GI & Surgery 4

oelomar's version from 2016-02-27 14:47


Question Answer
What is proctitis?Inflammation of the rectum and anus.
What are the intestinal signs/symptoms of ulcerative colitis?The major symptom is diarrhoea with blood and mucus, sometimes accompanied by lower abdominal discomfort. General features include malaise, lethargy and anorexia with weight loss. The disease runs a course of remissions and exacerbations. In an acute attack of UC, patients have bloody diarrhoea.
What is toxic megacolon?A serious complication of inflammatory bowel disease, namely ulcerative colitis (and Crohn’s disease rarely). It is characterised by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock. Urgent surgery is required in all patients in whom toxic dilatation has not resolved within 48 hours with intensive therapy. Otherwise the risk of death is significant.
What investigations can be done when a patient has an ulcerative colitis attack?A plain abdominal X-ray is the key investigation in moderate to severe attacks. The extent of disease can be judged by the air distribution in the colon and the presence of colonic dilatation can be noted. Radionuclide scans can also be used to assess the inflammation. A colonoscopy should not be performed in severe attacks of disease for fear of perforation.
How is ulcerative colitis managed (not including surgery)?Ulcerative colitis can be treated with a number of medications, including 5-ASA drugs such as sulfasalazine and mesalazine. Corticosteroids such as prednisolone can also be used due to their immunosuppressing and short-term healing properties, but because their risks outweigh their benefits, they are not used long-term in treatment. Immunosuppressive medications such as azathioprine and biological agents such as infliximab are given only if people cannot achieve remission with 5-ASA and corticosteroids.
In which situation would someone with ulcerative colitis be admitted for surgery?The main indication for surgery is for a severe attack which fails to respond to medical therapy.
For patients with inflammatory bowel disease, who is offered colonoscopic surveillance for neoplastic transformation?Offer colonoscopic surveillance to people whose symptoms started 10 years ago and who have: Ulcerative colitis (but not proctitis alone) or Crohn’s colitis involving more than one segment of colon. Offer the next colonoscopy based on the person’s risk at their last complete colonoscopy. Low risk – offer at 5 years. Intermediate risk – offer at 3 years. High risk – offer at 1 year.
What is microscopic colitis?This is an umbrella term for two different medical conditions, collagenous colitis and lymphocytic colitis, both of which are characterised by the presence of watery diarrhoea, normal macroscopic features on colonoscopy, and the presence of inflammatory cells in histopathological findings.
Which condition has a higher risk of developing colon cancer, Crohn’s disease or ulcerative colitis?Ulcerative colitis.


Question Answer
What is Hirschsprung’s disease?Also called congenital megacolon, this is a form of megacolon that occurs when part or all of the large intestine have no ganglion cells (no enteric nervous plexuses) and therefore cannot function. It gives rise to constipation and subacute obstruction.
What investigations can be carried out to help diagnose Hirschsprung’s disease?A biopsy can be performed and stained with special stains for ganglion cells in the submucosal plexus. Manometric studies show failure of relaxation of the internal anal sphincter, which is diagnostic of Hirschsprung’s disease.
What is diverticular disease? Where are diverticulae in the GI tract most commonly found?This is a condition of having diverticula in the colon. Diverticula are frequently found in the colon and occur in 50% of patients over the age of 50 years. They are most frequent in the sigmoid colon.
What is the link between low-fibre diets and diverticular disease?Diverticular disease seems to be related to the low-fibre diet eaten in developed countries.
What can diverticular disease (not diverticulitis) present with?Asymptomatic in 95% of cases. Otherwise it can present with painless rectal bleeding as bright red blood per rectum. Cramps and tenderness may also occur in the affected areas.
What is diverticulitis and what can cause it?Inflammation of a diverticulum. Diverticulitis occurs when faeces obstruct the neck of the diverticulum causing stagnation and allowing bacteria to multiply and produce inflammation.
What are the signs/symptoms of diverticulitis?This most commonly affects diverticula in the sigmoid colon. The classical presentation is: Left iliac fossa pain and tenderness; anorexia, nausea and vomiting; diarrhoea; features of infection (pyrexia, raised WBC and CRP).
What possible complications can diverticulitis lead to?Bowel perforation, abscess formation, fistulae into adjacent organs (e.g. bladder), generalised peritonitis, intestinal obstruction, bleeding.
What investigations can be undertaken to help diagnose diverticulitis?Blood tests – ESR and CRP are raised. Spiral CT scan of the lower abdomen can immediately diagnose diverticulitis.
How is diverticulitis treated?Treatment of uncomplicated symptomatic disease is with a well-balanced fibre diet with smooth muscle relaxants if required. Otherwise, antibiotics are given. A cephalosporin and a metronidazole are given.


Question Answer
What is duodenal atresia and what other condition is it associated with?Atresia is a condition in which an orifice or passage in the body is abnormally closed or absent. As such, duodenal atresia is the congenital absence or complete closure of a portion of the lumen of the duodenum. It causes obstruction in new-born babies. Approximately 20-40% of all infants with duodenal atresia have Down’s syndrome.
Are colonic adenomas (neoplastic polyps) common in the Western world?Yes. They are found in nearly 50% of adults living in the Western world by age 50.
What is the major worry regarding colonic adenomas?They are precursors to the majority of colorectal adenocarcinomas.
How can colonic adenomas be classified?Tubular, tubulovillous, and villous. Tubular adenomas have the lowest rate of malignant conversion whereas villous adenomas have the highest.
With regards to neoplastic polyps, what is the most important characteristic that correlates with risk of malignancy?Size.
What is familial adenomatous polyposis (FAP)?This is an inherited autosomal-dominant condition in which 100s of polyps form on the luminal surface of the colon. It progresses to colorectal cancer over 8-10 years.
What is hereditary nonpolyposis colorectal cancer (HNPCC)?An autosomal-dominant condition that can lead to colorectal cancer. Polyps form in the colon (very few of them) which can develop to colorectal cancer over 2-3 years.
What is Gardner’s syndrome?A variant of FAP in which, as well as the GI tract, there are also osseous and soft tissue tumours (e.g. tumour on skull (osteoma) and skin tumour (epidermoid cyst)).
NSAID use leads to an increased chance of developing colorectal cancer. True or false?False. NSAIDs have a protective effect.
The loss of which tumour suppressor protein leads to the formation of a carcinoma from an adenoma?p53.
In the context of colon cancer, what is the most common site of metastasis?Liver.
What are the two most important prognostic factors regarding colon cancer?Depth of invasion and the presence/absence of lymph node metastasis.


Question Answer
What investigations can be used for colon cancer?The gold standard is colonoscopy (as this also allows for biopsy). Flexible sigmoidoscopy then barium enema is offered for patients with significant co-morbidity. CT is used for evaluation. Serum carcinoembryonic antigen (CEA) levels are raised in colorectal carcinoma; measuring levels of CEA is therefore useful for follow-up as rising levels suggest recurrence.
How is colorectal cancer treated?80% of patients will undergo surgery (although fewer than half will survive for longer than 5 years). Radiotherapy can be used preoperatively. For advanced cancers (Duke C & D) the first line treatment is chemotherapy with folinic acid, fluorouracil, and oxaliplatin (the combination of these 3 drugs is known as FOLFOX); second line treatment is single agent irinotecan.
What is the faecal occult blood test?Faecal occult blood refers to the blood in the faeces that is not visibly apparent. A faecal occult blood test checks for hidden blood in the faeces. Positive tests may result from upper/lower GI bleeding and warrant further investigation for peptic ulcers or malignancy.
With regards to Dukes' stages of bowel cancer, what is “A”?Tumour confined to below the muscularis mucosae.
With regards to Dukes' stages of bowel cancer, what is “B” (including B1 and B2)?Tumour extends across the muscularis mucosae. B1= Extending into muscularis propria but not penetrating through it; nodes not involved. B2= Penetrating through muscularis propria; nodes not involved.
With regards to Dukes' stages of bowel cancer, what is “C” (including C1 and C2)?Involvement of regional nodes. C1= Extending into muscularis propria but not penetrating through it. Nodes involved. C2= Penetrating through muscularis propria. Nodes involved.
With regards to Dukes' stages of bowel cancer, what is “D”?Distant metastasis.
Which surgical procedure would be carried out in a patient with caecal, ascending colon, or proximal transverse colon tumours?Right hemicolectomy.
Which surgical procedure would be carried out in a patient with tumours in the distal transverse or descending colon?Left hemicolectomy.
Which surgical procedure would be carried out in a patient with sigmoid tumours?Sigmoid colectomy.
Which surgical procedure would be carried out in a patient with tumours in the low sigmoid or high rectum?Lower anterior resection.
Which surgical procedure would be carried out in a patient with tumours low in the rectum (<8cm from anus)?Abdomino-perineal resection (this is removal of the anus, rectum, and part of the sigmoid colon).
Which surgical procedure would be carried out in a patient with emergency bowel obstruction?Hartmann’s procedure.
What is Hartmann’s procedure?Removal of the recto-sigmoid colon and formation of an end colostomy. The remaining rectal stump is closed.
Colon cancer is the _____ most common cancer in the world.3rd.
What is the “apple core sign”?The image of an apple core can be seen on a barium enema x-ray. It is most frequently associated with constriction of the lumen of the colon by a stenosing annular colorectal carcinoma.


Question Answer
What are the different types of diarrhoea?Secretory, malabsorptive, osmotic, and inflammatory.
What is secretory diarrhoea characterised by?Isotonic stools; persists during fasting.
What is malabsorptive diarrhoea characterised by?It follows generalised failures of nutrient absorption and is associated with steatorrhoea and is relieved by fasting.
What is osmotic diarrhoea due to?It is due to the excessive osmotic forces exerted by unabsorbed luminal solutes (i.e. too much water drawn into bowel) e.g. in coeliac disease.
What is inflammatory diarrhoea characterised by?It is due to inflammatory disease and is characterised by purulent, bloody stools that continue during fasting.
Does chronic diarrhoea always require investigation?Yes. All patients should have a sigmoidoscopy and rectal biopsy.
What is pseudomembranous colitis and what are its features?Colitis resulting from infection with C.difficile, and may develop following the use of any antibiotic. Diarrhoea occurs in the first few days after taking the antibiotic or even up to 6 weeks after stopping the drug. Other features include abdominal pain, and a raised white blood cell count.
Which type of antibiotic is the leading cause for pseudomembranous colitis?Cephalosporins.
How is pseudomembranous colitis diagnosed?Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool.
How is pseudomembranous colitis managed?First-line therapy is oral metronidazole for 10-14 days. If severe or not responding then oral vancomycin may be used.
What is bile acid diarrhoea?Chronic diarrhoea that occurs when the terminal ileum fails to reabsorb bile acids.
How is bile acid diarrhoea diagnosed and how does it work?With the SeHCAT test. SeHCAT is a bile acid analogue (i.e. very similar to bile acid structure). This can be made radioactive. The test works by administering the radioactive bile acid analogue (orally with water) and then measuring the percentage retention (or loss of the compound in the faeces) after 7 days. A 7-day SeHCAT retention value greater than 15% is considered to be normal, with values less than 15% signifying excessive bile acid loss, as found in bile acid malabsorption.
How is bile acid malabsorption treated?Cholestyramine is first line and is used to treat the diarrhoea resulting from the bile acid malabsorption.
What is gastroenteritis?Gastroenteritis or infectious diarrhoea is a medical condition from inflammation of the GI tract that involves both the stomach and the small intestine, typically resulting from bacterial toxins or viral infection. It causes some combination of diarrhoea, vomiting, and abdominal pain and cramping.