Here’s the second part of the altered bowel habit question set we have. Make sure you don’t get stuck and miss the first part on constipation presentations!
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Stem 1 of 6
A 73YO male presents with severe diarrhoea, exhausted and weak. He is feverish with cramping, diffuse abdominal pain. History is notable for LRTI, for which he was successfully treated with ciprofloxacin orally in the community two weeks ago. His obs are T38.5ºC ; HR90 ; RR17 ; pO299% air ; BP140/95 ; GCS15 ; BM 4.5mmol/L
Given the most likely differential, what pathological process best explains the patient’s colitis?
Dendritic presentation to GALT
Inhibition of the chloride antiporter.
Overexpression of gp120 coreceptor.
Secretion of enterotoxin A and B.
Upregulation of ACE-2 receptor.
Question 1 Explanation:
The patient is likely to have a clostridium difficile acquired infection. This is causing colitis due to secretion of CD-mediated enterotoxin A and B. The chloride anti porter is implicated in cystic fibrosis. Gp120 is implicated in HIV. ACE-2 receptor is implicated in SARSCoV2 transmission and the presentation of epitope by antigen presenting cells is not the cause of the colitis, but a response to it.
Stem 2 of 6Select all the options that may apply to help confirm the diagnosis
36.9ºC tympanic temperature
Toxic megacolon on AXR
Ulcerated mucosa on endoscope
Yellow plaques on endoscope
Question 2 Explanation:
The patient would be expected to have an elevated temperature, decreased albumin, increased white cell/acute phase proteins. On scope you would find the characteristic “pseudomembrane” of CDI which is notable for a yellow adherent plaque and non ulcerating mucosal lesions. Toxic megacolon would be observable on plain X-ray, progressing to multi organ dysfunction.
Stem 3 of 6The physician orders an ELISA to confirm the diagnosis of CDI. What is the common antigen sought in this investigation?
Stem 4 of 6What further tests are required to distinguish non-pathological carriage from CDI?
Electron microscopy of stool
ELISA of toxin
NAAT of toxin
No further tests required
PCR of toxin
Question 4 Explanation:
Immunoassay and NAAT of the toxin (Enterotoxin A and B) are pathognomonic hallmarks of CDI.
Stem 5 of 6Which of the following are appropriate management techniques of CDI?
Isolate the patient within four hours
Mild CDI treated with vancomycin PO
Non-responders to therapy require metro+vanco IV
Severe CDI treated with metronidazole PO
Test within four hours
Question 5 Explanation:
According to the Oxford Handbook of Clinical Medicine 10thEd, a handy mnemonic is appropriate for the initial response to ?CDI = SIGHT aka suspect, isolate in 2hr, glove and apron (PPE), hand wash with soap, test immediately. Thus the isolation and testing windows are inappropriately slow. Mild CDI should be treated with PO metronidazole, with severe PO vancomycin monotherapy first line - consult Trust guidelines and changing NICE each year. Non-responsive CDI requires dual therapy of both the aforesaid medications with IV administration route.
Stem 6 of 6Which of the following would indicate a colectomy?
Deteriorating NEWS score despite monotherapy
Elevated LDH levels
Increasing albumin levels on serial screen
Yellow plaque on scope
Question 6 Explanation:
Increasing albumin is a good finding in CDI. Yellow plaques are hallmarks of the infection, but not alone an indication for surgery. Deterioration of the patient, toxic megacolon and climbing LDH levels all suggest a patient who is a good candidate for colectomy to ablate the nidus.
Stem 1 of 4
A 50 year old obese, hypertensive female presents with left lower quadrant pain. Her abdomen is tender in the left flank and constipation is reported for the last day. She has had some rectal bleeding (bright red) that quickly arrested. She is feverish and routine bloods reveal leukocytosis and elevated acute phase protein.
Which of the following definitions are true?
Diverticular are outpouchings of gut wall
Diverticular rarely occur at the site of entry of perforating arteries
Diverticulitis is most commonly seen in the sigmoid colon
Diverticulosis refers to the presence of diverticula
LLQ pain and frank blood in middle age females with low grade fever is common for diverticulosis
Question 7 Explanation:
Diverticulosis is usually asymptomatic, but when inflamed as in diverticulitis, the common presentation is as described in the textbooks. The terminology here can be tricky at first glance.
Stem 2 of 4What is the strongest risk factor of diverticular disease?
Age over 50 years old
A sodium and glucose-rich diet
Low dietary fibre
Obese type I BMI
Use of naproxen
Question 8 Explanation:
Advancing age is the strongest association found for diverticular disease. As many as ⅔ of all Westerners over the age of 60 have diverticulosis on incidental colonoscopy. To most it will not flare into acute diverticulitis. All others listed are risk factors for diverticular disease, but not currently as strongly associated as age.
Stem 3 of 4Given the best-matched diagnosis, what is the most diagnostic test?
Abdominal X ray
Question 9 Explanation:
In acute diverticulitis, the risk of perforation is too great for a scope without specialist guidance. The best modality for resolution would, therefore, be CT abdomen in this case to confirm the diagnostic hypothesis.
Stem 4 of 4Which of the option(s) below are best to manage this patient?
Bowel rest (NPO)
Changing diet to low residue
Question 10 Explanation:
Rest the bowel, give counsel on low residue diet to reduce stool volume and frequency, provide adequate simple analgesia and prescribe oral antibiotics at clinical diagnosis for uncomplicated, acute diverticulitis.
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