
- •CONTENTS
- •PREFACE
- •ABBREVIATIONS
- •GENERAL AND COLORECTAL
- •CASE 1:
- •ANSWER 1
- •CASE 2:
- •ANSWER 2
- •CASE 3:
- •ANSWER 3
- •CASE 4:
- •ANSWER 4
- •CASE 5:
- •ANSWER 5
- •CASE 6:
- •ANSWER 6
- •CASE 7:
- •ANSWER 7
- •CASE 8:
- •ANSWER 8
- •CASE 9:
- •ANSWER 9
- •CASE 10:
- •ANSWER 10
- •CASE 11:
- •ANSWER 11
- •CASE 12:
- •ANSWER 12
- •CASE 13:
- •ANSWER 13
- •CASE 14:
- •ANSWER 14
- •CASE 15:
- •ANSWER 15
- •CASE 16:
- •ANSWER 16
- •CASE 17:
- •ANSWER 17
- •CASE 18:
- •ANSWER 18
- •CASE 19:
- •ANSWER 19
- •CASE 20:
- •ANSWER 20
- •UPPER GASTROINTESTINAL
- •CASE 21:
- •ANSWER 21
- •CASE 22:
- •ANSWER 22
- •CASE 23:
- •ANSWER 23
- •CASE 24:
- •ANSWER 24
- •CASE 25:
- •ANSWER 25
- •CASE 26:
- •ANSWER 26
- •CASE 27:
- •ANSWER 27
- •CASE 28:
- •ANSWER 28
- •CASE 29:
- •ANSWER 29
- •CASE 30:
- •ANSWER 30
- •CASE 31:
- •ANSWER 31
- •CASE 32:
- •ANSWER 32
- •CASE 33:
- •ANSWER 33
- •CASE 34:
- •ANSWER 34
- •CASE 35:
- •ANSWER 35
- •CASE 36:
- •ANSWER 36
- •BREAST AND ENDOCRINE
- •CASE 37:
- •ANSWER 37
- •CASE 38:
- •ANSWER 38
- •CASE 39:
- •ANSWER 39
- •CASE 40:
- •ANSWER 40
- •CASE 41:
- •VASCULAR
- •CASE 42:
- •ANSWER 42
- •CASE 43:
- •ANSWER 43
- •CASE 44:
- •ANSWER 44
- •CASE 45:
- •ANSWER 45
- •CASE 46:
- •ANSWER 46
- •CASE 47:
- •ANSWER 47
- •CASE 48:
- •ANSWER 48
- •CASE 49:
- •ANSWER 49
- •CASE 50:
- •ANSWER 50
- •CASE 51:
- •ANSWER 51
- •CASE 52:
- •ANSWER 52
- •CASE 53:
- •ANSWER 53
- •CASE 54:
- •ANSWER 54
- •CASE 55:
- •ANSWER 55
- •CASE 56:
- •ANSWER 56
- •UROLOGY
- •CASE 57:
- •ANSWER 57
- •CASE 58:
- •ANSWER 58
- •CASE 59:
- •ANSWER 59
- •CASE 60:
- •ANSWER 60
- •CASE 61:
- •ANSWER 61
- •CASE 62:
- •ANSWER 62
- •CASE 63:
- •ANSWER 63
- •CASE 64:
- •ANSWER 64
- •ORTHOPAEDIC
- •CASE 65:
- •ANSWER 65
- •CASE 66:
- •ANSWER 66
- •CASE 67:
- •ANSWER 67
- •CASE 68:
- •ANSWER 68
- •CASE 69:
- •Questions
- •ANSWER 69
- •CASE 70:
- •ANSWER 70
- •CASE 71:
- •ANSWER 71
- •CASE 72:
- •ANSWER 72
- •CASE 73:
- •ANSWER 73
- •CASE 74:
- •ANSWER 74
- •CASE 75:
- •ANSWER 75
- •CASE 76:
- •ANSWER 76
- •CASE 77:
- •ANSWER 77
- •CASE 78:
- •ANSWER 78
- •CASE 79:
- •ANSWER 79
- •CASE 80:
- •ANSWER 80
- •CASE 81:
- •ANSWER 81
- •EAR, NOSE AND THROAT
- •CASE 82:
- •ANSWER 82
- •CASE 83:
- •ANSWER 83
- •CASE 84:
- •ANSWER 84
- •CASE 85:
- •ANSWER 85
- •NEUROSuRGERY
- •CASE 86:
- •ANSWER 86
- •CASE 87:
- •ANSWER 87
- •CASE 88:
- •ANSWER 88
- •CASE 89:
- •ANSWER 89
- •ANAESTHESIA
- •CASE 90:
- •ANSWER 90
- •CASE 91:
- •ANSWER 91
- •CASE 92:
- •ANSWER 92
- •CASE 93:
- •ANSWER 93
- •CASE 94:
- •ANSWER 94
- •POSTOPERATIVE COMPLICATIONS
- •CASE 95:
- •ANSWER 95
- •CASE 96:
- •ANSWER 96
- •CASE 97:
- •ANSWER 97
- •CASE 98:
- •ANSWER 98
- •CASE 99:
- •ANSWER 99
- •CASE 100:
- •ANSWER 100

General and Colorectal
CASE 20: inCreaSeD boWel FreQuenCy
anD reCtal bleeDing
history
A 40-year-old woman presents to the emergency department complaining of a 2-month history of bright red rectal bleeding, motions up to six times per day and cramping lower abdominal pains. She has lost 2 stone in weight. She finished a course of Augmentin for a chest infection 2 weeks ago. She had an appendicectomy at the age of 16 years with no other past history of note. She visited Thailand on a family holiday 3 weeks ago.
examination
The temperature is 37.5°C with a pulse rate of 98/min and a blood pressure of 140/70 mmHg. There is no lymphadenopathy. The abdomen is soft with tenderness to deep palpation in the left iliac fossa. Digital rectal examination shows soft stool with a small amount of bright red blood and mucus mixed in. Rigid sigmoidoscopy to 20 cm from the anal verge reveals bright red, friable rectal mucosa. A biopsy is taken.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
13.2 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
5.9 × 109/l |
4.0–11.0 × 109/l |
platelets |
302 × 109/l |
150–400 × 109/l |
Sodium |
147 mmol/l |
135–145 mmol/l |
potassium |
4.8 mmol/l |
3.5–5.0 mmol/l |
urea |
6.9 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
50 μmol/l |
44–80 μmol/l |
amylase |
68 iu/dl |
0–100 iu/dl |
aspartate transaminase (aSt) |
32 iu/l |
5–35 iu/l |
alkaline phosphatase (alp) |
74 iu/l |
35–110 iu/l |
gamma-glutamyl transferase (ggt) |
42 iu/l |
11–51 iu/l |
albumin |
37 g/l |
35–50 g/l |
bilirubin |
16 mmol/l |
3–17 mmol/l |
erythrocyte sedimentation rate (eSr) |
49 mm/h |
1–13 mm/h |
Questions
•What differential diagnoses would you consider?
•The biopsy suggests ulcerative colitis. What are the typical histological findings?
•How should the patient be managed acutely?
•What is the potential for malignant change associated with this condition?
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100 Cases in Surgery
ANSWER 20
!The main differential diagnoses for a patient with this history and symptoms
•Inflammatory bowel disease: Crohn’s disease or ulcerative colitis
•Infective diarrhoea: Shigella, Salmonella, Yersinia and Campylobacter
•Pseudomembranous colitis: secondary to antibiotic use
In view of the patient’s history, a biopsy of the rectal mucosa and stool sample should be sent. Microbiology can analyse the sample for an infective cause or test for Clostridium difficile toxin in cases of pseudomembranous colitis.
Ulcerative colitis occurs most commonly between the ages of 15 and 40 years, and usually involves the rectum then progresses more proximally. Typical histological changes include infiltration with acute and chronic inflammatory cells that is confined to the mucosa (unlike Crohn’s disease where changes are transmural). In severe cases there is fissuring and transmural inflammation, making it difficult to distinguish Crohn’s disease from ulcerative colitis on the basis of histology.
Medical management is aimed at controlling inflammation and reducing symptoms. In cases of severe colitis, nutritional support and correction of electrolyte disturbances may also be required. Corticosteroids can be used to induce remission, and salicylic acid derivatives employed to maintain remission – these can be administered as enemas or suppositories where the disease only involves the rectum. If diarrhoea is particularly problematic, agents such as codeine phosphate and loperamide may be considered.
The potential for malignant change is relatively high with long-standing ulcerative colitis and the risk in patients with pancolitis is approximately 3 per cent after 10 years. The risk of developing mucosal dysplasia increases with time, and surveillance should commence after 7 years. Colonoscopy and biopsy are performed every 2–3 years. If dysplasia is detected, the patient should undergo total colectomy with end ileostomy.
KEY POINTS
•long-standing ulcerative colitis carries an approximate 3 per cent risk of malignant change after 10 years.
•Colonoscopy and biopsy are performed every 2–3 years.
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