Rectal bleeding

Question 1

What conditions cause ‘mixed’ blood in stool?

Answer 1

Colon cancer
Inflammatory bowel disease
Diverticulitis
Bacillary dysentery

Question 2

Clinically differentiate colon cancer from IBD

Answer 2

IBD more associated with increased frequency
Mass may be felt in CRC
CRC tends to present in >60s rather than 20-40s

Question 3

Who gets screened via FIT testing in Scotland? how often

Answer 3

All men and women
50-74 years old
Every 2 years

Question 4

If a FIT test is abnormal, what investigation should be performed? What happens if this doesn’t work?

Answer 4

Colonoscopy
CT colonography alternative

Question 5

Who gets a 2 week referral for suspected colorectal cancer?

Answer 5

40 yrs…
Abdo pain + weight loss
50 yrs
unexpected rectal bleeding
>60 yrs
change in bowel habit/microcytic anaemia

Consider if mass or other red flag symptoms

Question 6

Name the resection and anastamosis
caecal –> proximal transverse

Answer 6

Right hemicolectomy
Ileo-colic

Question 7

Name the resection and anastamosis
Distal transverse –> descending colon

Answer 7

Left hemicolectomy
Colo-colon

Question 8

Name the resection and anastamosis
Sigmoid

Answer 8

High anterior
Colorectal

Question 9

Name the resection and anastamosis:
Upper rectum

Answer 9

Anterior resection
Colorectal

Question 10

Name the resection and anastamosis
Lower rectum

Answer 10

Anterior resection +/- defunctioning stoma bag

Question 11

Name the resection and anastamosis
Anal verge

Answer 11

Abdomino-perineal rectal excision
None

Question 12

What complication of surgery increases the risk of anastomosis? If this occurs what is the safest treatment option?

Answer 12

Bowel perforation
End colostomy

Question 13

Differentiate ileostomy and colostomy based on location, appearance and output

Answer 13

Ileostomy // Colostomy
RIF // Varies but likely left
Spouted // Flushed
Liquid // Solid

Question 14

Classify bowel cancer according to Duke’s Criteria

Answer 14

A: Limited to muscularis
B: Extends beyond muscularis
C: Regional Lymph Node Involvement
D: Distant metastases

Question 15

How do you monitor treatment response in colorectal cancer?

Answer 15

Blood CEA

Question 16

What criteria can help with diagnosing Lynch Syndrome

Answer 16

>=3 cases colorectal (or endometrial, small bowel, ureter or pelvis)
>=2 generations affected
>=1 of affected is first degree relative and/or <50yrs at diagnosis
FAP should be excluded

Question 17

How does HNPCC and FAP differ in terms of
Incidence
Implicated genes
Cancer site

Answer 17

HNPCC // FAP
More vs less common
MSH2/MLH1 vs APC
Proximal colon vs throughout

Question 18

FAP features + retinal pigmentation/head osteomas/thyroid caricinomas/epidermoid cysts a indicates what

Answer 18

Gardner’s syndrome
Variant of FAP

Question 19

Why are you worried about a teen with darkly pigmented mouth and GI polyps

Answer 19

Peutz-Jeugher’s syndrome
Small chance of malignant conversion to CRC so surveillance needed.

Question 20

24 year old male presents with mixed rectal bleeding, abdominal pain and increased frequency of stool passage. Likely diagnosis?

Answer 20

Inflammatory Bowel Disease

Question 21

How can the pain differ in IBD?

Answer 21

CD: Right as affects whole tract
UC: LIF as colon affected

Question 22

What IBD is associated with gallstones?

Answer 22

Crohn’s

Question 23

What IBD is more associated with primary sclerosing cholangitis?

Answer 23

UC

Question 24

What feature is this and which IBD is it more common in?

Answer 24

Thumbprinting

UC due to thickening of colon

Question 25

What is the imaging below and which IBD do you see it in?

Answer 25

Drainpipe/lead pipe colon Seen in AXR for UC Chronic inflammation causes muscularis hypertrophy, resulting in haustral loss

Question 26

'Deep skip lesions' 'Widespread, continuous ulceration' Match the IBD to the above endscopy report

Answer 26

Deep skip lesions ('Cobblestoning') ---\> Crohn's Widespread contiuous disease --\> UC

Question 27

What happens to goblet cells in the IBDs?

Answer 27

Crohn's: Increased goblet cells Ulcerative Colitis: Reduced goblet cells

Question 28

Crypt abcesses Granulomas Match the features to their IBDs

Answer 28

Crypt abscesses --\> UC Granulomas --\> CD

Question 29

What induction agents are used for Crohn's?

Answer 29

1. Glucocorticoids/budenoside 2. 5-ASA (mesalazine) + Azathioprine/mercaptopurine

Question 30

If induction agents don't work in Crohn's what can you give?

Answer 30

\>5 days without improvement Consider infliximab/adalimumab

Question 31

What induction agents are used for UC?

Answer 31

Mild-mod (4-6 stools) 1st: topical 5-ASA (-salazine) +/- oral 5-ASA or corticosteroid if proctitis Severe (\>6 stools) IV steroids + ciclosporin if no improvement

Question 32

What maintenance agent is used in Crohn's?

Answer 32

STOP SMOKING Azathioprine/mercaptopurine

Question 33

What maintenance agents are used in UC?

Answer 33

Mild-mod: Top/oral/both AS Severe (systemic unwell)/\>2 relapses: Azathioprine/mercaptopurine

Question 34

Since they both have rectal bleeding and LIF pain, clinically differentiate diverticulitis and UC

Answer 34

RIF pain more likely if Asian Patients tend to be over 40 N+V, low fever present

Question 35

How do you investigate for suspected diverticulitis? Whst should be avoided?

Answer 35

1st line: AXR shows dilated bowel, obstruction, abscesses GS: CT DON'T DO COLONOSCOPY DUE TO PERFORATION RISK

Question 36

How is suspected diverticulitis managed?

Answer 36

mild: oral Co-amoxiclav and non-NSAID analgesia Severe/\>72 hours: Admit for IV antibiotics

Question 37

What cause of rectal bleeding is most associated with AKI?

Answer 37

Bacillary dysentery

Question 38

How do you investigate and treat bacillary dysentery?

Answer 38

Stool culture to confirm Supportive; Abx if unwell/vulnerable

Question 39

What 4Cs increase C diff?

Answer 39

Cephalosporins Co-amoxiclav Clindamycin Ciprofloxacin

Question 40

What causes painful fresh rectal bleeding?

Answer 40

Fissure in ano Thrombosed Haemorrhoids

Question 41

Where are anal fissures found vs haemorrhoids?

Answer 41

Fissures: 6 and 12 O clock Haemorrhoids: 3, 7 and 11 O clock

Question 42

Apart from stool softeners, how do you treat haemorrhoids?

Answer 42

Rubber band ligation \> sclerotherapy Surgery if large or \<72 hour thrombosis history

Question 43

Faecal incontinence, perianal pain and bleeding are seen in which cancer?

Answer 43

Rectal cancer