A 25-year-old medical student presents with a 2-month history of abdominal pain and diarrhoea. She has no family history of bowel conditions, has not traveled recently, and has no sick contacts. During colonoscopy, seven polyps measuring <5 mm in diameter are found proximal to the sigmoid colon and removed for further analysis. Which of the following conditions linked to bowel polyps is considered non-hereditary?
A 68-year-old woman is admitted to the Surgical Unit with a painful, distended abdomen. The pain started 4 days ago and was initially colicky in nature but is now continuous. She has vomited several times and only emptied her bowels once in the last 3 days, which is unusual for her. She had a laparoscopic cholecystectomy 3 weeks ago, from which she made a rapid recovery. There is no past medical history of note. On examination, she appears unwell. The abdomen is tender and mildly distended. Bowel sounds are reduced. Observations: pulse rate 119 bpm, blood pressure 130/90 mmHg, temperature 38.7 °C.
What is the single most appropriate management for this patient?
A 42-year-old woman comes to her General Practitioner complaining of severe pain during bowel movements and passing fresh red blood while opening her bowels for the past 2 weeks. She is experiencing slight constipation but is otherwise healthy and has no significant medical history.
What would be the most suitable course of action for her management?
A 73-year-old woman with a history of diverticular disease undergoes emergency abdominal surgery. When examining this patient after her surgery, you notice she has an end colostomy.
What feature in particular will suggest that this patient has had a Hartmann’s procedure and not an abdominoperineal (AP) resection?
A 68-year-old man presents to the General Surgical Outpatient Clinic with a 4-week history of altered bowel habit. There is no history of rectal bleeding, although faecal occult blood testing is positive. He denies any other symptoms from the abdominal point of view, and his general examination is otherwise unremarkable.
You discuss this case with the patient and agree that the next best step would be to undergo a colonoscopy and some blood tests. The results are shown below:
Bloods:
Investigation Result Normal value
Haemoglobin 112g/l 135–175 g/l
White cell count (WCC) 7.2 × 109/l 4–11 × 109/l
Platelets 205 × 109/l 150–400 × 109/l
Urea 4.5 mmol/l 2.5–6.5 mmol/l
Creatinine 71 mmol/l 50–120 μmol/l
Sodium (Na+) 135 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Endoscopy Report:
The endoscope was passed to the caecum without complication. The caecum was identified with confidence as the ileocaecal valve and appendicular orifice were seen and also confirmed with transillumination. There are multiple diverticulae seen in the sigmoid colon. A large ulcerated and haemorrhagic lesion resembling a tumour was found at the splenic flexure. Multiple biopsies were taken and sent for histology. Small polyp found in ascending colon, snared without complication.
Follow-up with histology results in General Surgery Clinic in one week. Histology to be discussed at the next gastrointestinal multidisciplinary meeting.
The histology results come back as adenocarcinoma of the colon involving the splenic flexure. Further staging reveals no initial metastatic disease.
Which of the following is the next best course of action?
A 32-year-old man with inflammatory bowel disease undergoes emergency surgery involving resection of a portion of his bowel. At the clinico-pathological conference, the histological findings of the operative sample are discussed.
Which of the following features is most indicative of Crohn’s disease?
A 68-year-old man presents with sudden-onset abdominal pain, rectal bleeding and diarrhoea. On examination, he appears uncomfortable, with a heart rate of 105 bpm, blood pressure 124/68 mmHg, oxygen saturations on room air of 95%, respiratory rate of 20 breaths per minute and a temperature of 37.4 °C. His cardiovascular and respiratory examinations are unremarkable, except for a previous median sternotomy scar. Abdominal examination reveals tenderness throughout the abdomen, which is significantly worse on the left with guarding. Urgent blood tests are taken, and chest and abdominal X-rays are performed. The chest X-ray is normal, except for an increased cardiothoracic ratio, but the abdominal X-ray shows thumbprinting in the left colon but an otherwise normal gas pattern.
What is the most probable diagnosis?
A 65-year-old man presents to the clinic with three positive faecal occult blood specimens. He has had no significant symptoms, apart from mild fatigue over the past few months.
On examination, he has pale conjunctiva, but there are no other specific findings.
Investigations:
Investigation Result Normal value
Haemoglobin 105 g/l 135–175 g/l
Mean corpuscular volume (MCV) 79 fl 76–98 fl
White cell count (WCC) 4.5 × 109/l 4–11 × 109/l
Platelets 275 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 11 mm/hour 0–10mm in the 1st hour
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 100 μmol/l 50–120 µmol/l
Alanine aminotransferase (ALT) 35 IU/l 5–30 IU/l
Alkaline phosphatase 46 IU/l 30–130 IU/l
Flexible colonoscopy: abnormal vessels visualised on the right side of the colon
Which of the following is the initial therapy of choice?
You are the F2 in the Surgical Outpatient Clinic and have been asked to see Mrs Jones by the consultant. Mrs Jones is a 56-year-old lady who presents with trouble defecating, and although she still passes her motions normally, over the past month, she has noticed the uncomfortable feeling of still wanting to defecate after passing her motions. During the past 2 weeks, she has noticed she has been passing mucous and some blood but no change in colour. Examination is unremarkable.
Which of the following does the National Institute for Health and Care Excellence (NICE) guidance recommend as an initial investigation?
At an outpatient clinic, you see a 30-year-old patient referred by a gastroenterologist for a colectomy. The referral letter mentions that the patient has been screened for a genetic abnormality and that a mutation was found in a gene on chromosome 5q21.
What is the most likely underlying condition?