😀 EASY

Here is a nice, simple quiz on constipation.  There will be a second part on diarrhoea appearing later.  So for now, get your gloves on, grab yourself a Bristol Stool Chart and lets head to the murky world of altered bowel habits … 

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constipation

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Question 1

Stem 1 of 4

A patient comes to his GP with constipation and pain in the LLQ for 3 months. He feels “a little thin” and exhausted. His ICE includes a fear his father started seeing blood in his faeces before dying of rectal cancer.

Given the presentation above, which is the least specific finding that would correlate to the best-matched differential?
A
Age of the patient
B
Palpable rectal mass
C
Rectal bleeding
D
Reduced frequency of open bowels
E
Weight loss
Question 1 Explanation: 
Strong indications of CR cancer are advanced age, male sex, palpable mass (majority of patients), rectal bleeding associated with change in bowel habit. Weight loss is usually indicative of late stage disease. Anaemia is more associated with right-sided colonic cancer (90% of patients).
Question 2

Stem 2 of 4

Which of the following is not a first line investigation to order in this patient?
A
Carcinoembryonic antigen (CEA)
B
Contrast barium enema
C
FBC
D
LFT
E
sCreat
Question 2 Explanation: 
CEA is only used in follow-up to assess the efficacy of treatment regimen. It is not sensitive or specific enough to guide diagnosis. • A full blood, liver, renal screen with contrast enema, colonoscopy and CT TAP are indicated first line in ?CR cancer patients.
Question 3

Stem 3 of 4

A colonoscopy is performed and a sigmoidal mass is located. What is the root value most associated with the referred pain of this patient?
A
T8
B
T9
C
T10
D
T11
E
T12
Question 3 Explanation: 
T5-9 are associated with foregut structures. T10-11 are usually associated with midgut structures. T12-L1/2 are usually associated with hindgut structures.
Question 4

Stem 4 of 4

Staging of the tumour reports: T3N0M0. What is the first line management?
A
EGFR inhibitor
B
Preoperative chemotherapy
C
Sigmoid stenting
D
Surgical resection
E
VEGF inhibitor
Question 4 Explanation: 
EGFR and VEGF inhibitors are more commonly given as adjuncts in metastatic (stage IV) colorectal cancer. These have been found to decrease progression and increase survival to 5 years. • Stenting is an option more often considered in non-operative cancer of the colon. • The first line therapy in localised CR cancer is surgical resection - in this case a colectomy with regional nodal dissection.
Question 5

Stem 1 of 2

A patient is recovering after an emergent exploratory laparotomy. Surgical examination was normal and the procedure had no complications. He is constipated and on the highest titre of morphine possible.

The patient is co-prescribed medications to limit side effects. Which of the following options would you consider least appropriate?
A
Bisacodyl
B
Ispaghula husk
C
Lactulose
D
Macrogol
E
Senna
Question 5 Explanation: 
Stimulant and osmotic laxatives are the first line for managing opiate-induced constipation. A bulk-forming laxative is contraindicated.
Question 6

Stem 2 of 2

Which physiological receptors contribute to opiate-induced constipation?
A
Alpha-opiate receptor
B
Beta-opiate receptor
C
Delta-opiate receptor
D
Kappa-opiate receptor
E
Mu-opiate receptor
Question 6 Explanation: 
Both delta and mu subclasses of opiate receptors are strongly upregulated on enteric nervous system neurons. They both bind endogenous/exogenous opiates readily. This inhibits peristalsis, causing intraluminal stasis.
Question 7
A patient presents with a two month history of constipation. His stool is described as:
a single mass that is about 4cm wide and causes significant straining with some anal canal laceration. The patient states they have had more flatus recently.

Calculate the patient Bristol Stool score
A
1
B
2
C
3
D
4
E
5
Question 7 Explanation: 
Type two are type one stools impacted together with a large diameter that causes anal trauma and PR bleed. They are very hard to pass, with resultant straining causing haemorrhoids and fissure-in-ano commonly. .
Question 8

Stem 1 of 3

Post-operatively, a patient is constipated and bloated. On auscultation, no bowel sounds are present.

Which electrolyte disturbance below are you particularly concerned about?
A
Serum calcium 2.3mmol/L
B
Serum chloride 100mmol/L
C
Serum magnesium 0.8mmol/L
D
Serum potassium 6.0mmol/L
E
Serum sodium 140.0mmol/L
Question 8 Explanation: 
Hyperkalaemia is associated with postoperative paralytic ileus. Remember that potassium is the main intracellular cation and repolarisation is contingent on efficient concentration gradients for potassium efflux. Any delay to action potential progression could manifest as slowing of the enteric nervous system and subsequent paralytic ileus - of course the arrhythmogenic nature of potassium is more of a concern acutely in this patient.
Question 9

Stem 2 of 3

The myenteric plexus is located in which plane of the gut wall?
A
Within the adventitia
B
Within the mucosa
C
Within the muscularis propria
D
Within the serosa
E
Within the submucosa
Question 9 Explanation: 
The serosa and adventitia are often used synonymously - though strictly, the serosa should only be used when referring to peritoneal coverings. The mucosa is the deep-most mural layer consisting of the epithelium, lamina propria and muscularis mucosa. The submucosa consists of the submucosal enteric plexus of Meissner. The muscularis propria contains the myenteric plexus of Auerbach. The adventitia is the connective tissue, superficial-most of the wall.
Question 10

Stem 3 of 3

36hr after the procedure, the patient has a high fever and rigors. He has bibasal rales on auscultation and is coughing green sputum. Given the likely cause of the postoperative pyrexia, what is the most appropriate empirical therapy to commence?
A
Ceftriaxone
B
Coamoxiclav
C
Metronidazole
D
Nitrofurantoin
E
Trimethoprim
Question 10 Explanation: 
So soon after an operation, diaphragmatic ascension causing basal atelectasis, mucous stasis and lower lobar pneumonia is the most likely cause of the pyrexia. The mnemonic for the causes of postoperative pyrexia is: wind (aka pneumonia <2d), water (UTI at 3-4d), walking (5+ days suggesting DVT), wound (infection of the surgical site 5-7d) and wonder about medications (over a week for medication review). Ceftriaxone and metro would be started for a more tricky intra-abdominal visceral bacteria. Nitro and trimeth are suggestive of uncomplicated UTI.
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