1. Case 1 21 year old male office worker GP referral, “IBS not responding to Rx 3 month history of abdominal discomfort, worse after eating, can keep him awake Wight loss of ½ stone Intermittent loose motions

2. Case 1 Average build Slightly pale Abdomen not distended Mild tenderness in lower half No mass palpable Anus normal,∑ - normal rectal mucosa

3. Case 1 How would you investigate him?

4. Case 1

5. What is the diagnosis? – Confirmatory investigations? How would you manage the patient?

6. Case 2 30 year old anaesthetic registrar Presented as emergency: – acute abdominal pain and vomiting 3 month history of abdominal discomfort Wight loss of ½ stone Loose motions

7. Case 2 Unwell Fever 38 0 c Distended abdomen Tender, guarding

8. Case 2 AXR

9. Case 2 Laparotomy Small bowel obstruction Adhesions right iliac fossa to Inflamed appendix and ileocaecal area What operation?

10. Case 2 Laparotomy Small bowel obstruction Adhesions right iliac fossa to Inflamed appendix and ileocaecal area Appendicectomy performed (non specific acute inflammation)

11. Case 2 Next 4 months continued abdominal pain Diarrhoea persists Further weight loss Frightened to eat What investigations?

13. Case 2 What is the diagnosis? What management? Medical? Surgical?

15. Case 3 18 year old trainee chef Feels tired 6 month history of abdominal pain and diarrhoea Bowels opened up to 6 times per day Mucus in stool Occasional blood with motion

16. Case 3 Pale, clinically anaemic Tall and thin Abdomen soft, mild tenderness in left iliac fossa No mass palpable Anus – small tags only Rectal mucosa “normal” – slightly red

17. Case 3 Hb – 10.6 Platelets – 635 WCC – 8.9 CRP – 87 Barium enema

18. Case 3 Isolated left colonic stricture Distal sigmoid and rectum normal Proximal colon “looks normal”

19. Case 3 How would you manage this patient?

20. Case 3 What operation would you perform?

21. Case 3 Represents January 2006 Acute anal abscess Large tags Abscess partially draining from 2 sites EUA Chronic fistulous abscess posteriorly Ulcerated anal canal Active rectal inflammation

22. Case 3

23. How would you manage this patient now?

24. Case 4 56 year old female Previous resection for ileo-colic Crohn’s disease Previous anal abscess x 2 Now presents with increasing anal and labial pain Miserable

26. Case 4 How would you manage this patient – Further investigations – Treatment