Colon

Question 1

What’s the WHO definition for diarrhoea ?

Answer 1

> 3 loose stools or watery stools per day

Acute: < 14 days
Chronic > 14 days

Question 2

Name four causes of acute diarrhoea

Answer 2

Gastroenteritis
Diverticulitis
Antibiotic therapy
Constipation causing overflow

Question 3

A child presents with diarrhoea since 3 days. She also gets abdominal ache and the mother describes that she is normally rather constipated .
What’s your diagnosis ?

Answer 3

Overflow diarrhoea due to constipation

Question 4

A 21 year old man sees his GP for nausea associated with vomiting and diarrhoea for the last 2 days . He also gets occasional abdominal cramps .
What’s your initial diagnosis ?

Answer 4

Gastroenteritis

Question 5

A 45 year old male complains of left lower quadrant pain, diarrhoea and fever. Which condition do you need to think of?

Answer 5

Diverticulitis

Question 6

A 40 year old patient complains of diarrhoea for the last 2 days . Last week she was treated for tonsillitis by her GP.
What could be the diagnosis ?

Answer 6

Ask for antibiotic treatment

Can cause diarrhoea

Question 7

Name 5 conditions that can cause chronic diarrhoea

Answer 7

Crohns 
UC
IBS
Colorectal cancer
Coeliac disease

Question 8

A 4 year

Old child presents with failure to thrive , diarrhoea , buttock wasting and abdominal pain. What’s the diagnosis ?

Answer 8

Coeliac disease

Question 9

A 35 year
Old patient presents with diarrhoea , tiredness , weight loss and anaemia . He is currently treated for his autoimmune thyroiditis .
What condition do you suspect ?

Answer 9

Coeliac disease

Question 10

What type of bacterium is clostridium difficile?

Answer 10

Gram -

Rod shaped bacillus

Question 11

What does C diff cause and why is it so dangerous?

Answer 11

Pseudomembranous colitis

Can lead to toxic megacolon and organ failure

Question 12

In Cdiff how does the patient present?

Answer 12

Diarrhoea , fouly smelling , fever , high CRP and WCC

Systemically unwell

Question 13

What’s the treatment of c diff

Answer 13

Metronidazole oral

2. Oral vancomycin

Question 14

What’s the difference between a paralytic and a mechanical Ileus?

Answer 14

Impaired peristalsis vs mechanical obstruction

Question 15

What does ileus lead to?

Answer 15

Distended bowel wall, hypoxia , odema -> bowel ischaemia -> necrosis -> Perforation -> septic shock or hypovolemia

Question 16

Name the causes of a mechanical ileus?

Answer 16

Small bowel 
Adhesions post Op 
Hernia 
Tumour 
Stricture

Large bowel 
Cancer
Stricture : IBD, diverticulitis 
Voluvulus
Adhesions

Question 17

Give examples for an paralytic ileus

Answer 17

Intraabdominal surgery
Endocrine ( Diabetes , hypothyroid )
Mesenteric Infarkt 
Inflammation : Appendix , peritonitis 
Hypokalaemia 

Drugs: opioids , anti AcH, antidepressions

Question 18

On examination , how would you differentiate between paralytic and mechanical ileus ?

On x ray?

Answer 18

No bowels sounds vs high pitches tinkling sounds

Obstruction: dilation, air filled proximal , distal bowel collapsed

Paralytic : even distribution of gas , bowel distension, if voluvulus - kidney bean appearance

Question 19

A high serum lactate in a toxic megacolon patient suggests ?

Answer 19

Perforation

Question 20

What is constipation?

Answer 20

<2 bowel actions per week
Or
Less than normal habit
Or 
Passing with difficulty 
Or
Incomplete defecation

Question 21

Give primary and secondary causes of constipation.

Answer 21

Primary
Diet , insufficient exercise

Secondary 
Carcinoma 
Opioids 
DM
Hypokalaemia 
Hypothyroidism
MS
Hirschpsrung

Question 22

What’s the first

Line examination to perform in patients with constipation ?

Answer 22

Digital rectal exam

Question 23

Give 3 possible treatment options in the management of an adult with constipation ( and now organic cause found )

Answer 23

Lifestyle - high fibre, more fluid, exercise

Osmotic laxatives e.g Macrogol
Stimulant laxatives eg senna

Question 24

What is a megacolon and which types are there ?

Answer 24

Dilation of colon in absence of mechanical obstruction due to loss of peristalsis

Toxic
Acute
Chronic e. G Hirschsprung

Question 25

What diagnostic criteria need to be met in order to diagnose a toxic megacolon ?

Answer 25

3 of the following systemic symptoms - tachycardia - fever - leukocytosis - anemia ``` 1 of Dehydration Hypotension Altered mental state Electrolyte imbalance ```

Question 26

What might be the cause for toxic megacolon?

Answer 26

``` C diff , cmv Ulcerative colitis (Crohns ) ```

Question 27

What's the characteristic finding on the X-ray in toxic megacolon ?

Answer 27

Dilated colon with loss of haustra

Question 28

Explain the acute management of toxic megacolon and it's complications

Answer 28

NG tube, nil by mouth IV fluids , electrolytes In Cdiff: metronidazole In IBD: IV steroids Surgery if not responsive Complications Ischaemia Perforation Sepsis

Question 29

What does Crohn's disease commonly present with ?

Answer 29

Diarrhoea , bloody | Abdominal pain

Question 30

Name some extra- intestinal features that occur in Crohn's disease ?

Answer 30

``` Arthritis Erythema nodosum Episcleritis Osteoporosis Primary sclerosing cholangitis Clubbing Pyoderma gangrenous Uveitis ```

Question 31

Name the histological / endoscopic features of Crohns

Answer 31

Mouth to Anus ( common terminal ileum) Cobblestone appearance , ulceration Transmural inflammation Patchy Perianal skin tags or ulcers / fistula / abscesses

Question 32

A small bowel enema is performed in a patient suspected of Crohn's disease . What are classical findings?

Answer 32

Fistuale Rose thorn ulcers Strictures: Kantors string sign

Question 33

Name the management of a patient with Crohn's disease

Answer 33

Inducing remission - budesonide ( glucocorticoid ) (oral topical, iv ) -mesalazine (5ASA) second line - azathiprine (add on) In children : exclusive Enternal nutrition Maintaining - azathioprine - MTX (second line ) Surgery General advise stop smoking

Question 34

What's ulcerative Colitis? | What does it commonly present with?

Answer 34

Inflammatory condition ALWAYS starting at rectum and never beyond ileocaecal valve - colon only ! Diarrhoea - bloody, mucous Abdominal pain - left lower quadrant Tenesmus Extra intestinal features

Question 35

Name extraintestinal features of ulcerative colitis

Answer 35

``` Arthritis Erythema nodosum Episcleritis ( more on Crohn's) Osteoporosis Primary sclerosing cholangitis ( common in UC) Uveitis ( common in UC) Pyoderma gangrenosum Clubbing ```

Question 36

Describe the histological : endoscopic findings of ulcerative colitis

Answer 36

``` Rectum and colon only Bleeding Superficial inflammation limited to mucosa Continuous involvement Crypt abscesses Pseudopolyps ```

Question 37

A patient with ulcerative colitis undergoes barium enema . What are typical findings?

Answer 37

Loss of haustra Psrudopolyps - superficial inflammation If longstanding disease: Drainpipe colon- narrow and short

Question 38

How to manage a patient wit UC?

Answer 38

``` Inducing remission -rectal Mesalazine ( if distal) -oral mesalazine ( aminosalicyclates) -oral prednisolone (second line ) Maintaining Oral mesalazine Azathioprine and mercaptopurine ```

Question 39

What are complications of UC?

Answer 39

Toxic megacolon | Adenocarcinoma

Question 40

What are | Complications of Crohn's ?

Answer 40

Fistula formation Abscess formation Bowel obstruction Malignancy

Question 41

Name some causes for diverticulosis

Answer 41

``` Diet- high fat , meat and low fibres Age Obesity Smoking Marfan Ehlers Danlos ```

Question 42

Describe the processes that lead to diverticula and further to diverticulitis

Answer 42

Unequal pressure or chronic constipation leading to out pouching of colon wall Stool gets lodged in pouches can get inflamed , there is also more pressure and erosion of diverticular wall

Question 43

Name common features of diverticulitis

Answer 43

``` Fever Left Lower quadrant abdominal pain Change in bowel habits Nausea , vomiting Sometimes palpable mass ```

Question 44

How would you investigate a patient with suspected diverticulitis ?

Answer 44

``` Blood: leucocytosis , high CRP Abdominal CT ( first line ) with contrast Ultrasound -pouches -free fluid -fluid in fat ``` Colonoscopy ( but not if acute!! )

Question 45

What are complications of diverticulitis ?

Answer 45

Abscess Obstruction Perforation Fistula

Question 46

Treatment of diverticulitis

Answer 46

Prevention by diet changes ( high fibres ) and exercise , fluids Anitbiotics ( oral , IV if worse - hospital ) eg metronidazole + ciprofloxacin Surgical

Question 47

What is a Meckels Diverticulum ?

Answer 47

A congenital diverticulum of the small intestine Incomplete regression of opthalomesenteric duct (vitellointeatinal duct ) This duct connects yolk sac with midgut lumen and normally disappears after 6 weeks gestation

Question 48

What are features of a meckels diverticulum?

Answer 48

``` 2% in population 2 inches long 2 feet from ileocaecal valve Mostly in kids <2 2 types of mucosal lining ``` Asymptomatic Painless rectal bleeding Can cause obstruction of intestine Only treat when symptomatic ( surgery )