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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 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
18. A 43- year- old man with IBD attended the outpatient clinic asking if he
could manage his disease with nutritional measures.
Which of the following statements is most accurate?
A. Evidence supports dietary strategies in mild UC
B. Good evidence supports a low- residue diet and avoiding insoluble bre in stricturing CD
C. Probiotics in the management of IBD have no evidence base
D. The evidence base for elemental feed and polymeric diet is similar in CD
E. Total parenteral nutrition and complete bowel rest are a useful adjunct to medical therapy
in resistant CD
19. A 35- year- old Caucasian woman with ileocolonic CD was admitted
with worsening abdominal pain and diarrhoea. She was previously
controlled on azathioprine. After a partial response to corticosteroids,
she was commenced on adalimumab. She showed a good response
after induction and was maintained on fortnightly doses. She was seen
urgently in clinic with a ve- month history of worsening symptoms,
despite maintenance adalimumab.
Investigations:
Serum C- reactive protein (CRP) 57 mg/ L
Faecal calprotectin 256 µg/ g
Anti- drug antibodies Positive
Adalimumab level Undetectable
Which factor has been shown to predict low drug concentrations in
adalimumab therapy?
A. Concomitant immunomodulator
B. Disease duration
C. Ex- smoker
D. Male sex
E. Obesity
CHAPTER 7 | QUESTIONS
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20. A 35- year- old man diagnosed with ileocaecal CD ve years ago
presented to the gastroenterology clinic with abdominal pain, nausea,
and intermittent vomiting. His bowel frequency had reduced, going once
every three days with loose stools. He took azathioprine 150 mg/ day.
Investigations:
Haemoglobin 135 g/ L
Platelet count 340 × 109/ L
Serum C- reactive protein (CRP) 10 mg/ L
Albumin 35 g/ L
Colonoscopy Partial loss of vascular pattern in the caecum and
unpassable stricture at ileocaecal valve. Able to take
terminal ileal biopsies. No ulcers or erosions. Colon
biopsy series taken.
Histology Normal terminal ileum. Ulceration at the ileocaecal
valve with chronic inammatory changes. Otherwise
normal colon.
MR enterography 6cm stricture at the terminal ileum involving the
ileocaecal valve with proximal dilatation of the small
bowel. No evidence of fistula or abscess. Normal
What is the most appropriate next step for this patient?
A. Addition of anti- tumour necrosis factor (anti- TNF) therapy
B. Endoscopic dilatation +/ - stenting of ileocaecal valve
C. Prednisolone
D. Referral for ileocaecal resection
E. Referral for strictureplasty
colon.
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
21. A 28- year- old man was admitted with ASUC. He was treated with
intravenous hydrocortisone. On day three of admission, he complained
of increasing abdominal pain. On examination, he had diuse abdominal
tenderness with rebound.
Investigations and observations:
Heart rate 113 bpm
Temperature 38.9 oC
Haemoglobin 101 g/ L
Serum sodium 149mmol/ L
Serum potassium 2.4mmol/ L
Serum phosphate 0.56mmol/ L
Serum calcium 1.59mmol/ L
Serum magnesium 0.57mmol/ L
Serum albumin 22 g/ L
Abdominal radiograph Loop of featureless transverse colon with a
maximum diameter of 6.1cm.
Which electrolyte abnormality should be corrected rst to prevent
further colonic dilatation?
A. Hypernatraemia
B. Hypocalcaemia
C. Hypokalaemia
D. Hypomagnesaemia
E. Hypophosphataemia
22. A 35- year- old man with CD presented to clinic with lower back pain.
What is the next most appropriate investigation to make a diagnosis?
A. CRP
B. CT spine
C. HLA- B27 antigen
D. MRI pelvis
E. X- ray pelvis
CHAPTER 7 | QUESTIONS
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23. You reviewed a 23- year- old man in clinic with extensive UC for which
he took mesalazine and azathioprine. He had been well in the past year
and was clinically in disease remission. However, he showed you a new
skin lesion on his left shin (Fig. 7.1).
Fig.7.1 Clinical photograph of lower limb skin lesion. See also Plate 12
Reproduced with permission from Oxford Handbook of Medical Dermatology (2 ed.), Susan Burge, Rubeta Matin, and Dinny Wallis,
Figure5.5, page297, Oxford University Press, Oxford, UK, Copyright © 206
161
Which statement regarding the likely diagnosis of this skin lesion is
correct?
A. It is usually associated with active bowel inammation
B. It occurs more commonly in CD than UC
C. It never causes deep (sub- epidermal) inammation
D. It occurs in 5%– 10% of patients with UC
E. Lesions are often precipitated by trauma (pathergy)
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
24. A 37- year- old man with CD presented to the emergency department
with right iliac fossa pain and pyrexia. He had three previous ileal
resections for stricturing disease in the past 10years. He was taking
azathioprine (1 mg/ kg) once a day and an oral 5- ASA.
Investigations:
Haemoglobin 113 g/ L
WCC 18 × 109/ L
Platelet count 556 × 109/ L
Serum C- reactive protein (CRP) 358 mg/ L
Serum albumin 24 g/ L
CT abdomen and pelvis Tethered loops of small bowel in the right iliac
fossa with evidence of active disease and a 1 × 1cm
abscess in the region of the ileocaecal valve
What is the most appropriate next management step?
A. Cessation of azathioprine and prescribing of intravenous antibiotics
B. Intravenous antibiotics and azathioprine 2 mg/ kg once a day
C. Intravenous antibiotics and IFX induction regime
D. Laparotomy, ileocaecal resection, and end ileostomy
E. Radiologically guided percutaneous drainage and intravenous antibiotics
25. A 59- year- old woman with quiescent CD, asthma, and hypertension
presented to the emergency department with an acute febrile illness
following her annual inuenza vaccination. She complained of fever,
malaise, headache, mouth ulcers, and arthralgia. The emergency
department doctor noted the development of multiple erythematous
and tender papules on her neck and at her immunization site.
Investigations:
Haemoglobin 156 g/ L
WCC 15.9 × 109/ L
Platelet count 365 × 109/ L
Serum albumin 35 g/ L
Serum C- reactive protein (CRP) 67 mg/ L
Anti- neutrophil cytoplasmic antibodies:
c- ANCA Negative
p- ANCA Weakly positive
PR3- ANCA 8 U/ mL (<10)
MPO- ANCA 4 U/ mL (<10)
Which of the following is the most likely diagnosis?
A. Dermatitis herpetiformis
B. Erythema nodosum
C. Mycobacterium tuberculosis
D. Pyoderma gangrenosum (PG)
E. Sweet’s syndrome
CHAPTER 7 | QUESTIONS
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26. An 18- year- old man with a childhood diagnosis of small bowel CD
attended the emergency department with a painless, erythematous
right eye. His vision was reported to be unchanged.
What is the most likely diagnosis?
A. Anterior uveitis
B. Episcleritis
C. Intermediate uveitis
D. Posterior uveitis
E. Scleritis
27. A 29- year- old with small bowel CD attended clinic. He was opening his
bowels two to three times per day and reported mild right iliac fossa
discomfort. His primary complaint was fatigue, which was having an
impact on his work as a teacher.
Investigations:
Haemoglobin 103 g/ L
MCV 77 fL
Platelet count 475 × 109/ L
Ferritin 85 μg/L
Iron 8.9 umol/L
Serum albumin 32 g/ L
Serum C- reactive protein (CRP) 17 mg/ L
Which is not an indication for intravenous iron as rst- line treatment in
IBD patients with clinically active disease?
A. Patients on erythropoiesis- stimulating agents
B. Patients with a previous intolerance to oral iron
C. Patients with acute are of disease
D. Patients with Hb <100 g/ L
E. Patients with previous intestinal resection
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
28. A 42- year- old man with UC enquired about colonoscopy surveillance
for CRC. He was diagnosed with pancolitis 12years ago. He took
mesalazine 4 g daily for maintenance therapy. His paternal uncle and
a rst cousin had developed CRC. Acolonoscopy performed two years
ago for screening was macroscopically normal, but biopsies reported
extensive colitis with moderate microscopic activity (Nancy Histology
Index Grade 3).
Regarding colonoscopy surveillance, which of the following statements is
most accurate?
A. He is overdue a colonoscopy by one year
B. Left- sided colitis at the time of diagnosis warrants a screening colonoscopy at ve years
C. Post- inammatory polyps require annual surveillance
D. Surveillance should be scheduled for one year’s time
E. The family history of CRC warrants ve- yearly colonoscopy
29. A 43- year- old man with a 12- year history of pancolitis was overdue
colonoscopic surveillance. He enquired about his personal risk of CRC.
With respect to CRC and IBD, which statement is most accurate?
A. IBD patients diagnosed with CRC are older than sporadic CRC patients
B. Only IBD patients with a family history of CRC are at risk of developing malignancy
C. Patients with Crohn’s colitis have a higher risk of CRC than those with UC
D. Risk factors associated with UC- related CRC include pancolitis and male sex
E. Women have a preponderance to IBD- related CRC
30. A paediatric gastroenterologist wrote to you, asking you to take over
the care of a 16- year- old with two previous resections for small bowel
CD. He was maintained on azathioprine and IFX.
Which of the following statements is most accurate?
A. Ajoint paediatric- adult clinic, as part of a transition programme, is the ideal model
B. Atransition coordinator is only necessary for inter- hospital transfers
C. Consultations with adolescent patients should focus on disease and its treatment, in order
to avoid creating uncomfortable discussions about physical, emotional, educational, and
sexual development
D. Transfer of care is best achieved through a formal written handover
E. Transition should occur on completion of education
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31. A 24- year- old woman with UC is very well controlled on azathioprine
100 mg/ day and mesalazine 2 g/ day. She discovers that she is 10 weeks
pregnant and attends clinic concerned about her medications.
What would be the best advice for this patient?
A. Continue current medications
B. Halve the dose of azathioprine
C. Stop azathioprine
D. Stop azathioprine and mesalazine
E. Stop mesalazine
32. A 28- year- old lady with extensive UC was commenced on IFX
11months previously because of active disease despite mesalazine and
azathioprine therapy. She had subsequently been in clinical remission
for the past eight months. She wished to consider starting a family
imminently. She had not undergone any prior operations.
Investigations:
Colonoscopy Quiescent colitis, no macroscopic or microscopic evidence
of inammation.
What would be the most appropriate advice regarding
discontinuing IFX?
A. Continue treatment throughout pregnancy and breastfeeding, even if in disease remission
B. Stop three months prior to conception
C. Stop as soon as conception known if remains in disease remission
D. Stop at end of rst trimester (approx. 12 weeks’ gestation) if remains in disease remission
E. Stop at end of second trimester (approx. 26 weeks’ gestation) if remains in disease
remission
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
33. A 65- year- old woman with metastatic melanoma received four cycles
of combination immunotherapy including ipilimumab (anti- CTLA- 4)
and nivolumab (anti- PD1), which commenced 50days ago. She was
referred with two days of watery, non- bloody stool (six times per day)
and abdominal discomfort. She was taking methotrexate, folic acid, and
naproxen for rheumatoid arthritis. She also recently completed a week’s
course of co- amoxiclav for a chest infection.
Investigations:
Haemoglobin 130 g/ L
Haematocrit 44%
WCC 10.0 × 109/ L
Platelet count 389 × 109/ L
Erythrocyte sedimentation rate 8mm/ hr
Albumin 32 g/ L
Serum C- reactive protein (CRP) 9 mg/ L
Flexible sigmoidoscopy Patchy erythema and partial loss of vascular pattern
with small supercial ulcers from rectum to splenic
exure (Fig. 7.2).
Fig.7.2 Endoscopic image of sigmoid colon. See also Plate 13
Image courtesy of Dr Vincent Cheung, Oxford University Hospitals NHS Foundation Trust
Which is the most likely diagnosis?
A. Clostridiodes dicile- associated diarrhoea
B. Immunotherapy- associated colitis
C. Lymphocytic colitis
D. NSAID- associated enterocolitis
E. UC
CHAPTER 7 | QUESTIONS
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34. A 72- year- old woman presented to the emergency department. Twentyfour hours earlier, she developed acute onset, severe left- sided abdominal
pain, rectal bleeding, and loose stools. The pain since reduced and was
now more diuse. Her medication included lisinopril for hypertension,
bisoprolol for atrial brillation, and diclofenac for osteoarthritis. She
nished one week of amoxicillin for a chest infection 10days ago.
Examination revealed a tender left lower quadrant with guarding.
Her temperature was 37.8°C, blood pressure 98/ 60 mmHg, pulse 105
beats per minute, respiratory rate 16, oxygen saturations 98% on room air.
Investigations:
Haemoglobin 128 g/ L
Platelet count 365 × 109/ L
Serum C- reactive protein (CRP) 10 mg/ L
Serum albumin 34 g/ L
Lactate 3.5mmol/ L
Faecal culture Negative
Flexible sigmoidoscopy (Fig. 7.3)
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Fig.7.3 Endoscopic image of sigmoid colon. See also Plate 14
Courtesy of Oxford University Hospitals NHS Foundation Trust
What is the most likely diagnosis?
A. CD
B. Ischaemic colitis
C. NSAID- induced colitis
D. Pseudomembranous colitis
E. UC
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