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Theme: Rectal bleeding?AAnal carcinomaBAnal fissureCAngiodysplasiaDColonic carcinomaEColonic polypFCrohn’s diseaseGDiverticular diseaseHHaemorrhoidsIInfective colitisJIschaemic colitisKPeri-anal haematomaLPeptic ulcerationMUlcerative colitis?The following patients have all presented with rectal bleeding. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 61-year-old renal transplant patient is referred to you on-call with acute-onset severe bloody diarrhoea. He appears clinically very unwell. He has no history of bowel problems.B Your answerI Correct answerI – Infective colitisCytomegalovirus colitis can cause severe diarrhoea and torrential, even life-threatening, rectal bleeding. This diagnosis should always be considered first in patients on immunosuppression. This and other infections are common problems in acquired immune deficiency syndrome – other responsible organisms include herpes virus, and Cryptosporidium.Scenario 2 Correct A 27-year-old woman is seen with a 3-day history of acute diarrhoea which she attributes to food-poisoning. Today she has attended because of fresh rectal bleeding on the paper after wiping and once in the pan, separate from the stool.H Correct answerH – HaemorrhoidsBright-red rectal bleeding in a young patient is invariably the result of haemorrhoids. Such bleeding is often triggered by trauma leading to ulceration of previously asymptomatic small piles. This can often be confirmed on proctoscopy in the acute phase but quite often you see the patient in outpatients weeks or months later when the problem has completely resolved. No further action need be taken.Scenario 3 Incorrect A 92-year-old woman presents with painless, bright-red rectal bleeding without other symptoms. Following a blood transfusion a barium enema is performed, the result of which is normal, and she is sent back to the nursing home. One week later, she rebleeds and returns to The Emergency Department. Again the bleeding settles, and after re-transfusion, she undergoes a gastroscopy and colonoscopy at which no abnormality is detected.K Your answerC Correct answerC – AngiodysplasiaThese are a type of arteriovenous malformation and are one of the common causes of significant lower gastrointestinal bleeding in the elderly population. As in this case, it is notoriously difficult to pinpoint the actual offending vessel. Where direct vision fails, mesenteric angiography or radionucleotide scans can sometimes be of diagnostic use but often also yield negative results if the vessel is not actively bleeding at the time of investigation. Should angiography demonstrate the source of bleeding, therapeutic embolisation can be performed. In cases of continued bleeding with negative investigations, treatment may involve total colectomy as a life-saving measure.Theme: Constipation?AColorectal carcinoma BConstipation-predominant irritable bowel syndromeCDiabetes mellitus constipationDEating disorders EFunctional faecal retention FHirschsprung’s disease GHypercalcaemia HHypothyroidism IIatrogenic drug therapyJIdiopathic megabowelKIdiopathic ‘slow-transit’LNeurogenic constipationMPelvic nerve injuryNOutlet obstructionOSevere depressionPSimple constipation?The following patients all present with constipation. From the list above, select the most likely diagnosis. The items may be used once, more than once, or not at all. Constipation is the second most common gastrointestinal symptom in the developed world. In most patients, low fluid intake, low dietary fibre, and lack of exercise or mobility may contribute to ‘simple’ constipation. However, constipation may be caused by ‘organic’ pathology when it occurs secondary to structural or systemic abnormalities. Organic causes may affect the gastrointestinal tract itself, eg mechanical obstruction secondary to carcinoma/stricture, and persistent dilatation of the bowel (megabowel) occurring without obvious cause (idiopathic) or secondary to Hirschsprung disease. Extragastrointestinal pathology may also cause constipation. Examples include endocrine/metabolic, neurological and psychological disorders. Constipation may also occur secondary to certain medication (opiates, antidepressants, anticholinergics, anticonvulsants). In the absence of an organic cause for constipation, the term ‘functional’ constipation is adopted to indicate disordered function of the hindgut. On the basis of physiological investigations, such patients may be divided into those with a delay in transit through all or part of the colon (slow transit constipation), and/or those with abnormalities of rectal evacuation (outlet obstruction) or those with no abnormality (constipation-predominant irritable bowel syndrome). The causes in the list provided may be classified using this system to provide a comprehensive differential diagnosis for constipation.Scenario 1 Incorrect A 53-year-old woman presents with a 2-year history of increasing difficulty passing stool. She currently opens her bowels daily or on alternate days. However, she has to strain excessively and often has to press on her perineum to achieve evacuation. She also reports a ‘bulge’ in the vagina when she gets constipated. She has attended clinic for the results of her recent investigations. Blood investigations and colonoscopy were normal.M Your answerN Correct answerN – Outlet obstructionThis patient has ‘functional constipation’, because investigations have excluded an organic cause. Constipation may refer to the infrequent and/or difficult passage of stools. A predominance of symptoms of difficult evacuation, which is often referred to as obstructed defaecation (eg excessive straining, a sensation of incomplete evacuation, digitation etc) is suggestive of outlet obstruction, rather than slow transit constipation, although physiological confirmation is required as symptoms do not accurately predict underlying pathophysiology. The history of perineal massage and a ‘bulge’ in the vagina (posterior wall) is suggestive of the presence of a rectocoele, which may lead to outlet obstruction, as a result of redistribution of evacuatory forces during defaecation.Scenario 2 Incorrect A 74-year-old man presents to the surgical clinic with a 2-month history of constipation. Previously, he opened his bowels daily, passing stool of ‘normal’ consistency, but his bowels have become irregular, and he has experienced episodes of ‘diarrhoea’ during the last few weeks. On direct questioning, he reported episodic fresh bleeding per rectum, which he attributed to his ‘piles’. B Your answerA Correct answerA – Colorectal carcinomaThis diagnosis must always be excluded in patients presenting with altered bowel habit. It is now clear that most patients with colorectal cancer who present with altered bowel habit report loose stools or diarrhoea. This represents ‘overflow’ of proximal bowel content because of narrowing of the lumen in the affected segment of bowel. Careful history taking often reveals a period of constipation preceding the change in stool consistency. It is unwise to attribute potentially sinister symptoms (eg bleeding per rectum) to ‘benign’ pathology (eg haemorrhoids) until proximal pathology has been excluded.Scenario 3 Incorrect A 22-year-old man with a history of constipation since early childhood attends The Emergency Department having not opened his bowels for the previous 3 weeks. He was admitted with similar symptoms several months ago, when a rectal biopsy was performed. This demonstrated normal ganglion cells in the myenteric plexus, and no other abnormality. On examination he appears well. Abdominal examination reveals a large mass arising in the pelvis and extending to the umbilicus.J Correct answerJ – Idiopathic megabowelPersistent dilatation of the bowel is known as megabowel. This may occur secondary to an absence of ganglion cells in the myenteric plexus (Hirschsprung disease), where failure of relaxation of the affected segment leads to gross proximal dilatation. Alternatively, no obvious cause may be identifiable, when it is termed idiopathic megabowel. This condition is characterised by severe infrequency of defaecation, with several weeks between bowel movements. There is usually associated passive leakage of stool as a result of ‘overflow’ around impacted stool in the rectum. The diagnosis is confirmed on barium enema, which reveals dilatation of the rectum, and sometimes colon. Management involves behavioural, medical and, rarely, surgical treatment.Theme: DiarrhoeaAAmoebic dysenteryBBacterial enterocolitisCColonic carcinomaDCrohn’s diseaseEDiabetesFIrritable bowel diseaseGGiardiasisHMalabsorptionINeuro-endocrine tumourJOverflow (faecal impaction)KPancreatic exocrine insufficiencyLPseudomembranous colitisMThyrotoxicosisNUlcerative colitisThe following scenarios describe patients with diarrhoea. From the above list choose the most appropriate cause. Each item may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 35-year-old woman presents with a 1-month history of passing bloody diarrhoea/mucus up to seven times per day and lower abdominal pain. She was previously fit and well and her problems started following an episode of food poisoning in Thailand. She has associated lethargy and weight loss. On examination, she appears pale and abdominal examination reveals some lower abdominal tenderness. Haemoglobin 9.8 g/dl, mean corpuscular volume 60, white cell count 13 x 109/litre, erythrocyte sedimentation rate 65, C-reactive protein 130. A stool culture is negative. Sigmoidoscopy demonstrates active proctitis.B Your answerN Correct answerN – Ulcerative colitisInterestingly, both ulcerative colitis and irritable bowel syndrome (IBS) appear to be triggered in a proportion of patients following acute enteritis (the entity of post-infectious IBS is well established). The symptoms and signs are those of an acute attack of colitis confirmed by sigmoidoscopy. Clearly, before steroids are administered, stool culture must be performed, however, as in this case.Scenario 2 Incorrect A 24-year-old man presents to clinic with a few months of diarrhoea and abdominal pain. At colonoscopy, there is patchy active inflammation affecting the transverse and right colon. Biopsies are reported as indeterminate colitis.M Your answerD Correct answerD – Crohn’s diseaseThis patient (on balance) has evidence of Crohn’s colitis. This is supported by rectal sparing and skip lesions within the colon. It is not infrequent for biopsies to have insufficient findings to conclusively support a diagnosis either of Crohn’s disease or ulcerative colitis and these are usually described as indeterminate.Theme: Types of colitisACollagenous colitisBCrohn’s colitisCDiversion colitisDInfective colitisEIschaemic colitisFLymphocytic colitisGPseudomembranous colitisHRadiation colitisIUlcerative colitis?The following patients have all been referred by their general practitioners with possible colitis. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 47 year-old woman with long-standing diabetes is seen with a 6-month history of colicky lower abdominal pain and watery diarrhoea. Her symptoms are intermittent; however, during ‘attacks’ she finds that she may open her bowel up to seven times a day with the passage of watery diarrhoea. These episodes are associated with lower abdominal pain and leave her feeling dehydrated and weak. So far she has had multiple blood tests, including erythrocyte sedimentation rate and C-reactive protein, which are normal. A colonoscopy is arranged which demonstrates a macroscopically normal looking colonic and terminal ileal mucosa. An OGD demonstrates duodenal villous atrophy.B Your answerA Correct answerA – Collagenous colitisThis is an uncommon form of colitis and is part of the disease spectrum termed microscopic colitis (the other main subdivision is lymphocytic). It is most common among middle-aged women and there is an association with autoimmune disorders such as coeliac disease, thyroid disorders, diabetes and rheumatoid arthritis. Patients typically present with symptoms and signs of colitis, as in the case described. Stool and blood investigations tend to be normal. Endoscopic examination of the bowel similarly appears normal to the naked eye and the disorder is generally diagnosed on histolological examination of biopsies taken at endoscopy – hence the name, microscopic colitis. No cure is yet available. Treatment is directed at reducing inflammation and the symptoms of diarrhoea by means of drugs such as sulphasalazine and mesalazine. Short courses of steroids may be required for severe cases.Scenario 2 Incorrect A 77-year-old man is seen in The Emergency Department with a 1-day history of sudden onset of severe lower abdominal pain, vomiting and passage of bloody diarrhoea. On examination he is pyrexial (temperature 38°C), tachycardic (pulse 105/min) and hypotensive (blood pressure 85/46 mmHg). He has severe left-sided tenderness and guarding on abdominal examination.E Correct answerE – Ischaemic colitis The case describes the classical triad of acute onset of abdominal pain, rectal bleeding and shock in an elderly patient. The patient may have atrial fibrillation or another factor such as cardiac or liver disease. Treatment involves resuscitation with intravenous fluids, blood and blood products before laparotomy, at which the affected segment of bowel is resected. However, this may not be possible if the whole of the mesenteric supply is affected (superior mesenteric occlusion with infarction of the small bowel and right side of the colon).Scenario 3 Incorrect A 47-year-old man is referred for elective colectomy. You catch the end of the pathology discussion, which concludes that he has DALMs (Dysplasia-associated lesion or mass).D Your answerI Correct answerI – Ulcerative colitisDALMs (dysplasia-associated lesion or mass) are polyps with surrounding dysplasia that can occur in chronic ulcerative colitis. They are significant indicators of carcinoma elsewhere in the bowel or at least its imminent development. They are therefore a strong indication for colectomy.Theme: Investigation of disorders of the large intestine?AAbdominal radiographBAnorectal physiologyCBarium enemaDColonoscopyEComputed tomography scan of chest, abdomen and pelvisFExamination under anaesthesiaGFlexible sigmoidoscopyHLaparoscopyILaparotomyJMesenteric angiographyKMagnetic resonance imaging of pelvisLProctoscopyMWater-soluble contrast enemaNUltrasound scan of liver?The following patients have all presented with disorders of the large intestine. Please select the next most appropriate investigative step in the management. The items may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 52-year-old woman is seen in the outpatient department. She has no specific complaints herself but is worried as her sister, who is 43 years old, has been diagnosed with an adenocarcinoma of the sigmoid. There is no other family history of note.D Correct answerD – ColonoscopyWhen assessing a patient’s risk of developing colorectal cancer (CRC), the family history is of paramount importance. A family history of CRC in a first-degree relative is a significant finding and the age at which the diagnosis was made is similarly of importance when quantifying a patient’s overall relative risk. So an individual with a first-degree relative diagnosed with CRC earlier than age 55 years has a relative risk that is two- to fivefold above that of individuals without a family history of CRC. In this case, the patient is categorised as at moderate risk of developing CRC during her lifetime and as such this warrants screening by colonoscopy. Moderate risk is defined as having:one first-degree relative affected by CRC before the age of 45 years two (one aged less than 55 years) or three relatives at any age affected by CRC or endometrial carcinoma who are first-degree relatives of each other and one a first-degree relative of the patient two affected first-degree relatives (one aged less than 55 years).Scenario 2 Incorrect A 54-year-old man is seen in the clinic for follow-up. He initially presented with rectal bleeding. Proctoscopy and rigid sigmoidoscopy performed at the time revealed a 1-cm benign-looking polyp, 15 cm from the anal verge, which was biopsied. The histology report reads ‘fragments of a moderately dysplastic villous adenoma’.D Correct answerD – ColonoscopyComplete examination of the colon is warranted as this patient is at a high risk of having synchronous adenomatous polyps and/or colorectal carcinoma. This is on the basis of the findings of an adenomatous polyp > 1 cm in diameter and villous histology. Other criteria include multiple (more than two) adenomas and adenomas with high-grade dysplasia. The incidence of a synchronous lesion in such a case is of the order of 2%. Such lesions may be detected by barium enema examination; however, colonoscopy has the advantage of allowing endoscopic polypectomy to be performed. So it is not only diagnostic, but also therapeutic. Further follow-up colonoscopy timings are outlined in the British Society of Gastroenterology (BSG) guidelines and depend on the findings.Scenario 3 Incorrect An 86-year-old woman is admitted to hospital with a history of sudden onset of severe rectal bleeding. She has been resuscitated but continues to bleed. An OGD has been performed, which is normal, and a colonoscopy is performed which demonstrates the presence of a large volume of blood in the lumen of the bowel. The endoscopist is unable to define the source of bleeding because of the view being obscured by active bleeding which could not be aspirated. She is currently stable, blood pressure 120/65 mmHg, pulse 85/min, and is receiving her fifth unit of blood.J Correct answerJ – Mesenteric angiographyMesenteric angiography is the logical next step in the management of a patient in whom colonoscopy has failed to detect the source of bleeding. This is of particular importance in an elderly patient who has evidence of significant ongoing bleeding, but who is cardiovascularly stable. Angiography relies on active bleeding for diagnosis, following which therapeutic embolisation of the offending vessel may be performed. Should the investigation fail to demonstrate the cause, and the patient continue to bleed, then laparotomy and colectomy may be nescassary as a life-saving procedure.Scenario 4 Incorrect A 49-year-old man is referred with a history of weight loss and anaemia. He has undergone a flexible sigmoidoscopy, which demonstrated a friable, annular constricting tumour in the descending colon. the endoscopist was unable to examine the colon proximal to this lesion. The histology, from biopsies taken, demonstrates adenocarcinoma.E Correct answerE – Computed tomography (CT) scan of chest, abdomen and pelvisThis patient has beeen diagnosed with colorectal carcinoma and as such the next step is to stage the disease process. This requires imaging of the liver and chest for metastatic disease. Isolated ultrasound scanning of the liver is insufficient and in fact the use of CT is recommended in national cancer services guidelines. Were the tumour to be rectal, magnetic resonance imaging of the pelvis should also be performed for local ‘T’ staging.Scenario 5 Incorrect A 63-year-old man is seen in The Emergency Department with a 4-day history of colicky lower abdominal pain, absolute constipation and distension. On direct questioning he admits to recent weight loss and rectal bleeding. On examination his abdomen is distended but soft. Plain radiography demonstrates large bowel distension.M Correct answerM – Water-soluble contrast enemaAlthough the vignette strongly points to malignant large bowel obstruction, and a laparotomy will almost certainly, therefore, be required, it is imperative to exclude pseudo-obstruction before risking a potentially unnecessary laparotomy. This can be achieved by an enema or by computed tomography scan with rectal contrast. In modern practice, it may also identify whether a stent can be deployed, especially in unfit elderly patients.Theme: Faecal incontinence?AColorectal carcinomaBDementiaCExtra-rectal or rectovaginal fistulaDFaecal impactionEInflammatory bowel diseaseFPudendal neuropathyGSphincter disruptionHSpinal cord lesionISystemic neuropathology?The following patients have all presented with faecal incontinence. From the above list choose the most appropriate cause. Each item may be used once, more than once, or not at all. The aetiology of faecal incontinence should be thought of as a disturbance to the passage or passenger. The ‘passage’ consists of the rectum, which stores and expels faeces when appropriate, and the anal canal which is composed of two rings of muscle (the internal and external anal sphincter) that relax to allow emptying. The pudenal nerve is a mixed nerve that provides motor function to the external anal sphincter, as well as sensation to the anal canal providing sensory input that forms part of a ‘sampling reflex’. The ‘passenger’ or faeces, if loose, will frequently result in incontinence even in the presence of a normally functioning anorectal sphincteric complex (as anyone who has experienced severe dysentery would know). Alternatively, sphincteric disruption may lead to incontinence even for normal stool.Scenario 1 Incorrect A 26-year-old woman is referred from her general practitioner with passive faecal incontinence following the birth of her child 3 months ago.A Your answerG Correct answerG – Sphincter disruptionObstetric trauma frequently results in a transient degree of faecal incontinence in the immediate post-partum period in up to a third of women but this incontinence subsequently improves. This is related to traction of the sphincteric complex and the pudendal nerve. An alarming proportion of women sustain occult sphincteric damage and evidence suggests that many third-degree tears (extending from perineum to involve the anal sphincter complex) are inadequately repaired.Scenario 2 Incorrect A 68-year-old man presents with new onset of faecal incontinence. He has been previously fit and well but now describes passing loose stools with an increased frequency.B Your answerA Correct answerA – Colorectal carcinomaIn this case the ‘passenger’ is responsible for causing faecal incontinence. This scenario highlights the importance of excluding all organic pathology in a patient who has few other symptoms indicating that they have a carcinoma. Any new symptoms or change in bowel habit in a patient over 45 years old should prompt thorough examination and investigation, before assessing for a functional pathology.Scenario 3 Incorrect A 60-year-old woman with four children presents with a 3-year history of worsening urge faecal incontinence. She had two prolonged, instrumented deliveries.B Your answerF Correct answerF – Pudendal neuropathyMultiple, traumatic vaginal deliveries will result in a stretch injury to the pudendal nerve. This results in a weakness in the external anal sphincter, causing attenuated squeeze pressure. Patients subsequently complain of an inability to defer defaecation (urgency) with incontinence. This lady might benefit from a low-dose of amitryptiline, which has been demonstrated to reduce rectal sensitivity, and biofeedback. In the absence of a discrete sphincteric lesion, there are few surgical procedures that have sustained benefit. In extreme cases, a colostomy may be the only option available to such patients.Theme: Fistula-in-ano (classification)AExtrasphinctericBHigh transsphinctericCIntersphinctericDLow transsphinctericEMid-transsphinctericFSubmucosalGSuprasphinctericThe following are descriptions of fistula-in-ano. Please select the most appropriate anatomical description from the list. The items may be used once, more than once, or not at all. Successful surgical management of anal fistulae depends upon accurate knowledge of anal sphincter anatomy and the fistula’s course through it. Failure to understand either may result in fistula recurrence or incontinence. The most comprehensive and practical classification is that devised by St Mark’s Hospital. Sir Alan Parks’s cryptoglandular hypothesis (1976) is central, holding first that the majority of fistulae arise from an abscess in the intersphincteric plane, and second that the relation of the primary tract to the external sphincter is paramount in surgical management. The classic diagram of various fistulae is a favourite of vivas where you might be asked to reproduce it.Scenario 1 Incorrect A 34-year-old man is undergoing an examination under anaesthesia for long-standing fistula-in ano. The operating surgeon notes that the internal opening is at the level of the dentate line, with the fistula thence traversing both sphincters to an external opening 4 cm fromthe anal verge.C Your answerE Correct answerE – Mid-transsphinctericTranssphincteric fistulae have a primary tract that passes through both sphincters at varying levels into the ischiorectal fossa where they may lead to ischiorectal abscess formation. The fistula may be described as high, mid- or low depending on where the fistula crosses the external sphincter, ie above, at, or below the level of the dentate line respectively.Scenario 2 Incorrect A 42-year-old man is referred to the outpatient clinic for a 7-month history of recurrent peri-anal pain and swelling followed by discharge of purulent fluid. Examination reveals a small opening, 1 cm from the anal verge. Palpation of the surrounding tissue suggests an indurated tract, passing from the opening through the internal anal sphincter to the dentate line. It does not seem to traverse the external anal sphincter.D Your answerC Correct answerC – IntersphinctericSepsis having developed within the intersphincteric plane, it follows the path of least resistance down the intersphincteric space, emerging at the peri-anal skin, resulting in an intersphincteric fistula (and often presenting acutely as a peri-anal abscess).Scenario 3 Correct A 28-year-old woman with extensive peri-anal Crohn’s disease, continuously experiences peri-anal discharge of sero-sanguinous fluid following drainage of an ischiorectal abscess. STIR-sequence magnetic resonance imaging scans reveals a tract passing through the ischiorectal fossa and levator ani directly into the rectum.A Correct answerA – ExtrasphinctericThese rare fistulae run without relation to the sphincters and are classified according to their pathology. They often originate from a segment of sigmoid diverticular disease or from ileal or sigmoid Crohn’s disease. They can also be created by injudicious probing of peri-anal sepsis (iatrogenic).Theme: Treatment of benign anorectal disorders?ABarrier creamBBotulinum toxin injectionCDiltiazem ointmentDDrainage setonEFistulotomyFFormaldehyde therapyGGlycerol trinitrate ointmentHHaemorrhoidectomyIIncision and drainageJInjection sclerotherapyKLateral internal anal sphincterotomyLMapping excisional biopsyMPrednisolone enemaNRubber-band ligation?The following patients have all presented with symptoms of an anorectal disorder. Please select the most appropriate treatment from the above list. The items may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 37-year-old man presents with a 6-month history of intermittent peri-anal pain and swelling followed by purulent discharge; he is fully continent. A later examination under anaesthesia reveals a fistulous tract, commencing at the dentate line, following an intersphincteric course.K Your answerE Correct answerE – FistulotomyThis patient has an intersphincteric anal fistula. Successful surgical management of anal fistulae depends upon accurate knowledge of anal sphincter anatomy and the fistula’s course through it; failure to understand either may result in fistula recurrence or incontinence. This patient’s fistula is amenable to fistulotomy (a procedure with a > 90% success rate), as it only encircles a proportion of the internal sphincter muscle fibres which when laid open are unlikely to result in significant continence disturbance.Scenario 2 Incorrect A 19-year-old woman presents with a 2-month history of pain and fresh bleeding on defaecation; her past medical history includes cluster headaches. Examination reveals a peri-anal sentinel skin tag at the 12 o’clock position; proctoscopy cannot be performed because of patient discomfort.B Your answerC Correct answerC – Diltiazem ointmentThis patient has an anal fissure the initial management of which is medical. 50–70% of patients who apply 0.2% glyceryl trinitrate ointment three times daily for 8 weeks have significant symptomatic improvement/healing. Unfortunately, one of the side-effects is severe headaches which may result in poor patient compliance. In this situation 2% diltiazem ointment, which is equally efficacious but more expensive, is recommended. Scenario 3 Incorrect A 62-year-old woman presents 3 months after repeat injection sclerotherapy of haemorrhoids with an ongoing history of passing fresh blood per rectum, and the sensation of a lump coming down which she manually reduces. On examination, she has significant prolapsing haemorrhoids.I Your answerH Correct answerH – HaemorrhoidectomySmall internal (bleeding) or prolapsing haemorrhoids above the dentate line can be treated by injection sclerotherapy or rubber-band ligation, respectively. Haemorrhoids refractory to non-operative therapy, or those that are large and prolapsing with a significant external component usually require haemorrhoidectomy. There are essentially two commonly used surgical options: Milligan and Morgan’s sharp (now usually diathermy) excision and stapled haemorrhoidectomy (PPH). The patient should of course be appraised of the risks before embarking on surgery.Theme: Diseases of the anusAAnal carcinomaBAnal intra-epithelial neoplasiaCAnal fissureDAnal fistulaECondylomata acuminataFFibroepithelial anal polypGHaemorrhoidsHPeri-anal abscessIPeri-anal haematomaJPilonidal abscessKProctalgia fugaxLSkin tagsMSolitary rectal ulcer syndromeThe following are descriptions of local anorectal disorders. Please select the most appropriate diagnosis from the list. The items may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 24-year-old man presents with a 3-month history of pain and passage of fresh blood on defaecation. Examination reveals a small skin tag at the anal verge; attempted proctoscopy has to be abandoned because of patient discomfort.D Your answerC Correct answerC – Anal fissureThis is the typical presentation of this condition.Scenario 2 Incorrect A condition associated with chronic infection with human papillomavirus (especially serotypes 16 and 18). K Your answerA Correct answerA - Anal Carcinoma, (B - Anal intra-epithelial neoplasia, or E - Condylomata acuminata)Infection with human papillomavirus can lead to anal warts (molluscum contagiosum) and dysplastic changes within the anal epithelium (mild to severe: termed anal epithelial neoplasia). These may progress to anal carcinoma. So patients with warts and those with other sexually transmitted diseases affecting the anus should have biopsies and possibly thence surveillance if required.Scenario 3 Incorrect A 31-year-old man presents with a 1-year history of severe anal pain lasting for 2 to 3 minutes each night. Per rectum and proctosigmoidoscopic examinations are unremarkable.K Correct answerK – Proctalgia fugaxThis is defined as episodic, intense anal pain of short duration (usually at night) in which all other disorders have been excluded. Proctalgia fugax occurs in up to 18% of the US population, being more common in men, and those < 40 years old. It is thought to be secondary to sensory dysfunction, with possible hypersensitivity of the internal anal sphincter and rectal musculature, precipitated by psychological stress. Treatment can be problematic with many systemic (eg antidepressants) and local (eg glyceryl trinitrate) remedies tried.Theme: Rectal bleeding?ACrohn’s disease BFamilial adenomatous polyposis CFissure in ano DIntussusception EMeckel’s diverticulumFMid-gut volvulusGNecrotising enterocolitisHSolitary juvenile polyp?For each of the clinical scenarios below, select the most likely cause of rectal bleeding from the above list. Each option may be used once, more than once, or not at all. Rectal bleeding is a common symptom throughout childhood. Crohn’s disease may present in many ways but is frequently associated with weight loss or linear growth failure in children. Meckel’s diverticulum may present with acute GI haemorrhage leading to the typical brick-red coloured stool. Ulceration is caused by the ectopic gastric mucosa within the Meckel’s diverticulum and may also cause lower abdominal pain. Solitary juvenile polyps are a relatively common cause of painless rectal bleeding. Occasionally, juvenile polyps may be multiple. Familial adenomatous polyposis should be suspected in children presenting with rectal bleeding when there is a family history of early colorectal carcinoma in immediate family members. The polyps generally develop after puberty. Mid-gut volvulus is frequently preceded by a history of intermittent colicky abdominal pain with or without bile-stained vomiting – usually from the age of 3 months. This diagnosis should always be considered in a child with bile-stained vomiting and rectal bleeding.Scenario 1 Incorrect A 7-year-old girl presents with weight loss and anaemia.B Your answerA Correct answerA – Crohn’s diseaseScenario 2 Incorrect A 13-year-old boy presents with lower abdominal pain and shock.B Your answerE Correct answerE – Meckel’s diverticulumScenario 3 Incorrect A 3-year-old boy presents with painless bleeding, mixed with stool.G Your answerH Correct answerH – Solitary juvenile polypScenario 4 Incorrect A 16-year-old girl presents with painless bleeding, mixed with stool; her father died of colorectal cancer at the age of 35 years.B Correct answerB – Familial adenomatous polyposisScenario 5 Incorrect A 10-month-old girl with a previous history of intermittent bilestained vomiting has collapsed.F Correct answerF – Mid-gut volvulusTheme: Colorectal surgery?AAbdominoperineal resectionBAnterior resectionCHartmann’s procedureDIleocolonic bypassELeft hemicolectomyFPanproctocolectomyGSigmoid colectomy and primary anastomosisHSubtotal colectomyITransverse loop colostomy?For each of the patients described below, select the most appropriate surgical option from the above list. Each option may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 55-year-old man reattends the surgical outpatient department with rectal bleeding. He has recently completed a course of chemoradiotherapy for a squamous anal carcinoma. He underwent an examination under anaesthesia (EUA) which revealed some residual tumour.A Correct answerA – Abdominoperineal resectionThe first case is of a man with a recurrence of his anal carcinoma. He has undergone chemoradiotherapy which has failed. The only treatment for continued bleeding is surgery in the form of an abdominoperineal resection.Scenario 2 Incorrect A 30-year-old woman with known ulcerative colitis is admitted as an emergency with abdominal distension, vomiting, rectal bleeding and dehydration. She undergoes a course of conservative medical management but does not respond to steroids and immunosuppressive therapy. Her albumin level is 20 g/l, WBC 25 x 109/l and her colonic diameter on abdominal X-ray is 9 cm.H Correct answerH – Subtotal colectomyThe second case is of a young woman with a flare-up of ulcerative colitis, failed medical treatment and development of a toxic megacolon. The surgical option now is a subtotal colectomy with ileostomy, as she is at imminent risk of perforation. The rectum is not excised, as this would increase the length of surgery and increase her morbidity. In addition, as she is young the possibility of a future ileoanal pouch should be left open to her.Scenario 3 Incorrect A 45-year-old man is admitted as an emergency to the Emergency Department with generalised peritonitis. Following aggressive resuscitation he is taken to the operating theatre where a hard 4-cm mass is found in the sigmoid colon. There is gross faecal contamination of the peritoneal cavity. His liver has one umbilicated nodule in the left lobe. The rest of the laparotomy is normal.C Correct answerC – Hartmann’s procedureThe third case is of a probable perforated sigmoid carcinoma and single metastasis to the liver. The carcinoma should be resected. A primary anastomosis in the presence of gross faecal contamination would be unwise. However, purulent peritonitis is itself not an absolute contraindication to a primary anastomosis. This procedure should only be performed by an experienced surgeon and the majority would cover with a loop ileostomy.Theme: Treatments for anal painAAnal canal carcinoma BFissure in ano CLow subcutaneous anal fistula (below the dentate line)DPerianal abscess EPerianal haematoma with supralevator extensionFProctitis secondary to Crohn’s diseaseGRadiation proctitisHSolitary rectal ulcer syndromeITransphincteric anal fistulaFor each of the treatment options, select the most likely answer from the above list. Each option may be used once, more than once, or not at all. ?Scenario 1 Incorrect BiofeedbackA Your answerH Correct answerH – Solitary rectal ulcer syndromeSolitary rectal ulcer syndrome is a relatively common cause of bright red rectal bleeding. It classically produces an ulcer on the anterior wall of the rectum, but may also have a polypoid appearance. The aetiology of the condition is incompletely understood but is thought to be a combination of internal intussusception/anterior wall prolapse and increased intrarectal pressure. The resultant symptoms are that of rectal evacuatory difficulty. Surgical treatment (abdominal rectopexy) is often unsatisfactory and the first line management is biofeedback.Scenario 2 Incorrect 4% Formalin (topical)B Your answerG Correct answerG – Radiation proctitisRadiation proctitis following treatment for cervical or prostatic cancer is a troublesome condition that is difficult to treat. Topical application of 4% formalin can help the bleeding. Other options include Nd: YAG laser, and surgery in the form of a coloanal sleeve anastamosis.Scenario 3 Incorrect Insertion of setonG Your answerI Correct answerTransphenctric fistulaTreatment of anal fistula is complex when the tract extends high to involve a considerable portion of the external anal sphincter. The danger of laying open too much external anal sphincter is to render the patient incontinent. The difficulty in decision-making lies in estimating the ‘safe’ amount of sphincter to divide and thus how much sphincter is left behind. The decision varies according to the sex of the patient, the presence of sphincter defects, colonic and rectal function and also the patient. A low anal fistula, below the dentate line is usually safe to lay open; however, if there is concern regarding continence a seton (suture material: ethibond, nylon, silastic slings have all been used) can be placed through the tract to allow drainage and reassessment of treatment options.Scenario 4 Correct 2% Diltiazem ointmentB Correct answerB – Fissure in anoDiltiazem is a calcium antagonist that reduces the resting pressure of the internal anal sphincter muscle (smooth muscle). Trials have shown this to be an effective treatment for acute and chronic anal fissures (65% healing rates).Scenario 5 Correct Botulinum toxinB Correct answerB – Fissure in anoBotulinum toxin has also been demonstrated to be an effective treatment for chronic anal fissure (73% efficacy). The precise mechanism of action is unclear, but reduced myogenic tone and contractile response to sympathetic stimulation by directly acting on its smooth muscle or indirectly on the nerves through inhibition of acetylcholine release are possibilities.Theme: Abdominal system investigations?ABarium enema BColonoscopy CCT DEndoanal ultrasound EEvacuation proctogram enemaFFlexible sigmoidoscopyGMRIHRed cell scanISingle contrast gastrografin?For each of the following scenarios, select the most likely answer from the above list. Each option may be used once, more than once, or not at all. ?Scenario 1 Incorrect Family history of colonic cancer: brother (aged 35 years), sister (aged 32 years) and father (aged 60 years).A Your answerB Correct answerB – ColonoscopyScreening of colonic cancer in patients with a positive family history should be performed with colonoscopy as the whole colon must be visualised. The use of computed tomography (CT) colonography and magnetic resonance (MR) colonography for screening and primary detection of colorectal cancers is the subject of ongoing research.Scenario 2 Incorrect An 88-year-old lady with a change in bowel habit.B Your answerC Correct answerC – CTThe problem here is the age of the patient and whether they would be able to tolerate a colonoscopy or barium enema investigation. It is common practice in many centres to use CT to identify a primary colorectal cancer in the over 80-year age group.Scenario 3 Incorrect A 25-year-old man with bright red rectal bleeding.B Your answerF Correct answerF – Flexible sigmoidoscopyBright red rectal bleeding in a young patient with no change in bowel habit can be suitably investigated with flexible sigmoidoscopy, as it is most likely that the source is located in the left colon.Scenario 4 Incorrect Angiodysplasia of the colon.H Your answerB Correct answerB – ColonoscopyAngiodysplasia of the colon is most commonly located in the ascending colon and caecum and is therefore best visualised by colonoscopy. Mesenteric angiography can also be used to demonstrate this vascular malformation. The malformations consist of dilated tortuous submucosal veins that may be replaced by massive dilated vessels in severe cases.Theme: Abdominal system investigations?AColonoscopy BCT CEndoanal ultrasound DEvacuation proctogram EFlexible sigmoidoscopy enemaFMesenteric angiogramGMRIHRed cell scanISingle contrast gastrografin?For each of the following scenarios, select the most likely answer fromthe above list. Each option may be used once, more than once, or not at all.?Scenario 1 Incorrect Local invasiveness of rectal cancer in the pelvis.B Your answerG Correct answerG – MRITissue invasion within the pelvis by rectal cancer is best assessed with MRI as this modality gives the best contrast resolution. MRI can identify whether the fascial envelope in which the rectum lies has been breached, or has a margin which may be threatened with tumour during surgical resection. With this technique, MRI can predict if neoadjuvant chemoradiotherapy needs to be given.Scenario 2 Incorrect Evidence of secondary spread to the liver.A Your answerB Correct answerB – CTHepatic metastases can be visualised by both MRI and CT. CT has better spatial resolution whereas MRI has superior contrast resolution. Scenario 3 Incorrect A 35-year-old lady with passive and urge faecal incontinence following obstetric injury.B Your answerC Correct answerC – Endoanal ultrasoundThe most suitable investigation here would be an endoanal ultrasound to visualise the internal and external anal sphincters. Other investigations that need to be requested in such a patient would be anorectal manometry (to measure resting and squeeze anal pressures) and rectal sensory thresholds.Theme: Rectal bleeding?AAnal carcinoma BAnal fissure CAngiodysplasia DColonic carcinoma EColonic polyp FCrohn’s diseaseGDiverticular diseaseHHaemorrhoidsInfective colitisJIschaemic colitisKUlcerative colitis?For each of the following scenarios, select the most likely answer from the above list. Each option may be used once, more than once, or not at all. ?Scenario 1 Correct A 20-year-old lady presents with a 3-week history of bright red rectal bleeding associated with pain on defaecation. Her symptoms started post-partum.B Correct answerB – Anal fissurePain on defaecation can be due to an anal fissure, anal carcinoma or strangulated haemorrhoids. Haemorrhoids per se are not painful. Anal fissures are common in young adults and have an increased incidence following pregnancy.Scenario 2 Incorrect A 32-year-old man presents with a 1-week history of colicky lower abdominal pain. This is associated with bloody diarrhoea, increased stool frequency and weight loss. A mass is palpable in the right iliac fossa. He is anaemic and has a CRP of 200.C Your answerF Correct answerF – Crohn’s diseaseThis history is typical of inflammatory bowel disease. The most likely diagnosis here would be Crohn’s disease in view of the weight loss and a palpable mass. These latter features are uncommon in ulcerative colitis.Scenario 3 Incorrect A 37-year-old homosexual presents with a 3-month history of episodes of bright red rectal bleeding associated with pain and itching. On examination he has an area of ulceration at the anal verge with an everted irregular edge.J Your answerA Correct answerA – Anal carcinomaAnal carcinoma has a strong association with human papillomavirus (types 16, 18, 33) infection. The everted edge is characteristic of a neoplastic process and a carcinoma should be suspected. Bleeding is another common presentation of anal carcinoma.THEME: INHERITED COLONIC DISEASE A???? Peutz-Jeghers syndromeB???? Hereditary haemorrhagic telangiectasiaC???? Colon cancerFor the patient described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all. ?Scenario 1 Correct A man presents with a 6-month history of lethargy and has had several blood transfusions. His blood profile is normal. He has pigmented spots on lips and oral mucosa.A Correct answerThis patient is most likely to have Peutz-Jeghers syndrome. Peutz-Jeghers syndrome is an autosomal dominant disease which gives rise to hamartomatous polyps, characteristically in the small bowel. These polyps can also be found in the stomach and colon. Theme: Abdominal surgeryA???? Sigmoid colectomyB???? Abdomino-perineal excision of rectum (APR) C???? Hartmann's procedure D???? Sub-total colectomy and formation of ileostomy E???? Right hemicolectomyF???? Anterior resection of the rectumG???? Left hemicolectomyFrom the list above, choose the most appropriate procedure for each of the following scenarios. Each answer may be used once, more than once, or not at all. ?Scenario 1 Incorrect A 57-year-old man in good general health presents electively with bleeding per rectum, change in bowel habit and iron deficiency anaemia. A caecal tumour has been confirmed on barium enema.A Your answerE Correct answerThis is the most appropriate procedure for a patient with a right-sided colonic tumour.Scenario 2 Incorrect A 33-year-old woman with a 12-year history of ulcerative colitis. The patient presents as an emergency with shock. This is accompanied by severe abdominal pain and extensive bleeding per rectum.B Your answerD Correct answerThis patient has a long history of ulcerative colitis and is presenting as an emergency with a severe exacerbation of symptoms and a toxic megacolon. A sub-total colectomy with formation of ileostomy should be performed after aggressive resuscitation and administration of broad-spectrum antibiotics.Scenario 3 Incorrect An 85-year-old man with a history of ischaemic heart disease presents as an emergency with severe generalised abdominal pain. Initially the pain had arisen in the left iliac fossa and had progressively worsened over two days. The patient is pyrexial and tachycardic.B Your answerC Correct answerThis patient presents with peritonitis following a probable perforated diverticulum. A primary anastamosis should not be performed in the presence of faecal peritonitis. A Hartmann’s procedure is the most appropriate procedure in this emergency situation.Scenario 4 Incorrect A 72-year-old woman who presents electively with bleeding per rectum. She underwent a flexible sigmoidoscopy which demonstrated a tumour in the upper rectum.B Your answerF Correct answerAn Anterior Resection is appropriate for tumours of the upper rectum. Abdomino-perineal resection is a procedure reserved for lower-third tumours of the rectum.Theme: Rectal bleeding A???NoneB???rigid sigmoidoscopyC? ?Proctoscopy and rigid sigmoidoscopyD???rigid sigmoidoscopy and flexible sigmoidoscopyE???rigid sigmoidoscopy and colonoscopyFrom the list above, choose the most appropriate investigation(s) in addition to rectal examination,?for the following scenarios. Each answer may be used once, several times or not at all.?Scenario 1 Incorrect A 35-year-old man who presents with a 3-month history of bright red rectal bleeding seen on the paper.A Your answerC Correct answerC - Proctoscopy and rigid sigmoidoscopy This patient is relatively young and presents with common symptoms. This is likely to be associated with haemorrhoidal bleeding which can be confirmed with proctoscopy and rigid sigmoidoscopy to exclude any pathology in the upper rectum.Scenario 2 Incorrect A 55-year-old man seen in the outpatient clinic presents with 3 weeks of rectal bleeding. It is observed on defaecation and is mixed with the stool His bowel habit is altered and his father died from colorectal carcinoma aged 63 years.A Your answerE Correct answerE - rigid sigmoidoscopy and colonoscopyThe concern in this scenario is of a malignant lesion, especially with a positive family history. He should undergo urgent flexible colonoscopy. Scenario 3 Incorrect A 26-year-old female who presents with a 6-week history of rectal bleeding. It is described as mixed with stool and associated with diarrhoea. She has lost 5 kg in weight.A Your answerD Correct answerD - rigid sigmoidoscopy and flexible sigmoidoscopyIn this case there is rectal bleeding, diarrhoea and weight loss. The possibility of inflammatory bowel disease should always be considered. Proctoscopy should be performed along with rigid sigmoidoscopy which will allow rectal biopsies to be taken. A flexible sigmoidoscopy should also be performed to visualise the left colon. Rectal examination would be important to identify local disease.Scenario 4 Incorrect A 32-year-old man with a 4-month history of small quantities of fresh rectal bleeding. The blood is seen on the paper and he describes sharp pain on defaecation.B Your answerA Correct answerA - NoneThe history here is very important as it should raise the suspicion of an anal fissure. In these cases it is often not possible to perform a proctoscopy due to pain. Rectal examination will often reveal a sentinel pile secondary to chronic fissuring. If possible, proctoscopy and rigid sigmoidoscopy should be performed to exclude a more proximal cause, often general anaesthetic is needed for these to be done.Theme: Stomas A???? End ileostomyB???? Loop ileostomyC???? End colostomyD???? Loop colostomyE???? End colostomy and mucus fistulaFrom the list above, choose the most appropriate stoma for the following scenarios. Each answer may be used once, several times or not at all.?Scenario 1 Incorrect A 74-year-old man undergoes an elective abdomino-perineal resection of a lower-third rectal carcinomaB Your answerC Correct answerLower-third rectal tumours require an abdomino-perineal resection. This is a major procedure that leaves the patient with a permanent end colostomy sited in the left iliac fossaScenario 2 Incorrect A 36-year-old woman with known ulcerative colitis presents as an emergency with abdominal pain and profuse bloody diarrhoea. Plain abdominal X-ray is indicative of a toxic megacolonB Your answerA Correct answerThis patient is presenting with an acute and severe exacerbation of ulcerative colitis. The presence of a toxic megacolon indicates the need for urgent surgery in the form of a subtotal colectomy and formation of end ileostomy. Dependent upon her recovery it may be possible to perform an ileo-rectal anastamosis at a later point.Scenario 3 Correct A 58-year-old man undergoes an elective anterior resection of the rectum for a confirmed middle-third rectal carcinoma. The anastamosis is constructed with a stapling device given its relatively low position.B Correct answerPatients who undergo resection of relatively low tumours may require a temporary loop ileostomy, commonly in the right iliac fossa. This is constructed to protect the low-lying anastamosis. It can be reversed after approximately 6 weeks, providing that the anastamosis is satisfactory, usually confirmed via a contrast enema.Scenario 4 Correct A 69-year-old man has a confirmed upper-third rectal carcinoma. He is scheduled for pre-operative radiotherapy in an attempt to downsize the tumour and make surgery more feasible.D Correct answerPatients who have large tumours that are not immediately resectable may be suitable for pre-operative radiotherapy to downsize the lesion. In this case they require a loop colostomy to divert the faecal stream. This is commonly performed at the transverse or sigmoid colon.Theme: Findings at laparotomy A???? Colo-colic bypass procedureB???? Right hemicolectomyC???? Anterior resectionD???? Hartmann's procedureE???? Defunctioning colostomyFor each of the following situations, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1 Incorrect A 68-year-old man with a short history of generalised abdominal discomfort and pain with underlying weight loss goes to laparotomy on the (N)CEPOD ((National) Confidential Enquiry into Patient Outcome and Death) list. He is found to have a perforated tumour of the proximal sigmoid colon with faecal matter and fluid within the peritoneum. No synchronous tumour or liver nodules are felt and chest X-ray pre-op is clear. The colon is mobileA Your answerD Correct answerIt is always tempting at the time in these cases to try a primary anastamoses. DO NOT. Faecal peritonitis carries at least a 50% mortality, the patient is septic and even the most rigorous of washouts will not ensure a safe environment for anastamosis. Resection with washout and fashioning of a colostomy is the safest procedure, particularly as this patient is more amenable than most to a reversal in the futureScenario 2 Incorrect A frail cachexic 84-year-old lady with a pre-operative ASA (American Society of Anaesthetists) grade of 3 is reluctantly taken to theatre for colonic obstruction. The local CT (computerised tomography) scanner was broken and she was deteriorating rapidly over the 24 h since admission. Exploratory laparotomy found a fungating tumour at the hepatic flexure with collapsed bowel distal to it. Also, several suspicious nodules are felt on the liver surface. Also, the anaesthetist is becoming concerned with her peri-operative progressD Your answerA Correct answerIdeally a CT scan would have let you know what you were getting into, but this lady would still require decompression. A right hemicolectomy would have been the plan, but findings of liver metastases makes her prognosis much less favourable. She is unlikely to get another shot at surgery and the anaesthetist will want the shortest and least complicated procedure possible. Mobilising hepatic flexure and performing a right hemicolectomy will not improve prognosis. A bypass is a quick, easy and safe palliative procedure. A defunctioning ileostomy is perhaps a second optionScenario 3 Incorrect A 78-year-old female goes for a planned laparotomy for resection of a low rectal cancer. She has been staged by CT 2 months before. The staging was at that time said to be T2N0M0. At laparotomy she was found to have palpable liver masses and widespread peritoneal deposits. The tumour is annular and sizable to feelC Your answerE Correct answerPeritoneal deposits carry an awful prognosis. The risks of complications with low rectal tumours treated by anterior resection would devastate the quality of life remaining in this lady. Defunctioning will be palliative and prevent any obstruction in the future.Scenario 4 Incorrect An otherwise well 62-year-old lady with a T2N1M0 tumour at 8 cm from the anal margin is found to have a locally palpable lymph node at laparotomy.B Your answerC Correct answerThe staging already tells us the patient has local adenopathy. The patient will most likely receive adjuvant chemotherapy for this.THEME: Large bowel obstruction A???? Ischaemic stricture B???? Volvulus C???? Adhesions D???? Carcinoma E???? Pseudo-obstruction F???? Crohn's disease For each of the patients described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all. Pseudo-obstruction presents as colonic obstruction but where no mechanical cause can be found. The patient is often elderly and frequently bedridden. The abdomen is tympanic but not tender. The management is usually expectant, with correction of fluid and electrolyte abnormality. Decompression may be achieved by the passage of a sigmoidoscope and flatus tube. A contrast water-soluble enema disproves any mechanical obstruction.Scenario 1 Incorrect A 75-year-old woman presents with acute abdominal pain, distension and constipation, 6 days after total hip replacement for a fractured neck femur. An abdominal x-ray shows dilated loops of bowel, few fluid levels, and gas all the way to the rectum.B Your answerE Correct answerScenario 2 Incorrect A 55-year-old woman who resides in a long-term psychiatric hospital presents with absolute constipation and abdominal distension. There is no pain. She gives a long history of constipation and laxative use.B Your answerE Correct answer ................
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