chapter 7
Inflammatory bowel disease and colonic disorders
Questions
2.A 33-year-old woman with a 15-year-history of ileocolonic CD attended for her follow-up appointment. She had no family history of inflammatory bowel disease (IBD) and nor did her husband. She was 33 weeks’ pregnant and concerned about the risk of CD in her child.
Which of the following percentages most accurately reflects the child’s likelihood of developing CD?
Which of the following statements is most accurate?
A. Accelerated IFX dosing in hospitalized patients with UC reduces colectomy rate
B. Approximately 30% of patients with ASUC will require a colectomy
C. Approximately 40% of patients will require hospitalization because of ASUC
D. Smoking increases the risk of recurrence of ASUC
4.A 34-year-old man attended clinic with a new confirmed diagnosis of UC.
he had several questions about UC.
Regarding UC, which of the following statements is most accurate?
A. Around 25% of patients with pancolitis eventually have a colectomy
B. At 10 years, disease extent progresses in less than 10% of patients with proctitis
C. Maintenance 5-aminosalicylate (5-ASA) therapy reduces colorectal cancer (CRC) by 10%
D. The incidence of CRC is 20% at 20 years and 40% at 30 years
5.A 21-year-old woman presented to clinic with a one-week history of bloody diarrhoea eight times per day, with nocturnal motions and generalized abdominal pain. She had a long history of arthralgia in the hands and recurrent mouth ulcers. Her father had ankylosing spondylitis. Examination revealed aphthous mouth ulcers, a small ulcer in the right leg with a violaceous border, and mild right iliac fossa tenderness. Her temperature was 38°C, heart rate 110 beats per minute and blood pressure 100/60 mmHg.
What is the most appropriate first investigation?
Investigations:
| Gastroscopy | Normal including biopsies |
| Colonoscopy | Patchy inflammation in the left colon, normal terminal ileum. Biopsies consistent with Crohn’s colitis in the descending and sigmoid colon. |
Which of the following most accurately represents this patient’s Montreal classification?
7.A 22-year-old woman presents with a four-week history of abdominal pain, malaise, and bloody stools. She undergoes a flexible sigmoidoscopy with biopsies.
8.A 35-year-old woman with colonic CD presented complaining of perianal pain and rectal discharge.
Investigations:
| Haemoglobin | 145 g/L |
| White cell count (WCC) | 10.9 × 109/L |
| Platelet count | 534 × 109/L |
| Serum C-reactive protein (CRP) | 67 mg/L |
Which of the following statements is the most accurate?
A. Flexible sigmoidoscopy is useful in determining the management of perianal fistulae
B. Ileocolonic CD has a higher rate of perianal disease
C. Perianal disease presents late in the course of CD
D. Perianal pain commonly occurs with isolated perianal fistulae
Investigations:
| Haemoglobin | 178 g/L |
| WCC | 8.9 × 109/L |
| Platelet count | 145 × 109/L |
| Serum C-reactive protein (CRP) | 35 mg/L |
| Pelvic MRI | Inter-sphincteric perianal fistula; no abscess was demonstrated |
| Flexible sigmoidoscopy | Quiescent disease |
Which of the following treatments is the most appropriate?
10.A 21-year-old student with a seven-month history of intermittent post-prandial abdominal pain and fatigue was referred with worsening of symptoms during her final exams. On further enquiry, she reported 3 kg of weight loss with no diarrhoea or anorexia. She had a previous history of irritable bowel syndrome (IBS). She was a non-smoker and had no family history of IBD.
Investigations:
| Haemoglobin | 109 g/L |
| Serum albumin | 33 g/L |
| Serum C-reactive protein | 18 mg/L |
Which of the following would have the highest diagnostic yield for small bowel CD?
Investigations:
| Haemoglobin | 114 g/L |
| Serum albumin | 35 g/L |
| Serum C-reactive protein | 26 mg/L |
An abdominal ultrasound was performed in clinic.
Which is considered the most consistent ultrasound finding in CD?
A. It is only recommended in those with extensive colitis
B. It has high first-pass metabolism in the liver
C. It is a topical rectal preparation
13.Following rescue therapy for ASUC, a 27-year-old man is subsequently maintained on 5 mg/kg IFX eight-weekly alongside 50 mg of azathioprine and 2.4 g mesalazine. He initially had complete resolution of symptoms but six months later he reported four times stools per day with occasional blood.
Investigations:
| Serum C-reactive protein | 43 mg/l |
| Faecal calprotectin | 800 µg/g |
| IFX trough level | 2.6 µg/ml |
| Antibodies to IFX | undetectable |
What is the next most appropriate management step?
15.A 78-year-old woman with pancolitis was admitted with bloody diarrhoea (11 times per day) with a pulse of 92 beats per minute and blood pressure 124/70 mmHg. On day three of intravenous corticosteroids, her stool chart reported four bloody stools in the past 24 hours. She denied abdominal pain. Her pulse was 72 beats per minute and temperature 37.4°C. Her background included heart failure (NYHA IV), morbid obesity, obstructive sleep apnoea (requiring nocturnal continuous positive airway pressure), and chronic obstructive pulmonary disease. She had investigations performed on day three of admission.
Investigations:
| Haemoglobin | 90 g/L |
| WCC | 10.4 × 10⁹/L |
| Platelet count | 550 × 10⁹/L |
| Serum C-reactive protein | 46 mg/L |
| Cholesterol | 5.1 mmol/L |
| Magnesium | 0.97 mmol/L |
| Chest radiograph | Clear |
| Abdominal radiograph | No evidence of toxic megacolon |
What is the most appropriate next step?
A. Continue intravenous corticosteroids and reassess in 48 hours
B. IFX (5 mg/kg) induction regime
C. Intravenous ciclosporin (2 mg/kg per day)
D. Oral ciclosporin (5 mg/kg per day in divided doses)
Investigations:
| Haemoglobin | 142 g/L |
| WCC | 6.1.0 × 10⁹/L |
| Platelet count | 313 × 10⁹/L |
| Serum C-reactive protein | 4 mg/L |
| Alanine transferase (ALT) | 17 U/L |
| Alkaline phosphatase (ALP) | 77 U/L |
What treatment should be initiated?
17.A 34-year-old man underwent a proctocolectomy and ileal pouch-anal anastomosis for ulcerative pancolitis. There were no perioperative complications. Eight months later, he was reviewed in clinic and described a one-week history of increased frequency of non-bloody stools, abdominal cramping, tenesmus, and urgency.
Investigations:
What is the most appropriate management?
Which of the following statements is most accurate?
A. Evidence supports dietary strategies in mild UC
B. Good evidence supports a low-residue diet and avoiding insoluble fibre in stricturing CD
C. Probiotics in the management of IBD have no evidence base
D. The evidence base for elemental feed and polymeric diet is similar in CD
19.A 35-year-old Caucasian woman with ileocolonic CD was admitted with worsening abdominal pain and diarrhoea. She was previously controlled on azathioprine. After a partial response to corticosteroids, she was commenced on adalimumab. She showed a good response after induction and was maintained on fortnightly doses. She was seen urgently in clinic with a five-month history of worsening symptoms, despite maintenance adalimumab.
Investigations:
| Serum C-reactive protein (CRP) | 57 mg/L |
| Faecal calprotectin | 256 µg/g |
| Anti-drug antibodies | Positive |
| Adalimumab level | Undetectable |
Which factor has been shown to predict low drug concentrations in adalimumab therapy?
Investigations:
| Haemoglobin | 135 g/L |
| Platelet count | 340 × 109/L |
| Serum C-reactive protein (CRP) | 10 mg/L |
| Albumin | 35 g/L |
| Colonoscopy | Partial loss of vascular pattern in the caecum and unpassable stricture at ileocaecal valve. Able to take terminal ileal biopsies. No ulcers or erosions. Colon biopsy series taken. |
| Histology | Normal terminal ileum. Ulceration at the ileocaecal valve with chronic inflammatory changes. Otherwise normal colon. |
| MR enterography | 6 cm stricture at the terminal ileum involving the ileocaecal valve with proximal dilatation of the small bowel. No evidence of fistula or abscess. Normal colon. |
What is the most appropriate next step for this patient?
A. Addition of anti-tumour necrosis factor (anti-TNF) therapy
B. Endoscopic dilatation +/- stenting of ileocaecal valve
D. Referral for ileocaecal resection
Investigations and observations:
| Heart rate | 113 bpm |
| Temperature | 38.9 oC |
| Haemoglobin | 101 g/L |
| Serum sodium | 149 mmol/L |
| Serum potassium | 2.4 mmol/L |
| Serum phosphate | 0.56 mmol/L |
| Serum calcium | 1.59 mmol/L |
| Serum magnesium | 0.57 mmol/L |
| Serum albumin | 22 g/L |
| Abdominal radiograph | Loop of featureless transverse colon with a maximum diameter of 6.1 cm. |
Which electrolyte abnormality should be corrected first to prevent further colonic dilatation?
22.A 35-year-old man with CD presented to clinic with lower back pain.
What is the next most appropriate investigation to make a diagnosis?
23.You reviewed a 23-year-old man in clinic with extensive UC for which he took mesalazine and azathioprine. He had been well in the past year and was clinically in disease remission. However, he showed you a new skin lesion on his left shin (Fig. 7.1).
Fig. 7.1 Clinical photograph of lower limb skin lesion. See also Plate 12Reproduced with permission from Oxford Handbook of Medical Dermatology (2 ed.), Susan Burge, Rubeta Matin, and Dinny Wallis, Figure 15.5, page 297, Oxford University Press, Oxford, UK, Copyright © 2016
Which statement regarding the likely diagnosis of this skin lesion is correct?
A. It is usually associated with active bowel inflammation
B. It occurs more commonly in CD than UC
C. It never causes deep (sub-epidermal) inflammation
D. It occurs in 5%–10% of patients with UC
Investigations:
| Haemoglobin | 113 g/L |
| WCC | 18 × 109/L |
| Platelet count | 556 × 109/L |
| Serum C-reactive protein (CRP) | 358 mg/L |
| Serum albumin | 24 g/L |
| CT abdomen and pelvis | Tethered loops of small bowel in the right iliac fossa with evidence of active disease and a 1 × 1 cm abscess in the region of the ileocaecal valve |
What is the most appropriate next management step?
A. Cessation of azathioprine and prescribing of intravenous antibiotics
B. Intravenous antibiotics and azathioprine 2 mg/kg once a day
C. Intravenous antibiotics and IFX induction regime
D. Laparotomy, ileocaecal resection, and end ileostomy
E. Radiologically guided percutaneous drainage and intravenous antibiotics
25.A 59-year-old woman with quiescent CD, asthma, and hypertension presented to the emergency department with an acute febrile illness following her annual influenza vaccination. She complained of fever, malaise, headache, mouth ulcers, and arthralgia. The emergency department doctor noted the development of multiple erythematous and tender papules on her neck and at her immunization site.
Investigations:
| Haemoglobin | 156 g/L |
| WCC | 15.9 × 109/L |
| Platelet count | 365 × 109/L |
| Serum albumin | 35 g/L |
| Serum C-reactive protein (CRP) | 67 mg/L |
Anti-neutrophil cytoplasmic antibodies:
| c-ANCA | Negative |
| p-ANCA | Weakly positive |
| PR3-ANCA | 8 U/mL (<10) |
| MPO-ANCA | 4 U/mL (<10) |
Which of the following is the most likely diagnosis?
What is the most likely diagnosis?
27.A 29-year-old with small bowel CD attended clinic. He was opening his bowels two to three times per day and reported mild right iliac fossa discomfort. His primary complaint was fatigue, which was having an impact on his work as a teacher.
Investigations:
| Haemoglobin | 103 g/L |
| MCV | 77 fL |
| Platelet count | 475 × 109/L |
| Ferritin | 85 μg/L |
| Iron | 8.9 umol/L |
| Serum albumin | 32 g/L |
| Serum C-reactive protein (CRP) | 17 mg/L |
A. Patients on erythropoiesis-stimulating agents
B. Patients with a previous intolerance to oral iron
C. Patients with acute flare of disease
Regarding colonoscopy surveillance, which of the following statements is most accurate?
A. He is overdue a colonoscopy by one year
B. Left-sided colitis at the time of diagnosis warrants a screening colonoscopy at five years
C. Post-inflammatory polyps require annual surveillance
D. Surveillance should be scheduled for one year’s time
E. The family history of CRC warrants five-yearly colonoscopy
29.A 43-year-old man with a 12-year history of pancolitis was overdue colonoscopic surveillance. He enquired about his personal risk of CRC.
With respect to CRC and IBD, which statement is most accurate?
A. IBD patients diagnosed with CRC are older than sporadic CRC patients
B. Only IBD patients with a family history of CRC are at risk of developing malignancy
C. Patients with Crohn’s colitis have a higher risk of CRC than those with UC
D. Risk factors associated with UC-related CRC include pancolitis and male sex
30.A paediatric gastroenterologist wrote to you, asking you to take over the care of a 16-year-old with two previous resections for small bowel CD. He was maintained on azathioprine and IFX.
Which of the following statements is most accurate?
A. A joint paediatric-adult clinic, as part of a transition programme, is the ideal model
B. A transition coordinator is only necessary for inter-hospital transfers
D. Transfer of care is best achieved through a formal written handover
What would be the best advice for this patient?
A. Continue current medications
B. Halve the dose of azathioprine
D. Stop azathioprine and mesalazine
32.A 28-year-old lady with extensive UC was commenced on IFX 11 months previously because of active disease despite mesalazine and azathioprine therapy. She had subsequently been in clinical remission for the past eight months. She wished to consider starting a family imminently. She had not undergone any prior operations.
Investigations:
| Colonoscopy | Quiescent colitis, no macroscopic or microscopic evidence of inflammation. |
What would be the most appropriate advice regarding discontinuing IFX?
A. Continue treatment throughout pregnancy and breastfeeding, even if in disease remission
B. Stop three months prior to conception
C. Stop as soon as conception known if remains in disease remission
D. Stop at end of first trimester (approx. 12 weeks’ gestation) if remains in disease remission
E. Stop at end of second trimester (approx. 26 weeks’ gestation) if remains in disease remission
Investigations:
| Haemoglobin | 130 g/L |
| Haematocrit | 44% |
| WCC | 10.0 × 109/L |
| Platelet count | 389 × 109/L |
| Erythrocyte sedimentation rate | 8 mm/hr |
| Albumin | 32 g/L |
| Serum C-reactive protein (CRP) | 9 mg/L |
| Flexible sigmoidoscopy | Patchy erythema and partial loss of vascular pattern with small superficial ulcers from rectum to splenic flexure (Fig. 7.2). |
Fig. 7.2 Endoscopic image of sigmoid colon. See also Plate 13
Image courtesy of Dr Vincent Cheung, Oxford University Hospitals NHS Foundation Trust
Which is the most likely diagnosis?
A.Clostridiodes difficile-associated diarrhoea
B. Immunotherapy-associated colitis
D. NSAID-associated enterocolitis
Her temperature was 37.8°C, blood pressure 98/60 mmHg, pulse 105 beats per minute, respiratory rate 16, oxygen saturations 98% on room air.
Investigations:
| Haemoglobin | 128 g/L |
| Platelet count | 365 × 109/L |
| Serum C-reactive protein (CRP) | 10 mg/L |
| Serum albumin | 34 g/L |
| Lactate | 3.5 mmol/L |
| Faecal culture | Negative |
| CT abdomen and pelvis | Colitis from splenic flexure to the rectum |
| Flexible sigmoidoscopy | (Fig. 7.3) |
Fig. 7.3 Endoscopic image of sigmoid colon. See also Plate 14Courtesy of Oxford University Hospitals NHS Foundation Trust
What is the most likely diagnosis?
What is the best management option?
36.A 65-year-old woman presented to her GP with a four-year history of watery diarrhoea.
Her only comorbidity was depression, which was managed with sertraline.
Investigations:
| Haemoglobin | 132 g/L |
| WCC | 4.6 × 109/L |
| Platelet count | 470 × 109/L |
| MCV | 88.1 fL |
| Serum sodium | 137 mmol/L |
| Serum potassium | 3.8 mmol/L |
| Serum urea | 7 mmol/L |
| Serum creatinine | 89 µmol/L |
| Anti-tissue transglutaminase antibodies | 9 U/ml |
| Plasma thyroid-stimulating hormone | 3.4 mu/L |
| Faecal microscopy, culture, and sensitivities | Negative |
| Faecal elastase | 405 µg/g |
| Colonoscopy | Normal |
| Colonic histology | Pending |
B. Greater than 20 eosinophils per high-powered field
C. Greater than 20 lymphocytes per 100 epithelial cells
D. Preservation of crypt architecture
What is the overall sensitivity of glutamate dehydrogenase assay?
38.A 19-year-old British man spent the summer working as a water-sports instructor in America. He had no medical background. On his return, he presented to his GP complaining of an intermittent patch of raised itchy skin, which appeared and disappeared in a matter of hours, at different sites on his back. He had had an area of inflamed skin between his toes while abroad. He attributed this to a fungal infection.
He also complained of diarrhoea.
Investigations:
| Haemoglobin | 156 g/L |
| MCV | 92 fL |
| WCC | 10.2 × 109/L |
| Neutrophil count | 6.5 × 109/L |
| Lymphocyte count | 1.7 × 109/L |
| Eosinophil count | 1.6 × 109/L |
| Basophil count | 0.04 × 109/L |
| Platelet count | 420 × 109/L |
| Faecal microscopy and culture | Negative × 3 |
Which treatment is the most appropriate?
Investigations:
| Haemoglobin | 140 g/L |
| WCC | 15.1 × 109/L |
| Serum C-reactive protein (CRP) | 120 mg/L |
| Urea | 12.1 mmol/L |
| Creatinine | 130 µmol/L |
Which organism is the most likely cause of this patient’s symptoms?
40.A 32-year-old South African man recently moved to the UK and presented with a 12-day history of fevers and watery diarrhoea up to 20 times a day.
Investigations:
| Haemoglobin | 100 g/L |
| WCC | 0.9 × 109/L |
| CD4+ lymphocyte count | 42/µL |
| Serum C-reactive protein (CRP) | 120 mg/L |
| Urea | 15.1 mmol/L |
| Creatinine | 120 µmol/L |
| HIV antibody | Positive |
| Flexible sigmoidoscopy | Erythema, loss of vascular pattern and multiple, well-defined, punched out ulcers throughout the left colon. |
What is the best treatment option?
Investigations:
| Haemoglobin | 102 g/L |
| MCV | 72 fL |
| Iron level | 8.2 umol/L |
| Transferrin | 3.13 g/L |
| Transferrin saturation | 12% |
| Ferritin | 9 μmg/L |
| Gastroscopy | Normal |
| Duodenal biopsies | Normal |
| Colonoscopy Histology | 1.5 cm pedunculated polyp in the transverse colon, snared and retrieved. 15 mm tubulovillous adenoma with no low-grade dysplasia. |
What is the most appropriate follow-up for this patient?
A. Colonoscopy in one year’s time
B. Colonoscopy in two years’ time
C. Colonoscopy in three years’ time
D. Colonoscopy in five years’ time
42.A 42-year-old male patient attended clinic. He was diagnosed with acromegaly in his early twenties. He did not complain of any bowel symptoms, but had read about an increased risk of developing CRC.
His screening colonoscopy at age 40 years demonstrated one 3 mm hyperplastic polyp that was completely excised from the sigmoid colon. He was otherwise healthy and his body mass index (BMI) was 25 kg/m2.
Investigations:
| Thyroid-stimulating hormone | 2.4 mU/L |
| Insulin-like growth factor-1 | 42.6 nmol/L |
| Fasting plasma glucose | 4.9 mmol/L |
Which of the following is the most appropriate with regard to ongoing surveillance?
Which of the following is the most likely diagnosis?
A. Familial adenomatous polyposis
B. Hereditary non-polyposis CRC
C. Juvenile polyposis syndrome (JPS)
D. MUTYH-associated polyposis (MAP)
44.A 40-year-old female patient presented with a history of intermittent central abdominal pain. Examination revealed freckles on her lips, buccal mucosa, and eyelids. Her past medical history included breast cancer diagnosed a year ago.
What would be the most appropriate next step?
B. Colonoscopy and genetic testing for serine/threonine kinase 11 gene mutation
D. CT chest, abdomen, and pelvis
45.A 56-year-old man attended for a colonoscopy for a change in bowel habit.
Investigations:
| Colonoscopy | Multiple serrated polyps. 24 polyps counted in total; majority right sided (8 transverse, 6 ascending) with largest measuring 11 mm. All polyps measuring more than 5 mm were removed. |
| Histology | A mix of sessile serrated lesions without dysplasia and hyperplastic polyps |
What surveillance interval would you recommend for this condition?
D. Endoscopic surveillance interval dependent on family history
E. Surveillance timing stratified according to the presence of an associated genetic mutation
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