Lower GI

Question 1

What is an anal fissure?

What is the timeline for acute vs chronic.

Where are primary and secondary anal fissures commonly located?

Answer 1

A tear in squamous epithelium of anal canal

Acute< 6 weeks< chronic

Primary in posterior midline. Secondary in varying locations.

Question 2

Give 3 causes of secondary anal fissures.

Answer 2

• Constipation
• Crohn’s disease
• Pregnancy

Question 3

Give 2 features of a common anal fissure presentation.

What is a sign of a chronic ulcer?

Answer 3

• Young person
• Painful rectal bleeding on defecation
• Sentinel pile/ skin tag

Question 4

Anal fissure patients can enter a pain-constipation cycle.
What is the management for the pain?

What is the management for the constipation?

Answer 4

• Paracetamol/ ibuprofen
  + topical lidocaine.
  Topical GTN/ diltiazem if > 1 week.
• Increase fluid/ fibre intake
• Laxative.

Question 5

What are the two management options for chronic anal fissure?

Answer 5

• Botulinum injection

- Internal sphincterotomy

Question 6

What is the definition of a haemorrhoid?

Answer 6

Engorgement of vascular cushions in anal canal.

Question 7

What are the two differences between internal and external haemorrhoids?

What are the 4 grades of internal haemorrhoid?

Answer 7

Internal: above dentate line, not painful.

External: below dentate line, painful

1. project into lumen, not palpable
2. Prolapse w/ straining, spontaneously reduce
3. prolapse w/ straining, manually reducible
4. Irreducible

Question 8

Give two aetiologies of haemorrhoids.

Answer 8

• Constipation/ straining

- Raised intra-abdominal pressure: Pregnancy, lifting, chronic cough.

Question 9

What is the common presentation of haemorrhoids?

Give an individual complication for both external and internal haemorrhoids.

Answer 9

• Painless rectal bleeding- small amounts of bright red blood on wiping/ in bowl.
• Strangulation of internal haemorrhoid- severe pain, urgent haemorrhoidectomy.
• Thrombosis of external haemorrhoids- sever pain, purple oedematous perianal mass. <72 hours surgical incision

Question 10

Give two investigations for haemorrhoids.

Give 3 steps in management for haemorrhoids.

Answer 10

• Proctoscopy
• Anaemia

1. Stool softening: fibre/ fluid laxative
2. Rubber band ligation/ or injection sclerotherapy
3. Large grade 3/4 may require haemorrhoidectomy.

Question 11

What is the most common form of colorectal cancer? Describe it’s global epidemiology.

Answer 11

Usually adenocarcinoma.

3rd most common cancer in world.

Question 12

Give 4 etiological factors for colorectal cancer

Answer 12

1. Genetic: FAP (APC gene), HNPCC - autosomal dominant.
2. Demographic: old male
3. Environmental: smoking, diet, alcohol, obesity
   4: other: adenomatous/ neoplastic polyps. IBD (UC > Crohn’s)

Question 13

What screening tool is used for colorectal cancer for 60-74yrs and how often?

Answer 13

• Screening is Faecal immunochemical test (FIT). Test for trace amounts of blood.

Every 2 years

Question 14

Give 3 general symptoms of colorectal cancer.

Answer 14

• abdominal pain, weight loss, fatigue.

Question 15

Differentiate presentation of left (6 factors) and right (2 factors) sided colorectal cancer.

Answer 15

Left: more common, present earlier.

• PR bleeding
• Change in bowel habit
• Rectal tenesemus, mass on DRE
• Can present with obstruction.

Right: less common, present later,
- anaemia

Question 16

Give 3 blood results and 2 other investigations for colorectal cancer.

What 4 sites are common metastasis locations?

Answer 16

1. Blood:
   - FBC- iron deficiency anaemia
   - LFTs (mets)
   - CEA (tumour marker, not used for diagnosis)
2. Colonoscopy- gold standard.
3. Barium enema: apple core stricture.

TNM staging, used to be Duke’s

Common mets: liver, lungs, bone, brain

Question 17

Give the 1s and 2nd line management options for colorectal cancer treatment.

Answer 17

1st: Surgery- L/R hemicolectomy, sigmoid colectomy, rectum anterior resection.
2nd: radiotherapy, chemotherapy.

Question 18

When should you refer the following people to 2 week wait for colorectal cancer:

• age >40
• age >50
• age >60

Answer 18

40- unexplained weight loss, abdominal pain.
50- unexplained rectal bleeding
60- iron deficiency anaemia or change in bowel habit.

Question 19

Differentiate UC and Crohn’s disease in the following areas:

• Risk factors
• Pathology
• Presentation
• Complications

Answer 19

UC: 
RF: HLA-B27, not smoking
PA: Rectum- ileocaecal valve, continuous, mucosa
Pres: Abdo pain (L), bloody diarrhoea
Comp: Toxic megacolon, colorectal cancer

Crohn’s:
RF: smoking
Path: Anus- mouth, discontinuous, transmural
Pres: Abdo pain (R), diarrhoea, perianal lesions, mouth ulcers, malabsorption.
Comp: fistulae, abscesses.

Question 20

Differentiate UC and Crohn’s by their extraintestinal manifestations in the following:

• Eyes,
• Hepatobiliary

IBD also affects Musculoskeletal and skin.
- IBD gets MESSY

Answer 20

UC:

• Uveitis
• PSC/ cholangiocarcinoma

Crohn’s:

• Episcleritis
• Gallstones (+ kidney stones)

Question 21

Give 3 results from blood test of IBD (chronic inflammation).

Give 3 stool investigations:

What is gold standard investigation for IBD

Answer 21

• FBC: anaemia of chronic disease, high platelets, high white cell count
• LFT: low albumin
• ESR/ CRP raised.
• Stool culture
• Faecal calprotectin- marker of inflammation, distinguishes IBS and IBD.
• C. Difficile toxin

Gold standard is colonoscopy.

Question 22

In the management of UC: what are the induction and maintenance medications.

in the management of Crohn’s: what are the induction and management medications.

Answer 22

UC:
Induction: Mesalazine (5-ASA). Topical if L-sided, Topical + oral if whole colon). If severe, IV steroids.

Maintenance: Mesalazine topical/ oral. If severe, Azathioprine. mercaptopurine.

Crohn’s:
Induction: steroids: topical/ oral/ IV. Elemental, enteral feeding. If isolated perianal disease- metronidazole. 2nd line is Mesalazine, azathioprine, mercaptopurine, infliximab.

Maintenance: Azathioprine/ mercaptopurine. 2nd line methotrexate.

NBM and fluids.
Surgery common for Crohn’s

Question 23

IBS is more than 6 months of what 3 symptoms.

What criteria is used to diagnose IBS?

Answer 23

ABC:
- Abdominal discomfort/ pain on eating, relieved by defecation. Muscle contract causing cramps.
- Bloating- bacteria produce gas
- Change in bowel habit, stool form incl. mucus.
Pellet-like stool is buzzword. Epithelial lining produces mucus.

ROME criteria for diagnosis

Classically young women. Reconsider if >40 yrs.

Question 24

What two investigations exclude other causes from a diagnosis of IBS?

Answer 24

1. FBC/ CRP

2. Coeliac antibodies.

Question 25

Give 4 ways to manage the symptoms of IBS.

Answer 25

1. Diet: low fizzy/ alcohol/ caffeine drinks, lots of water. 2. Pain: Antispasmodics, low dose TCA. 3. Diarrhoea: Loperamide 4. Constipation: Laxative, NOT lactulose. Psychological therapy after 12 months.

Question 26

Give 3 presenting features of Coeliac disease.

Answer 26

1. Chronic GI symptoms: N&V, diarrhoea, bloating. 2. Malabsorption: weight loss, osteoporosis, anaemia, neuropathy, steatorrhoea 3. Dermatitis herpetiformis

Question 27

Give 2 risk factors for coeliac disease.

Answer 27

- Hx/ Fhx autoimmune disease- women | - HLA DQ2/8 alleles

Question 28

What 4 blood results would be seen for investigating coeliac disease?

Answer 28

- Micro/ macrocytic anaemia- increased RCDW - Low B12, low ferritin - Low calcium/ Vit D - LFT- non specific transaminitis.

Question 29

What 3 things can be seen by endoscopy/ duodenal biopsy of a patient with coeliac while having gluten? Need to be on a glutinous diet for 6 weeks before testing.

Answer 29

1. Villous atrophy 2. Crypt hyperplasia 2. Intraepithelial WBC

Question 30

Give 3 autoantibody tests for coeliac disease.

Answer 30

- Total IgA levels - IgA anti-tissue transglutaminase (TTG) - IgA anti-endomysial antibodies

Question 31

Give the two features of coeliac disease management. What condition is specific to untreated coeliac disease?

Answer 31

- Gluten free diet (excl. rice, corn, potatoes) - Pneumococcal vaccine ever 5 years due to hyposplenism Enteropathy associated T-Cell lymphoma (EATL).

Question 32

What is coeliac disease?

Answer 32

T-Cell mediated autoimmune reaction to dietary gluten. Leads to small bowel and systemic disease.