GI for ISCEs. Lorna Roden. What we’re covering…. History and examination 3 cases – differentials, investigations and management Common ‘lists’ of differentials.
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Mrs Gladys Brown is a 69-year-old retired lawyer. She has been referred to your outpatient clinic complaining of tiredness and loss of energy. She initially thought this was due to looking after her grandchildren twice a week, but since stopping this the symptoms have persisted. She describes loose bowel motions for the last few months and has lost 12.5kg in weight
Mrs Brown has been tired and lethargic for the last month
She describes a 6 month history of watery loose stools, up to 3 times per day, associated with bloating and flatulence. There is no blood. She has had abdominal cramps intermittently for the last few years on most days.
She has lost 12.5 kg in weight over 6 months unintentionally. She suffers from mouth ulcers every winter but not regularly. There have been no new rashes or additional symptoms.
She takes aspirin, lisinopril and levothyroxine and beclometasone and salbutamol inhalers and is compliant with these.
She is retired, drinks 2 units of alcohol per month and has never smoked.
There is no recent travel history and no relevant family history.
Malabsorption and malnutrition
Parenchymal liver disease
Alcoholic liver disease
Primary biliary cirrhosis
Secondary metastatic cancer
Right heart failure
Subacute bacterial endocarditis
RA (Felty’s Syndrome)
Examination reveals angular stomatitis and a few mouth ulcers. The abdominal examination was unremarkable with no palpable organomegaly or mass. The DRE was normal with good anal tone and no masses.
AIMS: Confirm diagnosis, look for consequences, supportive factors
Emma Ritchie is a 24 year old secretary. She has suffered with increased frequency of bowel opening, up to 5 times a day, abdominal pain and feeling generally unwell for the last 6 months.
Pale, oily, malodorous and difficult to flush
Watery and liquid; high frequency
Black, tarry and malodorous
Upper GI bleeding
Bacterial overgrowth or microscopic colitis
Malabsorption of fat
Weight loss, anaemia and sustained ill health can rule this out
Alcohol history and family history
What extra-intestinal features can you think of?
Arthritis is more common in Crohn’s than in UC
Duration, extent of disease, severity of inflammation, family history of CRC, concomittant PSC
Active small bowel disease/extensive small bowel resection
Iron, folate, B12, fat-soluble vitamins (ADEK)
Predilection of Crohn’s for the ileum – bile salts spill into the colon and cause bile-salt induced diarrhoea
Fat maldigestion and steatorrhoea
This leads to predilection for renal calculi – calcium readily binds unabsorbed fatty acids, allowing oxalate to be taken up by the bowel in greater quantity
From extensive resection
Now that you know the features, extra-colonic features and complications of the disease what would you examine in the ISCE station if you suspected IBD?
For both UC and Crohn’s suggest an MDT approach
Asceptic necrosis of bone
Adrenal cortex suppression
False-negative skin test
Infection – especially TB (screen for this prior to administration), Hep B
↑ risk of lymphoma
Ciclosporin for disease not responding to steroids
Betty Smith is a 45 year-old teacher who presents to her GP with itching for a few years that has gradually got worse. Her neighbour has also noticed a yellow tinge to her eyes. She has a past medical history of hypothyroidism.
On examination the sclera are yellow and her chest and abdomen are mildly excoriated.