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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
35. A 36- year- old woman presented with rectal bleeding, tenesmus,
and mucus discharge three years after a temporary loop ileostomy
for refractory colonic CD. After surgery, she was managed in the
community without further symptoms or medical therapy. She
underwent ileoscopy, at which the mucosa was macroscopically normal.
At exible sigmoidoscopy, a diagnosis of diversion colitis was made.
What is the best management option?
A. Acetarsol suppositories
B. Azathioprine
C. Mesalazine enemas
D. Oral corticosteroids
E. Short- chain fatty acid enemas (SCFAs)
36. A 65- year- old woman presented to her GP with a four- year history of
watery diarrhoea.
Her only comorbidity was depression, which was managed with
sertraline.
Investigations:
Haemoglobin 132 g/ L
WCC 4.6 × 109/ L
Platelet count 470 × 109/ L
MCV 88.1 fL
Serum sodium 137mmol/ L
Serum potassium 3.8mmol/ L
Serum urea 7mmol/ L
Serum creatinine 89 µmol/ L
Anti- tissue transglutaminase antibodies 9 U/ ml
Plasma thyroid- stimulating hormone 3.4 mu/ L
Faecal microscopy, culture, and sensitivities Negative
Faecal elastase 405 µg/ g
Colonoscopy Normal
Colonic histology Pending
Which of the following histological ndings would be most in keeping
with a diagnosis of collagenous colitis?
A. Focal active cryptitis
B. Greater than 20 eosinophils per high- powered eld
C. Greater than 20 lymphocytes per 100 epithelial cells
D. Preservation of crypt architecture
E. Subepithelial collagen layer 6 µm in thickness
CHAPTER 7 | QUESTIONS
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169
37. An 82- year- old diabetic woman was referred to the acute medical
take with severe diarrhoea and abdominal pain. She was a nursing
home resident and had recently completed a course of clindamycin
for a chronic infection of her third metatarsal. Clostridiodes dicile was
conrmed.
What is the overall sensitivity of glutamate dehydrogenase assay?
A. 78%
B. 80%
C. 85%
D. 91%
E. 96%
38. A 19- year- old British man spent the summer working as a water- sports
instructor in America. He had no medical background. On his return, he
presented to his GP complaining of an intermittent patch of raised itchy
skin, which appeared and disappeared in a matter of hours, at dierent
sites on his back. He had had an area of inamed skin between his toes
while abroad. He attributed this to a fungal infection.
He also complained of diarrhoea.
Investigations:
Haemoglobin 156 g/ L
MCV 92 fL
WCC 10.2 × 109/ L
Neutrophil count 6.5 × 109/ L
Lymphocyte count 1.7 × 109/ L
Eosinophil count 1.6 × 109/ L
Basophil count 0.04 × 109/ L
Platelet count 420 × 109/ L
Faecal microscopy and culture Negative × 3
Which treatment is the most appropriate?
A. Corticosteroids
B. Filaricides
C. Ivermectin
D. Metronidazole
E. Tiabendazole
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
39. A 45- year- old software engineer in France presented with a seven- day
history of bloody diarrhoea, no vomiting, and severe abdominal pain. He
was opening his bowels seven times a day and had a temperature of 39oC.
Investigations:
Haemoglobin 140 g/ L
WCC 15.1 × 109/ L
Serum C- reactive protein (CRP) 120 mg/ L
Urea 12.1mmol/ L
Creatinine 130 µmol/ L
Which organism is the most likely cause of this patient’s symptoms?
A. Campylobacter jejuni
B. Clostridiodes dicile
C. Norovirus
D. Salmonella typhi
E. Shigella
40. A 32- year- old South African man recently moved to the UK and
presented with a 12- day history of fevers and watery diarrhoea up to 20
times a day.
Investigations:
Haemoglobin 100 g/ L
WCC 0.9 × 109/ L
CD4+ lymphocyte count 42/ µL
Serum C- reactive protein (CRP) 120 mg/ L
Urea 15.1mmol/ L
Creatinine 120 µmol/ L
HIV antibody Positive
Flexible sigmoidoscopy Erythema, loss of vascular pattern and multiple,
well- dened, punched out ulcers throughout the
What is the best treatment option?
A. Clarithromycin and ethambutol
B. Intravenous foscarnet
C. Intravenous ganciclovir
D. Nitazoxanide
E. Supportive care including intravenous uids alone
left colon.
CHAPTER 7 | QUESTIONS
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41. A 75- year- old man is referred by his GP with iron- deciency anaemia.
Because he is t, active, and independent, with no other medical
comorbidities, it is decided that an upper and lower gastrointestinal
endoscopy is warranted.
Investigations:
Haemoglobin 102 g/ L
MCV 72 fL
Iron level 8.2 umol/ L
Transferrin 3.13 g/ L
Transferrin saturation 12%
Ferritin 9 μmg/ L
Gastroscopy Normal
Duodenal biopsies Normal
Colonoscopy
Histology
What is the most appropriate follow- up for this patient?
A. Colonoscopy in one year’s time
B. Colonoscopy in two years’ time
C. Colonoscopy in three years’ time
D. Colonoscopy in ve years’ time
E. No surveillance
1.5cm pedunculated polyp in the transverse
colon, snared and retrieved.
15mm tubulovillous adenoma with no lowgrade dysplasia.
42. A 42- year- old male patient attended clinic. He was diagnosed with
acromegaly in his early twenties. He did not complain of any bowel
symptoms, but had read about an increased risk of developing CRC.
His screening colonoscopy at age 40years demonstrated one 3mm
hyperplastic polyp that was completely excised from the sigmoid colon.
He was otherwise healthy and his body mass index (BMI) was 25kg/ m2.
Investigations:
Thyroid- stimulating hormone 2.4 mU/ L
Insulin- like growth factor- 1 42.6nmol/ L
Fasting plasma glucose 4.9mmol/ L
Which of the following is the most appropriate with regard to ongoing
surveillance?
A. Two- yearly colonoscopy
B. Three- yearly colonoscopy
C. Five- yearly colonoscopy
D. Ten- yearly colonoscopy
E. Annual colonoscopy
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
43. A 35- year- old woman presented with a history of chronic diarrhoea.
She was referred for a colonoscopy. Multiple polyps (around 50)were
found in the ascending and transverse colon. You asked about her family
history and she revealed that her great uncle died of bowel cancer and
her nephew recently had bowel surgery for polyps. Both her parents,
aged 65 and 70years, and her two brothers, aged 45 and 42years, were
healthy.
Which of the following is the most likely diagnosis?
A. Familial adenomatous polyposis
B. Hereditary non- polyposis CRC
C. Juvenile polyposis syndrome (JPS)
D. MUTYH- associated polyposis (MAP)
E. Peutz– Jeghers syndrome
44. A 40- year- old female patient presented with a history of intermittent
central abdominal pain. Examination revealed freckles on her lips,
buccal mucosa, and eyelids. Her past medical history included breast
cancer diagnosed a year ago.
What would be the most appropriate next step?
A. Colonoscopy and genetic testing for breast cancer susceptibility gene 1 and breast cancer
susceptibility gene 2
B. Colonoscopy and genetic testing for serine/ threonine kinase 11 gene mutation
C. Colonoscopy and mammogram
D. CT chest, abdomen, and pelvis
E. Urgent colonoscopy
45. A 56- year- old man attended for a colonoscopy for a change in
bowel habit.
Investigations:
Colonoscopy Multiple serrated polyps. 24 polyps counted in total; majority
Histology A mix of sessile serrated lesions without dysplasia and
What surveillance interval would you recommend for this condition?
A. One year
B. Three years
C. Five years
D. Endoscopic surveillance interval dependent on family history
E. Surveillance timing stratied according to the presence of an associated genetic mutation
right sided (8 transverse, 6 ascending) with largest measuring
11mm. All polyps measuring more than 5mm were removed.
hyperplastic polyps
CHAPTER 7 | QUESTIONS
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46. A 35- year- old woman was diagnosed with dyssynergic defecation.
Which of the following is the most eective treatment modality?
A. Biofeedback therapy (BFT)
B. Botulinum toxin injection
C. Diet
D. Laxatives
E. Myectomy of the anal sphincter
47. A 35- year- old woman complained of constipation for the past eight
months. She was treated with movicol and sodium docusate at the
maximum doses. This did not improve her symptoms.
Which is the most appropriate next drug to try?
A. Glycerol suppositories
B. Lactulose
C. Poloxamer drops
D. Prucalopride
E. Sodium phosphate enemas
48. A 49- year- old woman complained of accidental leakage of solid and
liquid stools for the past two years. There was no history of IBD.
However, she had been diagnosed with IBS. She had smoked 20
cigarettes a day for 28years. She had an episiotomy and vaginal forcepsassisted delivery at the age of 27years. On examination, she was
obese with a BMI 31kg/ m2. She had reduced anal tone on digital rectal
examination.
What is the strongest risk factor for faecal incontinence (FI) in
this woman?
A. Episiotomy
B. Forceps- assisted delivery
C. High BMI
D. IBS
E. Smoking
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
49. A 72- year- old woman underwent a colonoscopy because of abdominal
bloating and discomfort. The colonoscopy revealed brownish
discoloration of the colonic wall.
Colonic histology (Figs. 7.4 and 7.5)
Fig.7.4 Colonic histology specimen. See also Plate 15
Permission granted by Dr N.Ryley, Torbay Hospital; slides from his personal collection
Fig.7.5 Colonic histology specimen. See also Plate 16
Permission granted by Dr N.Ryley, Torbay Hospital; slides from his personal collection
The pigmentation found in the submucosa is most likely:
A. Haemosiderin
B. Iron sulphide
C. Lipofuscin
D. Melanin
E. Silicate
CHAPTER 7 | QUESTIONS
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50. A 51- year- old woman presented with a history of constipation for two
years. She opened her bowels every 4– 5days, passing hard and lumpy
stool; she also complained of abdominal pain and bloating. She denied
weight loss, fever, or bloody stools. There was no family history of
IBD and she had no past medical history of note. She subsequently
underwent a bowel transit study (Fig. 7.6).
175
Fig.7.6 Bowel transit study
Investigations:
Haemoglobin 125 g/ L
WCC 5.6 × 109/ L
Platelet count 290 × 109/ L
MCV 88.1 fL
Serum sodium 139mmol/ L
Serum potassium 3.9mmol/ L
Serum urea 6.7mmol/ L
Serum creatinine 89 µmol/ L
Anti- tissue transglutaminase antibodies 9 U/ mL
Plasma thyroid- stimulating hormone 3.4 mU/ L
Faecal microscopy, culture, and sensitivities Negative
Faecal elastase 405 µg/ g
Colonoscopy Normal
Colonic histology Normal
Ano- rectal manometry Normal
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CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS
Which of the following is the most likely diagnosis?
A. Dyssynergic defecation
B. Irritable bowel syndrome with predominant constipation (IBS- C)
C. Normal- transit constipation
D. Slow- transit constipation
E. Slow- transit constipation and dyssynergic defecation
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chapter
INFLAMMATORY BOWEL DISEASE AND
COLONICDISORDERS
7
ANSWERS
1. A. IFN- γ
• IBD is driven by dysregulated immune responses to environmental and microbial triggers
• IFN- γ and IL- 2 are produced in higher amounts in CD when compared with UC
Immunological factors play an important role in the pathogenesis of IBD. Chronic intestinal inammation
is driven by a dysregulated immune response to environmental and microbial triggers. Cytokines are
key mediators of cellular interactions in the intestine in both health and disease. Governed by cytokine
networks, epithelial barrier function, host defence pathways, immune regulation, and tissue repair are
key components of intestinal homeostasis. Disruption of these cytokine- guided networks can lead to
inammation, primarily by innate derived pro- inammatory cytokines and subsequent IBD.
Exposure to foreign antigens leads to activation of naïve CD4+ cells that dierentiate into either
Th1 cells, Th2 cells, or Th17 cells. Th1 cells produce pro- inammatory cytokines:IL- 2, IL- 6, IFN- γ
and tumour necrosis factor- alpha (TNF- α). Production of IL2 diers in CD versus UC. Mucosal
T- cells in CD produce more IL- 2, suggesting a more signicant response and T- cell function in CD.
Increased production of IFN- γ is also seen in CD, however not UC, supported by evidence of
increased levels of IL- 12 and IL- 18 (which induce IFN- γ) in CD. IL- 6 is expressed in abundance in
IBD mucosa. Its roles include immune cell activation, inhibition of apoptosis, and induction of Th17
cell dierentiation. Increased TNF- α activity weakens epithelial barrier function through alteration
in epithelial integrity and apoptosis of intestinal epithelial cells. Compromise of the barrier function
and microbial dysbiosis are key events in the initiation of IBD.
In UC, pro- inammatory cytokines IL- 5 and IL- 13 (derived from Natural Killer T [NKT] cells) are
produced in substantially higher amounts. In colitis, IL- 12 and IL- 23, produced by macrophages, drive
pathogenic T- cell responses in part due to deciencies in anti- inammatory IL- 10 and TGF- β pathways.
Th17 cells participate in the inammatory response by producing multiple cytokines, including IL- 17 in
conjunction with IL- 21, IL- 22, and IL- 23. IL- 17 leads to the induction of pro- inammatory cytokines
via stimulation of Th1 cells. Increased IL- 17 expression is seen in most patients with IBD. However,
it is consistently higher in those with CD than UC. IL- 22 promotes epithelial repair and antimicrobial
defence.
Friedrich M, Pohin M, Powrie F.Cytokine networks in the pathophysiology of inammatory bowel
disease. Immunity. 209;50(4):992– 006. Doi:0.06/ j.immuni.209.03.07.
2. B. 10%
• The greatest risk factor for the development of IBD is an aected rst- degree relative (FDR)
• Genetic susceptibility is greater in CD
• If only one parent has IBD, the risk is 9% and 6% for ospring CD and UC respectively
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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