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Gastroenterology 27.3.25 Dr Deepshikha Kumar and Dr Sophia HwaiLearningOutcomes To revise the main presentations within Gastroenterology including: ● The acute abdomen ● Diarrhoea ● Dysphagia ● Heartburn ● Abdominal masses ● Upper GI bleed ● Lower GI bleedsLearningOutcomesQuestion 1 A 60-year-old woman presents to the Emergency Department with worsening colicky abdominal pain and fatigue for the past 2 years. She does not appear jaundiced. Bloods show elevated ALP, GGT and bilirubin. On examination, there is marked guarding. Since arriving in the ED, she has started vomiting and an abdominal X-ray shows gas in the biliary tree. What’s the most likely diagnosis? a. Cholangiocarcinoma b. Cholecystitis c. Gallstone ileus d. Acute cholangitis e. Biliary colicQuestion 1 A 60-year-old woman presents to the Emergency Department with worsening colicky abdominal pain and fatigue for the past 2 years. She does not appear jaundiced. Bloods show elevated ALP, GGT and bilirubin. On examination, there is marked guarding. Since arriving in the ED, she has started vomiting and an abdominal X-ray shows gas in the biliary tree. What’s the most likely diagnosis? a. Cholangiocarcinoma b. Cholecystitis c. Gallstone ileus d. Acute cholangitis e. Biliary colicQuestion 1-Explanation Gallstone ileus is a rare but serious complication of gallstones. Patients can be asymptomatic with gallstones, meaning the first may be with a complication eg. cholecystitis, cholangitis etc. Gas in the biliary tree (pneumobilia) is pathognomonic of gallstone ileus.Gallstone ileus Gallstone ileus describes gallstones in the bowel, leading to small bowel obstruction. Clinical features: - Vomiting, abdominal pain - Generally preceded by cholecystitis - History of gallstones Investigations: - Bloods, AXR, CT abdo/pelvis - In practice: Bloods, cultures, ABG, ECG, pregnancy test, BMs, CXR, US abdo, CXR, CT abdo, ERCP/MRCP Management: 1. Emergency resuscitation 2. Drip & drain (NG tube, IV fluids) 3. Biliary drainageGallstone ileus Pneumobilia Rigler’s triad Source: RadiopaediaDifferentials forTheAcuteAbdomen 1. Think about anatomical location of pain 2. Use VITAMIN C DEF or VINDICATE differentials mnemonics 3. Investigate for all key differentials Source: PassmedicineDifferentials for gallbladder disease Ascending Acute Chronic Biliary colic Mirizzi’s Cholangioar Pancreatitis Gallstone cholangitis Cholecystitis Cholecystitis syndrome cinoma ileus Pain Steady, Steady, severe Occasionally Colicky, Chronic Progressive Severe, Severe, quality severe, colicky, intermittent, radiates to generalised shoulder tip intermittent, worse after back pain worse after eating eating Physical Charcot’s Murphy’s sign Confirmed Confirmed Intermittent Courvoisier’s Grey-turner’s Distended exam triad: inflammation of gallstones jaundice law: jaundice Cullen’s abdomen, jaundice + gall- bladder on on US + enlarged vomiting, fever + RUQ US gallbladder small bowel pain obstruction Clues High fever Thickened Pain comes Anorexia, High calcium, Obstruction gallbladder and goes in weight loss serum lipase, on imaging wall with raised a stable and/or inflammatory patient amylase markersQuestion 2 A 65-year-old man presents to the Acute Medical Unit with abdominal pain and bloody diarrhoea after coming back from a long walk in the Pentlands. On examination, he is apyrexial and tender in the left iliac fossa. Bowel sounds are present and normal. His NEWS is 0. He has a past medical history of asthma, hypertension, NAFLD and gout. Given the likely diagnosis, what is the most appropriate diagnostic investigation? a. CT abdomen b. Colonoscopy c. Abdominal X-ray d. Stool culture e. Venous blood gasQuestion 2 A 65-year-old man presents to the Acute Medical Unit with abdominal pain and bloody diarrhoea after coming back from a long walk in the Pentlands. On examination, he is apyrexial and tender in the left iliac fossa. Bowel sounds are present and normal. His NEWS is 0. He has a past medical history of asthma, hypertension, NAFLD and gout. Given the likely diagnosis, what is the most appropriate diagnostic investigation? a. CT abdomen b. Colonoscopy c. Abdominal X-ray d. Stool culture e. Venous blood gasQuestion 2-Explanation This gentleman has blood in his stool, with a background of hypertension and NAFLD, indicating that he has cardiovascular risk factors for ischaemic bowel. His long walk could precipitate dehydration, further increasing his risk.Ischaemicbowel Mesenteric Ischaemia Ischaemic colitis Clinical features Typically due to emboli, on a background of AF Transient pain, particularly after eating Sudden, severe onset, disproportional severity of Can present with bloody diarrhoea in late pain stages Affects the small bowel Affects the large bowl, particularly watershed areas Investigations Bloods (FBC, U&E, LFTs, CRP, INR, group & save) Bloods (FBC, U&E, LFTs, CRP, INR, group & VBG (lactate) save) CT angiography VBG (lactate) Haemodynamically unstable -> Consider emergency CT angiography OGD + colonoscopy Ongoing rectal bleeding -> Consider flexible sigmoidoscopy +/- colonoscopy Management Empirical antibiotics Medical optimisation of cardiovascular risk Urgent surgery: embolectomy OR arterial bypass +/- factors bowel resection High mortality practiceBMJ best Ischaemicbowel Pneumatosis intestinalis Thumbprinting practiceBMJ best Ischaemicbowel Thrombus in SMA SMA stenosisQuestion 3 An 11-month-old baby boy is brought to A&E because his mother is concerned he is losing weight over the past 3 months. He passes three loose stools a day. His older brother has Type 1 diabetes. On inspection, his abdomen is distended and his buttocks are wasted. His abdomen is soft with no hepatosplenomegaly. What is the gold standard investigation for diagnosing the likely condition? A. Anti-endomysial antibodies B. Anti-smooth muscle antibodies C. Trial of special exclusion diet D. Anti-tissue transglutaminase antibodies E. Small bowel biopsyQuestion 3 An 11-month-old baby boy is brought to A&E because his mother is concerned he is losing weight over the past 3 months. He passes three loose stools a day. His older brother has Type 1 diabetes. On inspection, his abdomen is distended and his buttocks are wasted. His abdomen is soft with no hepatosplenomegaly. What is the gold standard investigation for diagnosing the likely condition? A. Anti-endomysial antibodies B. Anti-smooth muscle antibodies C. Trial of special exclusion diet D. Anti-tissue transglutaminase antibodies E. Small bowel biopsyQuestion 3-Explanation This baby boy most likely has coeliac disease given that he has a family history of autoimmune disease and faltering growth. Although anti-TTG with IgA, anti-EMA, and anti-gliadin test are considered the first-line investigation, they have a sensitivity of 78% to 100% and a specificity of 90% to 100%. Small bowel biopsy is the gold standard.Coeliacdisease T cell-mediated inflammatory disease affecting the small bowel when in contact with gluten. Associated with HLA-DQ2 allele, Type 1 DM, autoimmune thyroid diseases. Clinical features: - Abdo pain, N&V, diarrhoea, steatorrhoea, fatigue, failure to thrive, vitamin deficiencies, anaemia, dermatitis herpetiformis Investigations: - Bloods, stool cultures, serology (anti-TTG + IgA, anti-EMA, anti-gliadin), OGD + jejunal biopsy (gold standard) - Biopsy will show villous atrophy, crypt hyperplasia, increased intra-epithelial T-lymphocytes Management: - Gluten-free diet, avoid wheat/barley/rye, vitamins Complications: - Anaemia, hyposplenism, osteoporosis, Enteropathy-associated T cell lymphoma EATL.Question 4 A 13-year-old girl is brought to the acute walk-in clinic at the GP by her mother. She reports extensive vomiting and diarrhoea starting about an hour ago. She hasn’t noticed any blood. The mother states that they attended a birthday party at a friend's house where she ate sandwiches and finger food. What is the most likely causative organism? A. Bacillus cereus B. Norovirus C. Salmonella enterica D. Campylobacter jejuni E. Staphylococcus aureusQuestion 4 A 13-year-old girl is brought to the acute walk-in clinic at the GP by her mother. She reports extensive vomiting and diarrhoea starting about an hour ago. She hasn’t noticed any blood. The mother states that they attended a birthday party at a friend's house where she ate sandwiches and finger food. What is the most likely causative organism? A. Bacillus cereus B. Norovirus C. Salmonella enterica D. Campylobacter jejuni E. Staphylococcus aureusQuestion 4-Explanation The onset of symptoms point towards Staph. Aureus as it has a rapid incubation period.Gastroenteritis Gastroenteritis is predominantly viral or bacterial. Investigations: - Bloods (U&Es, Mg, bone profile, phosphate), stool sample for culture, microscopy, sensitivities and c.diff, cultures if septic Management: - Barrier nursing, A-E supportive management, notifiable diseases, consider antibiotics after discussion with micro Gastroenteritis Classically bloody diarrhoea Incubation period Clues Campylobacter jejuni 16-48 hours Raw meat, summer BBQs Non-typhoidal Salmonella 12-48 hours Complications: endocarditis, osteomyelitis Typhoidal salmonella 6-30 days Rose spots on body E.coli 16-48 hours Farms, undercooked meat. E.coli O157 can cause enterohaemorrhagic/ verotoxin-producing E.coli Linked to HUS in children or elderly Gastroenteritis Classically non-blood diarrhoea Incubation period Clues Staph. Aureus 1-6 hours Rapid onset Profuse vomiting Associated with raw food, shellfish Bacillus cereus 0.5-6 hours Associated with rice, reheated food Norovirus 12-24 hours Projectile vomiting Highly infectious – spreads quickly Giardia lamblia 1-14 days Recent travel abroad Incubation over a long period of time Clostridium difficile 24-72 hours Previous antibiotics, PPIs. Can present with bloody diarrhoeaQuestion 5 A 40-year-old woman presents to the GP concerned about a persistent groin lump. She first noticed the lump about 1 month ago and is otherwise painless. On examination, there is a lump located below the inguinal ligament on the left, lateral to the pubic tubercle and has a cough impulse. There are no signs of inflammation. She has a BMI of 29. Which of the following is the most appropriate management plan? A. Urgent referral to A&E B. Urgent referral to general surgery C. Routine surgical referral D. Advise weight loss, surgical referral if no improvement E. Watchful waitingQuestion 5 A 40-year-old woman presents to the GP concerned about a persistent groin lump. She first noticed the lump about 1 month ago and is otherwise painless. On examination, there is a lump located below the inguinal ligament on the left, lateral to the pubic tubercle and has a cough impulse. There are no signs of inflammation. She has a BMI of 29. Which of the following is the most appropriate management plan? A. Urgent referral to A&E B. Urgent referral to general surgery C. Routine surgical referral D. Advise weight loss, surgical referral if no improvement E. Watchful waitingQuestion 5-Explanation Groin hernias are common and can be distinguished with clinical findings alone. This lady has a femoral hernia which has a high chance of strangulation and therefore must be referred urgently for a surgical opinion.Hernias Outpouchings of bowel through the abdominal wall. Differentials of hernias include lipoma, femoral artery aneurysm, lymph nodes Investigations: - Physical exam, US, (CT), (MRI groin), AXR + CXR if perforation suspected Management: - If femoral: Urgent lap/ open repair due to risk of strangulation (50% of femoral hernias strangulate within the first month) - If inguinal: Irreducible/ Incarcerated -> Urgent surgical referral - Any strangulation or signs of intestinal obstruction -> Emergency lap/open repair Incarcerated: Bulge cannot be pushed back Strangulated: Blood supply is compromised Source: Radiopaedia Hernias Femoral hernia Large, perforated inguinal hernia Source: Radiopaedia Hernias Pneumoperitoneum More subtle pneumoperitoneumHernias Femoral hernia Direct inguinal hernia Indirect inguinal hernia Clues - Middle-aged women - Older men - Young boys - Inferior to inguinal - Medial to inferior - Lateral to inferior ligament and epigastric vessels epigastric vessels infero-lateral to the through Hasselbach’s into the scrotum pubic tubercle triangle, supero-medial to the pubic tubercleQuestion 6 A white UK resident 64 male presents after 3-4 months of worsening dysphagia and odynophagia which is exacerbated by meats and breads. Whilst he has no issues with red flag symptoms, he reports 2 episodes of vomiting after meals in the last over the last 6 weeks. He is sent for a barium swallow which shows esophageal shouldering near the GOJ. He admits to enjoying, occasionally cured meats and hot curries most days of the week and he had a viral infection 1 month ago. There is a family history of autoimmune conditions in the family. What is the most likely diagnosis? A: Adenocarcinoma B: Squamous cell carcinoma C: Barrett's Oesophagus D: Gastro-Oesophageal reflux E: AchalasiaQuestion 6: A white UK resident 64 male presents after 3-4 months of worsening dysphagia and odynophagia which is exacerbated by meats and breads. Whilst he has no issues with red flag symptoms, he reports 2 episodes of vomiting after meals in the last over the last 6 weeks. He is sent for a barium swallow which shows esophageal shouldering near the GOJ. He admits to enjoying, occasionally cured meats and hot curries most days of the week and he had a viral infection 1 month ago. There is a family history of autoimmune conditions in the family. What is the most likely diagnosis? A: Adenocarcinoma B: Squamous cell carcinoma C: Barrett's Oesophagus D: Gastro-Oesophageal reflux E: AchalasiaQuestion 6Theme: Dysphagia Explanation swallow points to a growth and tumors near a GOJ are more likely to be adenocarcinoma due to migration ofarium the cells from the gastric lining. Adenocarcinoma increasingly the more common type of Oesophageal cancer with higher prevalence in those with background of GORD/ Barett’s. It is the more common histological type of Oesophgeal Ca in the developed world with SCC’s more common in the developing world. Cured meats can be a risk factor for SCC related esophageal Ca as they are rich in nitrosamines. SCC more common in upper third and adenocarcinoma in lower third Whilst Achalasia can be triggered by viral infection, the combined information in the stem points to a cancer with the history of progressive worsening symptoms predating the viral infection. Other redflags to clarify in the patient include weight loss, anorexia, melena, voice change, coughQuestion 6:OesophagealCancer Features ● Dysphagia: most common Investigations: symptom ● Endoscopic Ultrasound for locoregional ● Anorexia staging. NOT THE SAME AS ERCP! ● Vomiting ● CT TAP for staging ● Painful swallow, melena, voice ● FDG PET CT for occult mets ● Occasionally laparoscopic procedure for occult change peritoneal metastatic disease Differentials for dysphagia Management: ● Achalasia ● Foreign Object ● tumors: surgery preferred for early detected ● Oesophageal stricture cancers ● Eosinophilic Oesophagitis (EoE) ● Endoscopic mucosal resection or endoscopic ● Gastroesophageal reflux disease submucosal dissection for early-stage disease. (GORD) ● Adjuvant chemotherapy Question 6: Barium Swallowinterpretations Irregular stricturing Barium fluoroscopy: C5/C6 Bird beak, corkscrew- level, posterior pharyngeal and proximal tertiary corkscrewing wall above the upper shouldering Mediastinal widening oesophageal sphincter Oesophageal Ca Achalasia: dysphagia with Pharyngeal Pouch: liquid and solids! Dysphagia, aspiration Risk of aspiration pneumonia pneumonia, halitosis, neck corkscrew)phgeal spasm ( swelling, chronicQuestion 7: A 40 year old factory worker with plantar fasciitis presents to ED after a vasovagal episode. He reports a burning chest pain over the last few months but also adds that he had passed some foul smelling and thick tarry stools in the last week. Other than taking an OTC pain relief for the Plantar fasciitis every day for last 3 months, he is well in himself. He appears pale with a thready pulse and whilst his abdomen is soft and non tender there is intense epigastric tenderness. What is the 1st line treatment recommended in this patient's management? A: A- E assessment B: IV fluids C: IV Omeprazole D: Emergency OGD E: Interventional angiography with transarterial embolisationQuestion 7: A 40 year old factory worker with plantar fasciitis presents to ED after a vasovagal episode. He reports a burning chest pain over the last few months but also adds that he had passed some foul smelling and thick tarry stools in the last week. Other than taking OTC pain relief for the Plantar fasciitis every day for last 3 months he is well in himself. He appears pale with a thready pulse and whilst his abdomen is soft and non tender there is intense epigastric tenderness. What is the 1st line treatment recommended in this patient's management? A: A- E assessment B: IV fluids C: IV Omeprazole D: Emergency OGD E: Interventional angiography with transarterial embolisationQuestion 7Theme: Heartburn Explanation Melena and potential haemodynamic instability, and OTC pain relief ( likely NSAID) indicates these is bleeding so of the key differentials there is most concerns regarding: perforated ulcer or a bleeding ulcer. The questions asks for treatment and not 1st line management. If the question asked for management the 1st step would be to do A-E → IV fluids→ IV PPI → emergency OGD ( angiography for transarterial embolisation if the OGD embolisation didn’t work).Question 7: Heartburn differentials ● Perforated peptic ulcer: GI content enter the peritoneal cavity→ peritonitis(severe pain on abdominal palpations/? Tense abdomen)--> diffuse abdominal pain, abdominal distension, rigidity, and guarding. ● Acute gastritis: burning upper abdominal pain. No melaena or syncope ● Bleeding oesophageal varices: PMH of liver cirrhosis and portal hypertension + haematemesis. SH: ETOH excess, PMH: hepatitis ● Peptic ulcer: 75% of cases have bleeding as a complications. Gastroduodenal artery is the main cause of the bleeding.Question 8 A 45 yr old female with known colitis extending upto and into the ascending colon presents to the GP with 5 bloody motions/ day and mildly pyrexic at 37.6 C. She is already on rectal mesalazine. She hasn’t had any other flair up in last 3 years. What further management can be added to this lady’s regime to help her symptoms? A: Oral azathioprine B: High-dose oral aminosalicylate and a topical corticosteroid C: Prednisolone D: IV Ciclosporin E: Oral aminosalicylateQuestion 8 A 45 yr old female with known colitis extending upto and into the ascending colon presents to the GP with 5 bloody motions/ day and mildly pyrexic at 37.6 C. She is already on rectal mesalazine. She hasn’t had any other flair up in last 3 years. What further management can be added to this lady’s regime to help her symptoms? A: Oral azathioprine B: High-dose oral aminosalicylate and a topical corticosteroid C: Prednisolone D: IV Ciclosporin E: Oral aminosalicylate Question 8:Theme-UCmanagement UC grading: Truelove and Witt's criteria Inducing remission Mild/ Moderate Severe Colitis Mild Moderate Severe Proctitis: Proctosigmoiditis and Extensive disease Treat in hospital left-sided ulcerative 1st line: IV steroids Topical aminosalicylate: colitis -line < 4 stools/day, 4-6 stools/day, >6 bloody stools per day + distal colitis - rectal Topical (rectal) Steroid mesalazine > rectal aminosalicylate + contraindicated: IV small amount varying systemic involvement steroids + oral Topical aminosalicylate high-dose oral ciclosporin amounts of (fever, tachycardia, Remission is not achieved aminosalicylate: No response after 72 of blood aminosalicylates 4/52: + high-dose oral Remission is not achieved hours: consider blood, nil anaemia, raised CRP/ WCC/ Remission is not achieved to IV corticosteroids systemic issue Neuts) in 4/52: + oral aminosalicylate OR 4/52: Stop topical OR consider surgery aminosalicylate Switch to high-dose oral treatments & Offer oral Remission still not aminosalicylate + topical aminosalicylate + oral achieved: + topical/ oral corticosteroid corticosteroid corticosteroid Remission still not achieved: Stop topical treatments & Offer oral aminosalicylate + oral corticosteroid Maintain Remission Proctitis and proctosigmoiditis Left-sided + extensive Following a severe NB: ulcerative colitis relapse or >=2 Topical aminosalicylate (daily/ intermittent) OR exacerbations in Oral aminosalicylate + topical aminosalicylate (daily or oral azathioprine or Methotrexate: for Chrons intermittent) OR Low maintenance dose of Oral aminosalicylate alone itself. not as effective as oral aminosalicylate oral mercaptopurine combined therapy Probiotics: useful for UCQuestion 9 A 35 yr F has been referred from her GP to hospital due to 1 month history of of fluctuating diarrhoea and constipation and feelings of tenesmus and abdominal cramping. She notes blood on wiping after passing stool and at times also reports blood mixed in her stool. She is a lawyer and feels work has contributed to her feeling really tired of late as she has been staying late. Her fbc is as follows: Hb 10.8 g/dL (13.5-18.0 g/dL) MCV 65 fl (76-96 femtol). She is very anxious as her paternal grandmother died of endometrial cancer by age 65 and her paternal uncle of colorectal Ca. Both were diagnosed by the age of 50. What gene is likely to be implicated for this lady? A: EGFR B: CEA C: K ras D: MLH1 E: APC geneQuestion 9 A 35 yr F has been referred from her GP to hospital due to 1 month history of of fluctuating diarrhoea and constipation and feelings of tenesmus and abdominal cramping. She notes blood on wiping after passing stool and at times also reports blood mixed in her stool. She is a lawyer and feels work has contributed to her feeling really tired of late as she has been staying late. Her fbc is as follows: Hb 10.8 g/dL (13.5-18.0 g/dL) MCV 65 fl (76-96 femtol). She is very anxious as her paternal grandmother died of endometrial cancer by age 65 and her paternal uncle of colorectal Ca. Both were diagnosed by the age of 50 What gene is likely to be implicated for this lady? A: EGFR B: CEA C: K ras D: MLH1 E: APC geneQuestion 9:ThemeColorectalCa Explanation Colorectal Ca Oncogenes: EGFR, K-ras, Familial adenomatous polyposis:associated with familial syndrome. Large number of polyps form with the colon. Total colectomy is the prophylactic treatment Lynch Syndrome/ Hereditary nonpolyposis colorectal cancer (HNPCC): autosomnal dominant, MLH 1 is the gene implicated in Lynch syndrome. Cancers associated: Endometrial, Colorectal, Skin, Ovarian, Upper GI, Hepato-Biliary, CNS( brain), Urinary tract. Mainstay of Mx: Early surgery, surveillance, genetic counselling for family and family planning. Did you note the red flags: Bowel habit change/ anaemia/ fatigue/ melena/ FHQuestion 9:ThemeColorectalCa 2WW NICE 2WW criteria NICE 2WW criteria FIT for: FIT > 10 → urgent 2ww colonoscopy ● Abdominal mass, ● Bowel habit change * ● Offer FIT even if previous ● >40: unexplained weight FIT is Negative loss, abdominal pain ● ● <50: rectal bleeding, ● Adult with rectal mass? : unexplained weight loss, no FIT needed , 2ww abdominal pain * referral regardless ● > 50: rectal bleeding, weight loss, abdominal pain ● >60: anaemia without iron deficiency North Bristol 2ww symptom pathway for suspected colorectal caQuestion 10 A 60 yr old lady with a known GI disease presents to ED with fever, feeling more tired and left sided abdominal pain. She reports passing urine that had a fecal odour and that it feels like a bubbling sensation when she passes urine. She has a history of going to her GP with vaginal discomfort and infections in the last 12 months. In the last 2 days she has been feeling worse. Her observations are: Temp: 38.3C, BP: 110/70, HR: 120, SPO2: 96% RA, RR: 22 O/E: Abdomen is tender, peritonitic and there is guarding with LIF pain 9/10, Erect CXR and AXR shows some air under the diaphragm. What’s the most appropriate initial management? A: Urgent colonoscopy B: IV abx, and IV fluids, keep NBM as Cat 1 and admit to surgical ward C: Urgent Laparoscopy D: Admit to medical ward, IV Abx, IV fluids E: CT scanQuestion 10 A 60 yr old lady with a known GI disease presents to ED with fever, feeling more tired and left sided abdominal pain. She reports passing urine that had a fecal odour and that it feels like a bubbling sensation when she passes urine. She has a history of going to her GP with vaginal discomfort and infections in the last 12 months. In the last 2 days she has been feeling worse. Her observations are: Temp: 38.3C, BP: 110/70, HR: 120, SPO2: 96% RA, RR: 22 O/E: Abdomen is tender, peritonitic and there is guarding with LIF pain 9/10, Erect CXR and AXR shows some air under the diaphragm. What’s the most appropriate management? A: Urgent colonoscopy B: IV abx, and IV fluids, keep NBM and admit to surgical ward C: Urgent Laparoscopy D: Admit to medical ward, IV Abx, IV fluids E: CT scanQuestion 10: Explanation She might need a CT scan and an urgent laparoscopy but managing her means stabilizing her! Fever: needs Abx Tachycardia/ Low BP: needs IV fluids Air under diaphragm/ air in urine/ peritonitic: needs urgent surgery→ Keep NBM for surgery What does she have as a Dx? Diverticulitis with a colovaginal and colo-ureteric fistula and infection Surgery of choice: Hartmann’s procedureLearningOutcomes SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! 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