chapter 10
Miscellaneous
Questions
What advice is most appropriate regarding his medication prior to his planned procedures?
B. Stop apixaban 48 hours before, continue aspirin
C. Stop apixaban 48 hours before, omit aspirin on morning of procedure
D. Stop apixaban 72 hours before, continue aspirin
E. Stop apixaban 72 hours before, omit aspirin on morning of procedure
2.A 65-year-old man underwent a colonoscopy. A 2.5 cm sessile polyp in the ascending colon was removed by endoscopic mucosal resection with hot snare polypectomy. He was discharged from the endoscopy department the same day. Two days later, he presented with increasing abdominal pain. Clinical examination revealed tachycardia and abdominal tenderness.
Investigations:
| Haemoglobin | 135 g/L |
| White cell count | 13.0 × 10/L |
| Platelet count | 450 × 109/L |
| Serum C-reactive protein | 34 mg/L |
What is the best next step in this patient’s management?
Which of the following scenarios is most likely to require antibiotic prophylaxis?
C. ERCP for stones within the common bile duct without intercurrent sepsis
D. Gastroscopy and oesophageal dilatation for a benign oesophageal stricture
E. Previous history of an aortic valve replacement undergoing a colonoscopy and polypectomy
4.A 22-year-old university student presented to the emergency department following a suicide attempt. He reportedly ingested 250 mls of bleach 12 hours earlier. He complained of odynophagia. His background included deliberate self-harm.
On assessment, his vital observations were normal and his airway was uncompromised.
Investigations:
| Gastroscopy | Oesophageal haemorrhage, erosions, blisters, and superficial ulcers |
Which Zargar classification is described here?
5.A 69-year-old man with Barrett’s oesophagus attended for a surveillance gastroscopy. He asked to have sedation for the procedure.
Which of the following is the most important risk factor for sedation-related complications?
Which of the following is a key performance measure for ERCP?
A. Adequate antibiotic prophylaxis before ERCP in at least 95% of procedures
B. Appropriate stent placement in patients with biliary obstruction below the hilum in at least 90%
C. Bile duct cannulation rate in at least 90%
D. Bile duct stone extraction in at least 85%
7.A 48-year-old man with motor neurone disease attended for an elective endoscopic gastrostomy placement. Due to his neurological condition, he was unable to sign his signature during the consenting process.
With respect to valid consent in endoscopy, which statement is best practice?
A. Additional consent must be obtained for taking photos or videos as part of standard care
C. In those lacking capacity, the next of kin may sign consent on their behalf
D. The formal consent process should be completed before entry into the procedure room
8.A 50-year-old man presented with 48 hours of abdominal pain, distension and vomiting.
Investigation:
| CT abdomen and pelvis | In the distal ileum, there is an intraluminal mass with classic ‘target sign’ appearance consistent with invaginated bowel. There is moderate proximal small bowel dilatation but no free air to suggest perforation. |
Which of the following statements is true regarding this disease in adults?
A. It is the third most common cause of bowel obstruction
B. It most commonly occurs in the colon
C. Neoplastic lesions account for two-thirds of cases
D. Ninety per cent of cases are idiopathic
E. The majority are treated successfully with hydrostatic enema
Investigation:
| Colonoscopy | Large prolapsing haemorrhoids which have to be manually reduced. |
Which of the following would be the next best intervention?
10.A 25-year-old girl with constipation-predominant irritable bowel syndrome (IBS-C) was referred to clinic with ongoing anal pain. She described excruciating pain on defecation with hard stools. On rectal examination, her GP had identified an anal fissure. Treatment with warm baths, stool softeners, and topical anaesthetic gels had failed to provide relief.
What would be the next most appropriate treatment?
11.A 34-year-old teacher was referred to the clinic with a history of rectal bleeding. He had suffered with constipation in the past. A flexible sigmoidoscopy was requested.
Investigations:
| Flexible sigmoidoscopy | Insertion to proximal sigmoid. Rectal oedema with superficial ulcerations and mucosal erythema. |
| Histology | Fibromuscular obliteration of the lamina propria and surface erosion consistent with solitary rectal ulcer syndrome. |
With respect to solitary rectal ulcer syndrome (SRUS), which statement is most accurate?
A. A minority of patients have associated dyssynergic defaecatory disorder
B. Rectal bleeding on defaecation is a hallmark feature
C. SRUS is a misnomer: only 40% of patients have a solitary ulcer
D. Topical treatments, including sucralfate and mesalazine, are first line
Investigations:
| Flexible sigmoidoscopy | Distal proctitis, pus in rectum |
| Colonic histopathology | Consistent with Crohn’s colitis |
Which of the following most closely resembles Crohn’s disease on histopathology?
13.A 38-year-old accountant was seen in the IBD clinic. He had ileal Crohn’s disease for which he had been on azathioprine for several years. His background also included HIV (on HAART). He reported anal discharge and pruritus. Perineal examination revealed a suspicious, pigmented, scaly lesion with associated white plaque.
Which of the following is true for anal intraepithelial neoplasia (AIN)?
A. Ablative therapy is preferable to excision of small lesions
B. Human papilloma viruses (HPV) infection reduces the risk of AIN
C. Screening is indicated in high-risk groups only
D. The presence of ulceration in an AIN lesion is pathognomonic
E. There is an increased incidence of AIN in the immunosuppressed and HIV-positive individuals
14.A 45-year-old woman is referred to gastroenterology with faecal incontinence (FI). She is normally fit and well. Her general practitioner attempted to manage her symptoms with dietary modifications and anti-diarrhoeal agents with no improvement. Clinical examination, including digital rectal examination, was unremarkable.
Which is the next best investigation to perform?
Which statement regarding glucose-hydrogen breath testing is correct?
A. A double peak in expired breath hydrogen should be considered normal
C. Glucose-hydrogen breath testing correlates well with jejunal aspirates
D. Lactulose is well absorbed across the small intestinal mucosa
chapter 10
Miscellaneous
Answers
1. B. Stop apixaban 48 hours before, continue aspirin
• Aspirin is safe to continue prior to routine endoscopic procedures
• Apixaban should be stopped 48 hours prior to high-risk procedures
• Cardiology advice should be sought for patients with high-risk conditions
AF and ischaemic heart disease with long-standing stents are low-risk conditions for stopping anticoagulant and antiplatelet agents. Therefore, consulting a cardiologist is not required. Diagnostic gastroscopy is a low-risk procedure. However, the colonoscopy should best be considered a high-risk procedure to allow for polypectomy, given the patient’s preference. Aspirin is safe to continue prior to routine endoscopy.
High-risk conditions
Low-risk conditions
Direct oral anticoagulants (apixaban,dabigatran, edoxaban, rivaroxaban)
Low-risk procedures: omit on the morning of procedure
High-risk procedures: stop 48 hours before procedure (72 hours for dabigatran with CrCl 30–50 ml/min)
Warfarin
Low-risk procedures: continue therapy, check international normalized ratio (INR) does not exceed therapeutic range
High-risk procedures: assess risk of underlying condition
P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor)
Low-risk procedures: continue
High risk procedures:
Veitch AM et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut. 2016;65:374–389. Doi: 10.1136/gutjnl-2015-311110.
2. B. CT abdomen
Post-polypectomy syndrome:
• presents similarly to colonic perforation and often requires a CT to differentiate
• Occurs more commonly in larger polypectomies (>2 cm)
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