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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_40_библиотеки_им_акад_М_И_Перельмана
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CHAPTER 6 | SMALL INTESTINALDISORDERS
105 CFU/ ml or the presence of atypical ora on small intestinal aspirates. Treatment includes
addressing any primary cause and using antibiotics such as metronidazole, co- amoxiclav, cotrimoxazole, ciprooxacin, noroxacin, and rifaximin. Some patients may require cyclical antibiotics
on rotation. Drugs such as anticholinergics and opioids should be avoided because they slow gut
transit and may exacerbate symptoms.
Intraepithelial lymphocytosis alone on duodenal biopsies is not sucient to diagnose coeliac disease
in the absence of villous atrophy and an inammatory inltrate in the lamina propria. Inammatory
bowel disease and pancreatic exocrine insuciency are unlikely here.
Shah SC, Day LW, Somsouk M etal. Meta- analysis:antibiotic therapy for small intestinal bacterial
overgrowth. Aliment Pharmacol Ther. 203;38(8):925– 934. Doi:0./ apt.2479.
23. C. Colestyramine
• Bile acid malabsorption (BAM) is common in patients with Crohn’s disease especially in the
context of distal ileal resection
• BAM usually responds to bile acid sequestrants such as colestyramine
• There is a dose– response relationship between the severity of BAM and the eect of bile acid
sequestrants
The most likely diagnosis here is BAM. Resection of the distal ileum (usually >100cm) prevents
reabsorption of bile salts that subsequently enter the colon causing diarrhoea. BAM may also be
caused by primary diseases of the terminal ileum, HIV infection, or defects in bile acid synthesis or
transport mechanisms. Previous cholecystectomy and post- infectious diarrhoea may predict BAM.
The severity of BAM can be assessed by measuring seven- day retention of an orally administered,
selenium- labelled bile acid (SeHCAT scan):10%– 15% retention=mild; 5%– 10%=moderate;
<5%=severe. The lower the retention, the more likely the patient is to respond to bile acid
sequestrants (colestyramine, colesevelam, colestipol).
Recurrence of Crohn’s disease or bacterial overgrowth is less likely. There is no consistent evidence
for the use of mesalazine in the management of Crohn’s disease.
Wilcox C, Turner J, Green J.Systematic review:the management of chronic diarrhoea due to bile acid
malabsorption. Aliment Pharmacol Ther. 204;39(9):923– 939. Doi:0./ apt.2684.
24. C. NSAID metabolites
• Non- steroidal anti- inammatory drug (NSAID) enteropathy classically presents with small
bowel ulceration, abdominal pain, iron- deciency anaemia and hypoalbuminaemia
• Patients may often deny taking NSAIDs
• Diaphragm- like structures in the small bowel are pathognomonic
The association between gastro- duodenal ulceration and NSAID use is well recognized but jejunum,
ileum, and colon can also be aected. Aspirin appears to be less harmful than other NSAIDs at
inducing small bowel damage. The signs and symptoms of NSAID enteropathy can be varied but
typically include iron- deciency anaemia, hypoalbuminaemia (from a protein- losing enteropathy),
and small bowel ulceration. Abdominal pain may result from partial small bowel obstruction caused
by diaphragm- like structures. These are rare, brotic structures causing luminal narrowing and are
pathognomonic of the condition.
Establishing the diagnosis requires an index of suspicion based on clinical presentation. Acareful
history of NSAID ingestion has to be taken including prescribed and over- the- counter medications,
combination medications (e.g. ibuprofen with caeine and paracetamol). Patients may deny using
CHAPTER 6 | ANSWERS
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NSAIDs, and serum or urinary NSAID measurements may need to be considered to conrm the
diagnosis. Acid- suppressants such as omeprazole and ranitidine do not protect against small bowel
ulceration secondary to NSAIDs. Management of the condition involves cessation of NSAID
intake and treatment of anaemia. Ulceration should resolve upon drug cessation. Obstructive
symptoms secondary to diaphragm disease may require endoscopic dilatation or surgical resection
of stricturoplasty.
Shin SJ, Noh CK, Lim SG etal. Non- steroidal anti- inammatory drug- induced enteropathy. Intest Res.
207;5(4):446– 455. Doi:0.527/ ir.207.5.4.446.
25. B. Bone marrow culture
• Enteric fever is characterized by fever and gastrointestinal involvement including abdominal
pain, diarrhoea or constipation, and, rarely, intestinal perforation
• Blood, urine, and stool culture for microbiological diagnosis perform poorly compared with
bone marrow culture
Typhoid and paratyphoid fever (collectively enteric fever) are caused by Salmonella enterica serovar
typhi (formerly Salmonella typhi) and Salmonella paratyphi A, B, and C.Typical presentation includes
fevers, rose spots and relative bradycardia or pulse– temperature dissociation. Later, gastrointestinal
features predominate including abdominal pain (60%), diarrhoea or constipation (30%), and rectal
bleeding (10%). Intestinal perforation from necrosis of ileocaecal Peyer’s patches occurs in 10% of
hospitalized patients. Laboratory investigations usually demonstrate leucopenia or leukocytosis,
and mildly elevated LFTs. Transmission is faecal– oral and is endemic in South Asia, parts of SouthEast Asia, the Middle East, Central and South America, and Africa. Oral and parenteral vaccines
are available for Salmonella enterica serovar typhi but are imperfect, with the oral vaccine oering a
cumulative three- year ecacy of 50%. Amicrobiological diagnosis can be made by positive cultures
of blood (40%), stool (37%), and urine (7%). Although invasive, bone marrow culture is positive in
90% of cases, making it the most sensitive diagnostic investigation, and it should be considered in
complicated cases of suspected treatment failure due to antimicrobial resistance.
Parry CM, Wijedoru L, Arjyal Aetal. The utility of diagnostic tests for enteric fever in endemic
locations. Expert Rev Anti Infect Ther. 20;9(6):7– 725. Doi:0.586/ eri..47.
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chapter
INFLAMMATORY BOWEL DISEASE AND
COLONICDISORDERS
1. A 40- year- old man with a 5- year history of Crohn’s colitis was admitted
7
QUESTIONS
to hospital with a severe are necessitating intravenous hydrocortisone.
Which pro- inammatory cytokine is produced in higher amounts in
Crohn’s disease (CD) than ulcerative colitis (UC)?
A. IFN- γ
B. IL- 5
C. IL- 6
D. IL- 13
E. TNF- α
2. A 33- year- old woman with a 15- year- history of ileocolonic CD
attended for her follow- up appointment. She had no family history of
inammatory bowel disease (IBD) and nor did her husband. She was
33weeks’ pregnant and concerned about the risk of CD in her child.
Which of the following percentages most accurately reects the child’s
likelihood of developing CD?
A. 1%
B. 10%
C. 25%
D. 30%
E. 45%
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0007
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
3. A 29- year- old man was admitted with acute severe ulcerative colitis
(ASUC) and required iniximab (IFX) after failing intravenous steroids.
He was previously well and a non- smoker. During the ward round, he
had several questions regarding his condition.
Which of the following statements is most accurate?
A. Accelerated IFX dosing in hospitalized patients with UC reduces colectomy rate
B. Approximately 30% of patients with ASUC will require a colectomy
C. Approximately 40% of patients will require hospitalization because of ASUC
D. Smoking increases the risk of recurrence of ASUC
E. The presence of mucosal islands (areas of oedematous mucosa surrounded by deep
ulceration) or colonic dilatation >5.5cm on a plain abdominal radiograph is associated with
colectomy in 50% of patients
4. A 34- year- old man attended clinic with a new conrmed
diagnosis of UC. He had several questions about UC.
Regarding UC, which of the following statements is most accurate?
A. Around 25% of patients with pancolitis eventually have a colectomy
B. At 10years, disease extent progresses in less than 10% of patients with proctitis
C. Maintenance 5- aminosalicylate (5- ASA) therapy reduces colorectal cancer (CRC) by 10%
D. The incidence of CRC is 20% at 20years and 40% at 30years
E. The relapse rate is 20% per year
5. A 21- year- old woman presented to clinic with a one- week history of
bloody diarrhoea eight times per day, with nocturnal motions and
generalized abdominal pain. She had a long history of arthralgia in
the hands and recurrent mouth ulcers. Her father had ankylosing
spondylitis. Examination revealed aphthous mouth ulcers, a small
ulcer in the right leg with a violaceous border, and mild right iliac
fossa tenderness. Her temperature was 38°C, heart rate 110 beats per
minute and blood pressure 100/ 60 mmHg.
What is the most appropriate rst investigation?
A. Colonoscopy
B. Faecal culture
C. Flexible sigmoidoscopy
D. HLA- B27
E. Magnetic resonance (MR) enterography
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6. A 52- year- old Afro- Caribbean man with a 13- year history of Crohn’s
colitis underwent a gastroscopy and colonoscopy. He was maintained on
azathioprine.
Investigations:
Gastroscopy Normal including biopsies
Colonoscopy Patchy inammation in the left colon, normal terminal ileum.
Biopsies consistent with Crohn’s colitis in the descending and
sigmoid colon.
Which of the following most accurately represents this patient’s
Montreal classication?
A. A1 L1 B1
B. A2 L2 B1
C. A2 L4 B3
D. A3 L2 B3
E. A3 L3 B2
7. A 22- year- old woman presents with a four- week history of abdominal
pain, malaise, and bloody stools. She undergoes a exible sigmoidoscopy
with biopsies.
Which histological feature has the highest predictive value for a
diagnosis of UC over infective colitis?
A. Basal plasmacytosis
B. Crypt abscess formation
C. Granuloma formation
D. Lamina propria hypercellularity
E. Paneth cell metaplasia
8. A 35- year- old woman with colonic CD presented complaining of perianal
pain and rectal discharge.
Investigations:
Haemoglobin 145 g/ L
White cell count (WCC) 10.9 × 109/ L
Platelet count 534 × 109/ L
Serum C- reactive protein (CRP) 67 mg/ L
Which of the following statements is the most accurate?
A. Flexible sigmoidoscopy is useful in determining the management of perianal stulae
B. Ileocolonic CD has a higher rate of perianal disease
C. Perianal disease presents late in the course of CD
D. Perianal pain commonly occurs with isolated perianal stulae
E. Routine assessment of perianal stulae includes pelvic magnetic resonance imaging (MRI),
examination under anaesthesia (EUA), and anorectal ultrasound
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
9. A 63- year- old lorry driver with a previous diagnosis of ileal CD and a
perianal stula attended the IBD specialist nurse clinic. On examination,
his stula was producing purulent uid.
Investigations:
Haemoglobin 178 g/ L
WCC 8.9 × 109/ L
Platelet count 145 × 109/ L
Serum C- reactive protein (CRP) 35 mg/ L
Pelvic MRI Inter- sphincteric perianal stula; no
abscess was demonstrated
Flexible sigmoidoscopy Quiescent disease
Which of the following treatments is the most appropriate?
A. Defunctioning ileostomy
B. IFX induction 5 mg/ kg
C. Intravenous ciclosporin 4– 5 mg/ kg/ day
D. Seton suture and antibiotics
E. Total parenteral nutrition
10. A 21- year- old student with a seven- month history of intermittent postprandial abdominal pain and fatigue was referred with worsening of
symptoms during her nal exams. On further enquiry, she reported 3kg
of weight loss with no diarrhoea or anorexia. She had a previous history
of irritable bowel syndrome (IBS). She was a non- smoker and had no
family history of IBD.
Investigations:
Haemoglobin 109 g/ L
Serum albumin 33 g/ L
Serum C- reactive protein 18 mg/ L
Which of the following would have the highest diagnostic yield for small
bowel CD?
A. Capsule endoscopy (CE)
B. CT enteroclysis
C. Double- balloon enteroscopy
D. Faecal calprotectin
E. MR enterography
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11. A 26- year- old man with a ve- month history of diarrhoea, abdominal
pain, and fatigue was referred. On further enquiry, he reported 4kg of
weight loss. He had been a smoker, and had a family history of IBD.
Investigations:
Haemoglobin 114 g/ L
Serum albumin 35 g/ L
Serum C- reactive protein 26 mg/ L
An abdominal ultrasound was performed in clinic.
Which is considered the most consistent ultrasound nding in CD?
A. Altered echogenicity of the bowel wall
B. Decreased peristalsis
C. Enhanced mesenteric nodes
D. Increased bowel wall thickness (BWT)
E. Vascularity of the mesentery
12. A 48-year-old man is diagnosed with UC and commenced on oral
and rectal 5-ASA. After two weeks of treatment, he continues to
experience loose stools three times per day with occasional blood. He is
subsequently commenced on budesonide multimatrix (MMX).
Which of the following statements is correct regarding budesonide MMX?
A. It is only recommended in those with extensive colitis
B. It has high rst- pass metabolism in the liver
C. It is a topical rectal preparation
D. It leads to double the rate of clinical improvement compared with mesalamine 2.4 g in
mild– moderate UC
E. The recommended dosing is 6 mg once daily for 16 weeks
13. Following rescue therapy for ASUC, a 27- year- old man is subsequently maintained on 5 mg/ kg IFX eight- weekly alongside 50 mg of azathioprine and
2.4 g mesalazine. He initially had complete resolution of symptoms but six
months later he reported four times stools per day with occasional blood.
Investigations:
Serum C- reactive protein 43 mg/ l
Faecal calprotectin 800 µg/ g
IFX trough level 2.6 µg/ ml
Antibodies to IFX Undetectable
What is the next most appropriate management step?
A. Change IFX to adalimumab
B. Change IFX to vedolizumab
C. Colectomy
D. Continue IFX and restart oral corticosteroids
E. Increase dose of IFX
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
14. You review a 73- year- old man with steroid- dependent left- sided UC. You
wish to counsel him regarding azathioprine.
What would be this patient’s approximate annual risk of incident
lymphoma if commenced upon azathioprine?
A. 1 in 100
B. 1 in 300
C. 1 in 1,000
D. 1 in 3,000
E. 1 in 10,000
15. A 78- year- old woman with pancolitis was admitted with bloody
diarrhoea (11 times per day) with a pulse of 92 beats per minute
and blood pressure 124/ 70 mmHg. On day three of intravenous
corticosteroids, her stool chart reported four bloody stools in the
past 24 hours. She denied abdominal pain. Her pulse was 72 beats
per minute and temperature 37.4°C. Her background included heart
failure (NYHA IV), morbid obesity, obstructive sleep apnoea (requiring
nocturnal continuous positive airway pressure), and chronic obstructive
pulmonary disease. She had investigations performed on day three of
admission.
Investigations:
Haemoglobin 90 g/ L
WCC 10.4 × 10⁹/ L
Platelet count 550 × 10⁹/ L
Serum C- reactive protein 46 mg/ L
Cholesterol 5.1mmol/ L
Magnesium 0.97mmol/ L
Chest radiograph Clear
Abdominal radiograph No evidence of toxic megacolon
What is the most appropriate next step?
A. Continue intravenous corticosteroids and reassess in 48 hours
B. IFX (5 mg/ kg) induction regime
C. Intravenous ciclosporin (2 mg/ kg per day)
D. Oral ciclosporin (5 mg/ kg per day in divided doses)
E. Subtotal colectomy
CHAPTER 7 | QUESTIONS
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16. A 35- year- old man was diagnosed with UC. His exible sigmoidoscopy
reported mild activity extending to 15cm from the anus. His bowel
frequency was two times per day with occasional rectal bleeding and
mucus. His main concern was tenesmus and urgency. Examination was
unremarkable.
Investigations:
Haemoglobin 142 g/ L
WCC 6.1.0 × 10⁹/ L
Platelet count 313 × 10⁹/ L
Serum C- reactive protein 4 mg/L
Alanine transferase (ALT) 17 U/ L
Alkaline phosphatase (ALP) 77 U/ L
What treatment should be initiated?
A. Mesalazine enema
B. Mesalazine suppository
C. Oral mesalazine
D. Oral prednisolone
E. Prednisolone enema
17. A 34- year- old man underwent a proctocolectomy and ileal pouch- anal
anastomosis for ulcerative pancolitis. There were no perioperative
complications. Eight months later, he was reviewed in clinic and
described a one- week history of increased frequency of non- bloody
stools, abdominal cramping, tenesmus, and urgency.
Investigations:
Pouchoscopy Mucosal oedema, friability, and loss of vascular
What is the most appropriate management?
A. IFX
B. Mesalazine enema
C. Oral budesonide
D. Oral ciprooxacin
E. VSL#3 probiotic
pattern. Biopsy histology pending.
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