Q1:
Which laxative should not be used to treat acute constipation because of its slow onset of action?
(A) glycerin
(B) bisacodyl suppository
(C) psyllium
(D) milk of magnesia
Answer
C
Glycerin and the bisacodyl suppository all produce stools in 30 mins to a few hours, whereas psyllium, a
bulk-forming laxative, produces stool in 24 to 72 hrs in the same manner as a normal bolus of food or fi ber.
----
Q 2- 4 :
An 8-year-old girl presented with a 6-month history of fresh PR blood on the toilet paper and clearly mixed in with stools. She occasionally has pain on defecation, and intermittent, generalized sharp abdominal pain that resolves spontaneously. She denies any significant constipation. There is no vomiting, diarrhoea or weight loss. She has a normal diet and is growing well. On examination, her abdomen was soft and mildly
tender over the right side with stool palpable in her ascending colon. In the perianal region, there is a sentinel
skin tag but no evidence of a fissure. Urea, electrolytes and creatinine, liver function tests, Creactive
protein, erythrocyte sedimentation rate and full blood count were all within normal limits.
(Q2 ) What is the most likely diagnosis given this history?
A- Constipation
B- Inflammatory bowel disease
C- Campylobacter enterocolitis
D- Meckel’s diverticulum
Abdominal X-ray revealed no faecal loading and a 99mTc pertechnetate scintigraphy (Meckel’s scan) showed no evidence of functional ectopic gastric tissue. An upper endoscopy and colonoscopy were done with biopsy of the intestinal mucosa. Histology showed no active inflammation, normal crypt architecture, no granulomas, no evidence of epithelial dysplasia nor evidence of malignancy. There was however raised mucosal eosinophil density with basophilic blush and positive Steiner staining.
(Q 3) This is diagnostic of
A- Coeliac disease
B- Helicobacter pylori infection
C- Crohn’s disease
D- Intestinal spirochaetosis
E- C. enterocolitis
(Q 4) Treatment should be with
A- Gluten exclusion diet
B- Triple agent therapy: omeprazole, amoxicillin and metronidazole
C- Elemental diet
D- Metronidazole
E- Symptomatic relief only
Answers
Q 2: A
Q 3: D
Q 4: D
PR bleeding has a number of different aetiologies. A comprehensive history and examination should be obtained to help direct the most appropriate investigations and in order to make an accurate diagnosis. Intestinal spirochaetes, IS, are difficult to diagnose because of non-specific symptoms. The causative organisms are Brachyspira aalborgi or Brachyspira pilosicoli.
Biopsy specimens obtained during endoscopy, can be suggestive of infestation when there is basophilic blush and positive Steiner staining with eosinophilic infiltration.
Definitive diagnosis is with electron microscopy that shows spirochaetes attached to epithelial cells However, if histology-staining is suggestive of IS, it may be pertinent to treat with a 7e10 day course of oral metronidazole, rather than proceeding to expensive confirmatory testing.
Inflammatory bowel disease, IBD, includes Crohn’s disease, CD, and ulcerative colitis, UC. They can present with abdominal pain, diarrhoea, bloody stools and weight loss. Weight loss is more common in CD, and blood loss in UC. CD can affect any part of the gastrointestinal tract whereas, by definition, UC will only affect the colon.
Diagnosing and differentiating IBD requires clinical assessment in correlation with biochemistry, radiology, endoscopy and histology investigations. UC is diagnosed by clinical history supported with colonoscopy findings. CD is diagnosed by history and the demonstration of focal lesions on colonoscopy with histology showing transmural inflammation and granulomas.
Constipation can be diagnosed on history and examination alone. Bleeding is often the result of an anal fissure. Abdominal X-ray can show faecal loading. Campylobacter enterocolitis can cause dysentery with
severe, crampy abdominal pain. It is transmitted mainly via infected food and its course is usually self-limiting over a few days.
Most children infected with Helicobacter pylori, are asymptomatic.
-----------------
Q 5:
A 12-year-old girl has had intermittent periumbilical abdominal pain for the past 4 years.
Sometimes the pain worsens when she drinks a glass of milk. A lactose breath hydrogen test
demonstrates a breath hydrogen of 40 ppm after 1 hour (normal, <20 ppm).
Of the following, the food that this girl is MOST likely to tolerate is
A. buttermilk
B. cheddar cheese
C. ice cream
D. skim milk
E. whole milk
Answer
B
Lactose intolerance (lactose maldigestion) is a common cause of pediatric recurrent abdominal
pain. Lactase is a digestive enzyme located on the intestinal villi that converts the disaccharide
lactose to the monosaccharides glucose and galactose. The monosaccharides can be
absorbed across the intestinal epithelial cells. In an individual who has low intestinal lactase
(lactose intolerance), the lactose cannot be broken down and passes into the lower intestine and
colon. The malabsorbed lactose can cause osmotic diarrhea or be fermented by bacteria,
resulting in pain, gas, and bloating. Lactose intolerance can either be primary (lactase activity
that gradually declines with aging) or secondary (an infection or enteropathy damages the villi,
resulting in lactose intolerance).
Lactose intolerance may be diagnosed clinically by elimination diet and rechallenge or
through lactose breath hydrogen testing. Breath testing offers the advantage of providing a more
definitive diagnosis, so milk is not withdrawn from the diet unnecessarily. In a breath hydrogen
test, an adult is given approximately 50 g of lactose (the equivalent of 4 cups of milk) as a single
dose. Patients who cannot digest and absorb this amount of lactose have the lactose fermented
to hydrogen by intestinal bacteria, which can be measured in the breath. Because intestinal
bacterial fermentation is essential for an accurate test, patients should not receive antibiotics for
at least 2 weeks prior to the test.
Many patients who have lactose intolerance diagnosed on breath test can tolerate small
amounts of lactose in their diet. Specifically, hard cheeses, such as cheddar, which often have
very little lactose (<0.5 g/serving), can be eaten by many patients who have lactose intolerance.
Other products, such as whole or skim milk, ice cream, or buttermilk, have more lactose
(approximately 10 g/serving) and are less likely to be tolerated
Answer
C
Glycerin and the bisacodyl suppository all produce stools in 30 mins to a few hours, whereas psyllium, a
bulk-forming laxative, produces stool in 24 to 72 hrs in the same manner as a normal bolus of food or fi ber.
----
Q 2- 4 :
An 8-year-old girl presented with a 6-month history of fresh PR blood on the toilet paper and clearly mixed in with stools. She occasionally has pain on defecation, and intermittent, generalized sharp abdominal pain that resolves spontaneously. She denies any significant constipation. There is no vomiting, diarrhoea or weight loss. She has a normal diet and is growing well. On examination, her abdomen was soft and mildly
tender over the right side with stool palpable in her ascending colon. In the perianal region, there is a sentinel
skin tag but no evidence of a fissure. Urea, electrolytes and creatinine, liver function tests, Creactive
protein, erythrocyte sedimentation rate and full blood count were all within normal limits.
(Q2 ) What is the most likely diagnosis given this history?
A- Constipation
B- Inflammatory bowel disease
C- Campylobacter enterocolitis
D- Meckel’s diverticulum
Abdominal X-ray revealed no faecal loading and a 99mTc pertechnetate scintigraphy (Meckel’s scan) showed no evidence of functional ectopic gastric tissue. An upper endoscopy and colonoscopy were done with biopsy of the intestinal mucosa. Histology showed no active inflammation, normal crypt architecture, no granulomas, no evidence of epithelial dysplasia nor evidence of malignancy. There was however raised mucosal eosinophil density with basophilic blush and positive Steiner staining.
(Q 3) This is diagnostic of
A- Coeliac disease
B- Helicobacter pylori infection
C- Crohn’s disease
D- Intestinal spirochaetosis
E- C. enterocolitis
(Q 4) Treatment should be with
A- Gluten exclusion diet
B- Triple agent therapy: omeprazole, amoxicillin and metronidazole
C- Elemental diet
D- Metronidazole
E- Symptomatic relief only
Answers
Q 2: A
Q 3: D
Q 4: D
PR bleeding has a number of different aetiologies. A comprehensive history and examination should be obtained to help direct the most appropriate investigations and in order to make an accurate diagnosis. Intestinal spirochaetes, IS, are difficult to diagnose because of non-specific symptoms. The causative organisms are Brachyspira aalborgi or Brachyspira pilosicoli.
Biopsy specimens obtained during endoscopy, can be suggestive of infestation when there is basophilic blush and positive Steiner staining with eosinophilic infiltration.
Definitive diagnosis is with electron microscopy that shows spirochaetes attached to epithelial cells However, if histology-staining is suggestive of IS, it may be pertinent to treat with a 7e10 day course of oral metronidazole, rather than proceeding to expensive confirmatory testing.
Inflammatory bowel disease, IBD, includes Crohn’s disease, CD, and ulcerative colitis, UC. They can present with abdominal pain, diarrhoea, bloody stools and weight loss. Weight loss is more common in CD, and blood loss in UC. CD can affect any part of the gastrointestinal tract whereas, by definition, UC will only affect the colon.
Diagnosing and differentiating IBD requires clinical assessment in correlation with biochemistry, radiology, endoscopy and histology investigations. UC is diagnosed by clinical history supported with colonoscopy findings. CD is diagnosed by history and the demonstration of focal lesions on colonoscopy with histology showing transmural inflammation and granulomas.
Constipation can be diagnosed on history and examination alone. Bleeding is often the result of an anal fissure. Abdominal X-ray can show faecal loading. Campylobacter enterocolitis can cause dysentery with
severe, crampy abdominal pain. It is transmitted mainly via infected food and its course is usually self-limiting over a few days.
Most children infected with Helicobacter pylori, are asymptomatic.
-----------------
Q 5:
A 12-year-old girl has had intermittent periumbilical abdominal pain for the past 4 years.
Sometimes the pain worsens when she drinks a glass of milk. A lactose breath hydrogen test
demonstrates a breath hydrogen of 40 ppm after 1 hour (normal, <20 ppm).
Of the following, the food that this girl is MOST likely to tolerate is
A. buttermilk
B. cheddar cheese
C. ice cream
D. skim milk
E. whole milk
Answer
B
Lactose intolerance (lactose maldigestion) is a common cause of pediatric recurrent abdominal
pain. Lactase is a digestive enzyme located on the intestinal villi that converts the disaccharide
lactose to the monosaccharides glucose and galactose. The monosaccharides can be
absorbed across the intestinal epithelial cells. In an individual who has low intestinal lactase
(lactose intolerance), the lactose cannot be broken down and passes into the lower intestine and
colon. The malabsorbed lactose can cause osmotic diarrhea or be fermented by bacteria,
resulting in pain, gas, and bloating. Lactose intolerance can either be primary (lactase activity
that gradually declines with aging) or secondary (an infection or enteropathy damages the villi,
resulting in lactose intolerance).
Lactose intolerance may be diagnosed clinically by elimination diet and rechallenge or
through lactose breath hydrogen testing. Breath testing offers the advantage of providing a more
definitive diagnosis, so milk is not withdrawn from the diet unnecessarily. In a breath hydrogen
test, an adult is given approximately 50 g of lactose (the equivalent of 4 cups of milk) as a single
dose. Patients who cannot digest and absorb this amount of lactose have the lactose fermented
to hydrogen by intestinal bacteria, which can be measured in the breath. Because intestinal
bacterial fermentation is essential for an accurate test, patients should not receive antibiotics for
at least 2 weeks prior to the test.
Many patients who have lactose intolerance diagnosed on breath test can tolerate small
amounts of lactose in their diet. Specifically, hard cheeses, such as cheddar, which often have
very little lactose (<0.5 g/serving), can be eaten by many patients who have lactose intolerance.
Other products, such as whole or skim milk, ice cream, or buttermilk, have more lactose
(approximately 10 g/serving) and are less likely to be tolerated
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