsic bowel lesions, intrinsic bowel wall lesions, luminal occlusions

Question 49

Large bowel obstruction

Answer 49

- Colonic distension proximal to the obstruction - Dilatation of >6cm for colon, >9cm for caecum - Haustra are visible - Less common than SBO (20% of cases

Question 50

Causes and complications of large bowel obstruction

Answer 50

Causes: 50-60% malignancy colonic diverticulitis volvulus (Caecal vs Sigmoid) ischaemic stricture, faecal impaction/faecoloma hernias (uncommon)  Complications: Perforation, the more distended the greater the risk. At site of obstruction or proximal to obstruction due to ischaemia

Question 51

Volvulus

Answer 51

- Can be caecal or sigmoid - Only 11% are caecal- torsion of the caecum around its own mesentery - Cause of large bowel obstruction - Due to chronic constipation and/or laxative abuse, fibre rich diet and chagas disease - Presents with the coffee bean sign on x-ray

Question 52

AXR- IBD

Answer 52

- Can be entirely normal - Signs of acute inflammation causing bowel wall thickening - Thickening of haustral folds causes a 'thumbprinting' appearance

Question 53

Toxic megacolon

Answer 53

- Secondary to Clostridium Difficile Colitis - Look for bowel wall thickening and mucosal islands

Question 54

Gas in the biliary tree

Answer 54

The patient has a biliary stent in situ, the gas in the biliary tree proves the stent is patent

Question 55

Endoscopic ultrasound

Answer 55

Ultrasound transducer on the end of an endoscope Gives good images of gallbladder, bile duct and pancreas Useful for identifying bile duct stones and gallbladder microlithiasis Detecting and staging pancreatobiliary tumours Assessing pancreatic cystic lesions Can take fine needle aspirate