17/07/2021 Revise - MRCEM Success

DASHBOARD
STATISTICSREVIEW TEXTBOOK START REVISING

Gastroenterology & Hepatology  QUESTION 27

> SCORE 67%

 18 9

 REFERENCE RANGES

QUESTIONS

Q23. X
Answered
Q24. X
Answered
Q25. X
Answered
Q26. ✓
Answered

Q27. X
Answered
Q28. Unanswered

A 19 year old woman presents to the Emergency Department with tender

"lumps" over her lower legs. She has no past medical history but does Something wrong?
complain of abdominal pain and diarrhoea over the last month,
https://intermediate.mrcemsuccess.com/dashboard/revise/ 1/11
17/07/2021
p p ,
Revise - MRCEM Success

occasionally associated with blood and mucus. What is the most likely
diagnosis?

x Clostridium difficile colitis 8%

Coeliac disease 14%

✓ Ulcerative colitis 73%

Lactose intolerance 0%

Gastroenteritis 5%

ANSWER
This is erythema nodosum, a type of panniculitis presenting as tender, red or violet
subcutaneous nodules, 1–5 cm in diameter, usually seen on the anterior tibial area or extensor
surfaces of the legs or arms. This is an extra-intestinal manifestation of inflammatory bowel
disease. Other causes include: infections (e.g. Streptococcal disease, TB, leprosy, Salmonella,
Campylobacter), drugs (e.g. sulfonamides, oral contraceptives) other inflammatory conditions
(e.g. sarcoidosis, Behçet disease) or malignancy (e.g. leukaemia, lymphoma).

Previous Save End Session Next

https://intermediate.mrcemsuccess.com/dashboard/revise/ 2/11
17/07/2021 Revise - MRCEM Success

Inflammatory Bowel LAST UPDATED: 1 2TH

FEBRUARY 2021
SEARCH

Disease  Bookmark
Search "Peptic Ulcer Disease:
Diagnosis"
GASTROENTEROLOGY & HEPATOLOGY
OR
Inflammatory bowel disease (IBD) is a lifelong condition, typified by periods of Search textbook...
relapse and remission with recurrent cycles of inflammation.

Definitions
Something wrong?

Crohn's disease is a chronic, relapsing-remitting, non-infectious

inflammatory disease of the gastrointestinal tract. The inflammation
involves discrete parts of the gastrointestinal tract, anywhere from the
mouth to the anus; these are called 'skip lesions' because they leave
normal areas in between. The full thickness of the intestinal wall is
inflamed, in contrast to the inflammation in ulcerative colitis, which is
limited to the intestinal mucosa.
Ulcerative colitis is a chronic, relapsing-remitting, non-infectious
inflammatory disease of the gastrointestinal tract. It is characterised by
diffuse, continuous, superficial inflammation of the large bowel limited to
the intestinal mucosa, and usually affects the rectum with a variable
length of the colon involved proximally.

Clinical features

Symptoms
Unexplained persistent diarrhoea (frequent loose stools for more
than 4–6 weeks) including nocturnal diarrhoea
https://intermediate.mrcemsuccess.com/dashboard/revise/ 3/11
17/07/2021 Revise - MRCEM Success
than 4–6 weeks), including nocturnal diarrhoea
Faecal urgency and/or incontinence
Blood or mucus in the stool
Tenesmus (persistent, painful urge to pass stool even when the
rectum is empty)
Pre-defecation pain, which is relieved on passage of stool
Abdominal pain or discomfort
Non-specific symptoms such as fatigue, malaise, anorexia, or
fever
Weight loss, faltering growth or delayed puberty in children
Symptoms of complications e.g. fistulae or bowel obstruction
Signs
Pallor, clubbing, aphthous mouth ulcers
Abdominal tenderness or mass
Perianal pain or tenderness, anal or perianal skin tag, fissure,
fistula, or abscess
Signs of malnutrition and malabsorption
Extra-intestinal manifestations, including abnormalities of the
joints, eyes, liver, and skin

Extra-intestinal manifestations

Extra-intestinal manifestations related to disease activity include:

Pauciarticular arthritis
This affects fewer than five large joints, such as the ankles,
knees, hips, wrists, elbows, and shoulders. It is usually
asymmetric, acute, and self-limiting (lasting for weeks
rather than months), and joints tend not to be permanently
damaged. There is often associated enthesitis
(inflammation where a tendon attaches to a bone),
tenosynovitis (inflammation of a tendon and its sheath) or
https://intermediate.mrcemsuccess.com/dashboard/revise/ 4/11
17/07/2021 Revise - MRCEM Success
tenosynovitis (inflammation of a tendon and its sheath), or
dactylitis (inflammation of an entire finger or toe).
Erythema nodosum
Tender, red or violet subcutaneous nodules, 1–5 cm in
diameter. Usually on the anterior tibial area or extensor
surfaces of the legs or arms.
Aphthous mouth ulcers
Painful, clearly defined, round or ovoid, shallow ulcers of the
smooth surfaces of the mouth and underside of the tongue.
Episcleritis
Red eye with injected sclera and conjunctiva. May be
painless or painful, itching or burning.
Metabolic bone disease (osteopenia, osteoporosis, osteomalacia)
Osteoporosis occurs in up to 30% of men and women with
IBD. Contributing factors include age, corticosteroid
treatment, smoking status, low physical activity, extensive
small bowel disease or resection, and nutritional
deficiencies. Osteopenia is a precursor of osteoporosis
causing reduced bone mineral density. Osteomalacia is a
condition of defective bone matrix mineralisation resulting
from vitamin D malabsorption.
Venous thromboembolism
The risk of VTE is increased in IBD and the risk is greatest
during active disease.
Extra-intestinal manifestations not related to disease activity include:
Axial arthritis
This affects the sacroiliac joint (sacroiliitis) or spine
(spondylitis), causing buttock and back pain.
https://intermediate.mrcemsuccess.com/dashboard/revise/ 5/11
17/07/2021 Revise - MRCEM Success
Polyarticular arthritis
This affects five or more joints, such as the small joints of
the hands. It is usually symmetrical and persistent, and it
damages the affected joints.
Pyoderma gangrenosum
Single or multiple erythematous papules or pustules
develop into deep ulcers containing sterile pus unless they
are secondarily infected. Occurs anywhere, most
commonly on the shins, and often at the site of previous
trauma.
Psoriasis
A systemic, immune-mediated, inflammatory skin disease
which typically has a chronic relapsing-remitting course,
and may have nail and joint involvement.
Uveitis (also known as 'iritis' or 'iridocyclitis').
Uveitis is usually bilateral, with an insidious onset and
chronic course. It presents as a painful red eye, with
injected conjunctiva, blurred vision, photophobia, and
headache.
Hepatobiliary conditions, such as primary sclerosing cholangitis,
pericholangitis, steatosis, autoimmune hepatitis, cirrhosis, and
gallstones.
They often present as an incidental finding of abnormal liver
function tests, rather than as biliary symptoms.
Others
Rare extra-intestinal manifestations of inflammatory bowel
disease include bronchiectasis, bronchitis,
hyperhomocysteinemia, pancreatitis and renal stones.

Complications

https://intermediate.mrcemsuccess.com/dashboard/revise/ 6/11
17/07/2021
Co p ca o s Revise - MRCEM Success

Psychosocial impact — for example on school, work, or leisure activities.

Toxic megacolon — a potentially life-threatening complication with
segmental or total non-obstructive dilatation of the colon accompanied
by escalating abdominal pain and systemic symptoms, which may
require colectomy. Typically there is dilatation of the transverse colon on
abdominal X-ray. It may occur spontaneously as a result of relapse, or be
precipitated by infection, hypokalaemia, hypomagnesaemia, medical
bowel preparation, or the use of anti-diarrhoeal drugs.
Bowel obstruction — suggested by lack of passing stool or flatus,
abdominal pain, distension, or vomiting.
Bowel perforation — may complicate acute severe colitis and may be
associated with inappropriate total colonoscopy investigation or toxic
megacolon if colectomy has been inappropriately delayed.
Intestinal strictures — where the intestine narrows and partially or
completely obstructs the passage of bowel contents.
Fistulas — where the bowel wall is perforated, allowing faecal matter to
track through to adjacent organs, such as the intestine, bladder, vagina,
abdominal wall, or perianal skin.
Significant haemorrhage - especially if the disease affects the colon.
Anaemia — may be due to iron deficiency (through blood loss or
nutritional deficiency), vitamin B12 or folate deficiency (through
decreased absorption), anaemia of chronic disease, or drug-associated
anaemia.
Malnutrition, faltering growth, and delayed pubertal development (in
children) — may be due to reduced oral intake, increased nutrient
requirements, increased gastrointestinal losses and malabsorption, long-
term corticosteroid use, and drug-nutrient interactions.
Increased risk of malignancy in the small and large intestine.
Perianal disease — a frequent complication of colonic and ileocolonic
disease characterised by fissures fistulae or abscesses
https://intermediate.mrcemsuccess.com/dashboard/revise/ 7/11
17/07/2021 Revise - MRCEM Success
disease, characterised by fissures, fistulae, or abscesses.

Differential diagnosis

Infective colitis
Pseudomembranous colitis (Clostridium difficile infection)
Microscopic colitis
Intestinal ischaemia
Acute appendicitis
Diverticulitis
Coeliac disease
Irritable bowel syndrome
Anal fissure
Malignancy (such as colorectal cancer, small bowel cancer, and
lymphoma)
Endometriosis
Laxative misuse

Investigations

If a diagnosis of IBD is suspected, consider arranging the following

investigations:
Serum full blood count — anaemia may be due to blood loss,
malabsorption, or malnutrition; an increased platelet count may suggest
active inflammation.
Serum inflammatory markers such as C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR) — may be raised if there is active
inflammation or an infectious complication.
Serum urea and electrolytes — to assess for electrolyte disturbance and
signs of dehydration.
Serum liver function tests, including albumin — a low serum albumin may
https://intermediate.mrcemsuccess.com/dashboard/revise/ 8/11
17/07/2021 Revise - MRCEM Success
Serum liver function tests, including albumin a low serum albumin may
indicate protein-losing enteropathy and reflects disease activity and
severity as well as nutritional status.
Serum ferritin, vitamin B12, folate, and vitamin D levels — may be
nutritional deficiencies due to malabsorption or intestinal losses.
Thyroid function tests — to exclude hyperthyroidism.
Coeliac serology — to exclude coeliac disease.
Stool microscopy and culture, including Clostridium difficile toxin — to
exclude infective gastroenteritis or pseudomembranous colitis.
Faecal calprotectin (a faecal white cell marker, for adults) — if raised may
suggest active inflammation (compared with a normal result which is
expected in irritable bowel syndrome).
Additional tests if extra-intestinal manifestations such as pancreatitis,
inflammatory arthritis, or primary sclerosing cholangitis are suspected,
depending on clinical judgement.
Specialist investigations may include:
Colonoscopy with histology of multiple intestinal biopsy specimens,
which allows classification of disease extent and severity.
Upper intestinal endoscopy for children and young people, and if there
are upper gastrointestinal tract symptoms in adults.
Magnetic resonance enterography (MRE) of the small bowel and
additional small bowel imaging.
Pelvic MRI to evaluate suspected perianal disease, to allow definition of
the extent and location of abscesses and fistulas.
Computed tomography (CT) to stage disease and look for extraluminal
complications, such as abscesses and fistulas.
Abdominal ultrasound to assess bowel thickness and dilatation
(suggesting obstruction), abscesses, fistulas, and strictures.
Plain abdominal X-rays to identify small bowel or colonic dilatation,
which may indicate complications such as bowel obstruction and toxic
megacolon
https://intermediate.mrcemsuccess.com/dashboard/revise/ 9/11
17/07/2021 Revise - MRCEM Success
megacolon.

Management

Suspected IBD:
Arrange emergency hospital admission if the person is
systemically unwell with symptoms of bloody diarrhoea, fever,
tachycardia, or hypotension.
Do not prescribe anti-diarrhoeal drugs if the clinical diagnosis is
uncertain, as they may precipitate toxic megacolon.
If hospital admission is not indicated, arrange an urgent referral to
secondary care (paediatric gastroenterologist for children or
gastroenterologist for adults) for confirmation of the diagnosis and
initiation of specialist drug treatments. Options include:
Corticosteroids
Aminosalicylates e.g. mesalazine and sulfasalazine
Calcineurin inhibitors e.g. tacrolimus or ciclosporin
Immunosuppressive drugs e.g. thiopurines (azathioprine,
mercaptopurine) or methotrexate (second-line)
Biologic therapy e.g. anti-tumour necrosis factor alpha
monoclonal antibody agents infliximab and adalimumab
Specialist enteral nutritional supplementation
Confirmed IBD flare-up:
Arrange an emergency hospital admission if the person has a
suspected flare-up of IBD and is systemically unwell with severe
symptoms, such as:
Severe diarrhoea (more than 6–8 stools a day).
Fever, dehydration, tachycardia, or hypotension.
Severe abdominal pain.
Suspected intestinal obstruction or intra-abdominal or
https://intermediate.mrcemsuccess.com/dashboard/revise/ 10/11
17/07/2021 Revise - MRCEM Success

perianal abscess.
Cachexia with body mass index (BMI) less than 18.5 kg/m2,
or unintended sudden weight loss.
Raised inflammatory markers and/or anaemia.
Persistent symptoms despite optimal management in
primary care.

https://intermediate.mrcemsuccess.com/dashboard/revise/ 11/11