Altered Bowel Habit Flashcards
what is acute diarrhoea?
3 or more loose stool in 24 hours and/or stools that are more frequent than normal for the individual lasting <14 days and/or stool weight
acute <14 days
persistent >14 days
chronic >4 weeks
what is chronic diarrhoea?
chronic diarrhoea is the presence of more than 3 loose stools per day for more than 4 weeks
what are the differentials for acute diarrhoea?
Rotavirus Norovirus Enteric adenovirus Campylobacter Shigella Salmonella E.coli C.diff Vibrio cholerae Staphylococcus aureus Bacillus cereus Clostridium perfingens Listeria Giardia Entamoeba histolytica Microsporidiosis Medications Ulcerative colitis Crohn’s disease Irritable bowel syndrome
what are the differentials for chronic diarrhoea?
Ulcerative colitis Microscopic colitis Viral, bacterial, parasitic, HIV enteropathy Irritable bowel syndrome Drug effects Faecal impaction Coeliac disease Crohn’s disease Bile salt malabsorption Brush border enzyme deficiency Small intestinal bacterial overgrowth Pancreatic insufficiency Alcohol Hyperthyroidism Diabetes mellitus Radiation enteritis/colitis Eosinophilic enteritis Chronic ischaemic colitis Surgical bypass or resection
what are the diagnostic features of rotavirus?
Children in day care centres. Fever, vomiting, diarrhoea-watery, yellow, no blood or mucus
what is the incubation period of rotavirus?
2 days
what are the diagnostic features of norovirus?
Consumption of shellfish, prepared foods, salads, sandwiches, fruit.
Nausea, abdominal cramps followed by diarrhoea and vomiting, it is watery, moderate, no blood or mucus, fever, malaise, myalgia, headache
what is the incubation period of norovirus?
12-48 hours
what are the diagnostic features of enteric adenovirus?
Common in infants, older adults and immunocompromised people. Secondary to contaminated food. Common in daycare centres and institutions. Mild, self-limiting diarrhea with no fever
what is the incubation period of enteric adenovirus?
3-10 days
what are the diagnostic features of campylobacter?
Ingesting of undercooked poultry, raw milk or cheese. Diarrhoea either watery profuse or bloody with mucus. Resolve after 5-7 days. Crampy periumbilical pain and fever. Bloody diarrhoea from 3rd say
what is the incubation period of campylobacter?
2-4 days
what are the diagostic features of shigella?
Usually in children in daycare. Eating vegetables. Fever then develop diarrhoea, watery becoming mucoid and bloody. Small in amount. 10-12 stools a day. 1/3 have fever and tenesmus.
what is the incubation period of shigella?
12 hours to 7 days (usually 1-3 days)
what are the diagnostic features of salmonella?
Usually from food and foecally contaminated water, common with pets. Nausea, vomiting, fever, diarrhoea (uto 10 days, cramping)
what is the incubation period of salmonella?
6-72 hours
what are the diagnostic features of E.coli?
Travellers, children, dysentery usually contaminated food. Profuse watery diarrhoea or bloody diarrhoea. Abdominal pain but no fever. Rare-dehydration, low BP, high HR
what is the incubation period of E.coli?
3-4 days
what are the diagnostic features of C.diff?
History of antibiotic use, hospitalisation, chemotherapy development of diarrhoea in 2-3 weeks. Acute watery diarrhoea. Can be mild or severe number of times a day and pain. ?
what is the incubation period of C.diff?
7 days
what are the diagnostic features of vibrio chloerae?
Mild disease-cannot distinguish between it and gastroenteritis. Watery diarrhoea. Severe-diarrhoea with volume loss (rice water stool), abdominal cramps
what is the incubation period of vibrio cholerae?
2-3 days
what are the diagnostic features of staphylococcus aureus?
Ingestion of beef, pork, poultry, eggs 4-6 hours before symptoms. Nausea, vomiting, later watery diarrhoea, no fever or abdominal pain
what is the incubation period of staphylococcus aureus?
1-6 hours
what are the diagnostic features of bacillus cereus?
Eating reheated rice. In 6 hours develop nausea, vomiting then followed by diarrhoea. Also consumption of beef pork and vegetables, no fever
what is the incubation period of bacillus cereus?
30 mins to 6 hours
what are the diagnostic features of clostridium perfingens?
Nausea and vomiting followed by diarrhoea 8-12 hours after eating beef, pork, poultry and home foods. No fever or abdominal pain
what is the incubation period of clostridium perfingens?
8-12 hours
what are the diagnostic features of listeria?
Eating beef, pork, poultry, milk, cheese, coleslaw, hotdogs or potato salad. Pregnancy, neonates, immunocompromised. Watery diarrhoea, moderate frequency, nausea and vomiting, mild abdominal pain, fever
what are the diagnostic features of giardia?
Travel to endemic areas. Person to person, contaminated food, water. Sudden onset watery diarrhoea, abdominal bloating, cramps, nausea, vomiting, foul smelling fatty stool, flatulence
what are the diagnostic features of entamoeba histolytica?
Gradual onset over 1-3 weeks. Abdominal pain, rare-fever and haematochezia. Abdominal tenderness, enlarged liver, electrolyte imbalance
what are the diagnostic features of microsporidosis?
Immunocompetent people, rarely chronic diarrhea (older people), immunocompromised people-diarrhoea, non bloody, watery, continuous or intermittent. Associated with crampy abdominal pain, weight loss, wasting, nausea and vomiting. Fever rare
describe the diagnostic features to suggest medications lead to diarhoea?
Recently started medication, followed by diarrhoea within says to weeks. Antibiotics, antacids, PPIs, laxatives, NSAIDs, diarrhoea is watery, no mucus or blood
what are the diagnostic features of ulcerative colitis?
Blood in stools and mucus. Extra-intestinal manifestations
what are the diagnostic features of Crohn’s disease?
Abdominal pain, fever, weight loss, diarrhoea, gradual onset, large volume watery diarrhoea suggest small bowel involvement.
what are the diagnostic features of Crohn’s disease?
Diarrhoea-small frequent loose stools, small to moderate volume preceded by urgency and common after meals, no night waking, alternate with constipation
what is the incubation period of microsporidosis?
11-15 days
what is the incubation period of entamoeba histolytica?
2-4 weeks
what is the incubation period of giardia?
1-14 days
what is the incubation period of listeria?
30 days
what are the diagnostic features of microscopic colitis?
Presence of coeliac disease-concern of lymphocytic colitis. Frequent diarrhoea and large volume. May be associated with mild abdominal pain, weight loss and fatigue
what are the diagnostic features of viral, bacterial, parasitic, HIV enteropathy?
Onset likely acute, history of travel, sick contacts, immunosuppression
what are the diagnostic features of faecal impaction?
Usual history of severe or worsening constipation, cramping, gas and abdominal pain. Examination-hard faecal mass on rectal examination
what are the diagnostic features of bile salt malabsorption?
surgical history resection
what are the diagnostic features of brush border enzyme deficiency?
Diarrhoea associated with bloating, cramping, wing and flatulence usually occurs within an hour of ingesting offending substance. Symptoms are often gradual, becoming increasing
what are the diagnostic features of small intestinal bacterial overgrowth?
History of diabetes, past surgery, coeliac or crohn’s. bloating, wind, flatulence, cramping, mild to moderate diarrhoea
what are the diagnostic features of pancreatic insufficiency?
History of pancreatitis, alcohol abuse, cystic fibrosis, onset gradual but progressive
what are the diagnostic features of hyperthyroidism?
History of other autoimmune disease, increased appetite, weight loss, heat intolerance, hair loss, fine tremor, goitre, exophthalmos, tachycardia, hypertension
what are the diagnostic features of diabetes mellitus?
Nausea and early satiety. Chronic diarrhoea is uncommon as presenting symptom of new-onset diarrhoea
what are the diagnostic features of radiation enteritis/colitis?
Radiation exposure to abdomen (men-prostate cancer and women-uterine cancer). Fresh blood in stools is common
what are the diagnostic features of eosinophilic enteritis?
Abdominal pain, nausea, vomiting, diarrhoea, history of other allergic conditions
what are the diagnostic features of chronic ischaemic colitis?
Older patients with history of vascular disease and on antihypertensives. Cramping abdominal pain and fresh blood in stools, tenderness
if onset of diarrhoea occurs within 6 hours of ingestion what does this suggest about the cause?
preformed toxins such as staph. aureus or bacillus cereus
why should you ask about the frequency of diarrhoea?
infectious cause=more frequent
why should you ask about the amount of stool produced?
toxin induced=greater volume (cholera
osmotic diarrhoea=smaller volume
why is it important to ask about the consistency of the stool?
watery=non invasive and toxin inducing pathogens
what does blood in the stool suggest?
invasive pathogens or inflammation
what does mucus or pus in the stool suggest?
colonic involvement with inflammatory process or infective pathogen
what does fever associated with diarrhoea suggest?
invasive bacteria, enteric viruses or cytotoxic organism
what other things is it important to ask about for a patient experiencing diarrhoea?
travel dietary history pets pain nausea vomiting bloating flatus fever tenesmus anal itch medications past medical history social history occupation
what should be part of the examination in a patient with diarrhoea?
- General appearance
- Pulse
- Skin turgor
- Mucous membranes (dry?)
- Capillary refill time
- Blood pressure
- Orthostatic changes
- abdominal examination may help diagnoses.
- hyperactive, normal, or absent bowel sounds, localised or generalised abdominal tenderness, rebound tenderness, abdominal distension, enlarged liver (inSalmonella, amoebic liver abscess), or an abdominal mass.
- Rectal examination can help in characterising stool and content, presence of mucus, or blood and faecal occult blood testing.
what are the indications for further investigations in a patient with diarrhoea?
Dysentery
Moderate to severe disease
More than 7 days
High risk of spreading to others
what stool tests are performed in patients with diarrhoea?
- Presence of faecal leukocytes and positive occult blood test support diagnosis of invasive or inflammatory diarrhoea eg IBD
- Faecal lactoferrin-distinguish inflammatory diarrhoea from non-inflammatory
- Calprotectin-marker of faecal inflammation
- Stool culture when; immunocompromised, multiple comorbidities, severe inflammatory diarrhoea, underlying IBD, test for stool leukocytes is positive, outbreak investifations
- PCR tests-quicker identification of pathogen
- Laxative screen
- Stool weight, electrolytes and osmotic gap
what blood tests would be used on a patient with acute diarrhoea?
- FBC (haemoconcentration, anaemia, leucocytosis)
- Serum chemistry (electrolytes, urea nitrogen, creatine, hypokalaemia, acidosis, renal dysfunction, serum albumin, lactic acid)
what radiological tests are performed in a patient with acute diarrhoea?
- Abdominal X-ray
- CT scan of abdomen and pelvis
- Identify ileus, perforation or megacolon
what endoscopic investigations can be used in a patient with acute diarrhoea?
- done If all other tests are negative.
- It can distinguish IBD from infectious diarrhoea
- Diagnose C.diff
- Evaluate for cytomegalovirus and herpes simplex
what should be asked for in a history in a patient with chronic diarrhoea?
- Duration (more than 4 weeks)
- Number of episodes per day
- Waking up at night
- Presence of blood in stools
- Associated symptoms`
what associated symptoms may coincide with chronic diarrhoea?
- Weight loss (coeliac disease, IBD, malignancy, chronic pancreatitis, hyperthyroidism, diabetes)
- Abdominal pain (coeliac disease, Crohn’s disease, malignancy)
- Nausea and vomiting (small bowel Crohn’s, diabetes, faecal impaction)
- Fresh blood or melaena (IBD, ischamia malignancy)
- Skin changes (coeliac, IBD)
- Steatorrhea, abdominal distension, flatulence, borborygmy, anorexia, increased infections
- Medications: NSAIDs, laxative use, PPI, quinine, antibiotics
what would look for on examination in a patient with chronic diarrhoea?
skin rashes
lymphadenopathy
blood on rectal examination
what laboratory tests would be performed in a patient with chronic diarrhoea?
FBC Electrolytes Glucose Liver function tests C-reactive protein Thyroid function tests Coeliac serology IgA level Haematinic (B12, folate, ferritin) Faecal calprotectin-differentiate IBD from IBS Test for parasites
what is the role of endoscopic investigation in a patient with chronic diarrhoea?
- Allows visual assessment of disease and IBD
- Provide prognostic information
- Histological assessment-presence of macroscopic and microscopic colitis
- Suspected coeliac disease-gastroscopy with duodenal biopsies obtained
what are the physiological changes causing diarrhoea?
During an episode of diarrhoea there is increased motility of the GI tract, with increased secretion and decreased absorption of fluids leading to loss of electrolytes
what are the main approaches to treatment in patients with diarrhoea?
- Electrolyte balance and fluids
- Use of anti-infective agents
- Use of spasmolytic or other antidiarrhoeal agents
- oral rehydration
- In campylobacter ciprofloxacin may be used
- Opioid agonists
give examples of opioid agonists used in treatment of diarrhoea?
loperamide
diphenoxylate
how long after end of vomiting and diarrhoea should you wait before entering a clinical area?
48 hours
where should communicable diseases be reported to?
-infection prevention and control team
Registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases.
-Complete a notification form immediately on diagnosis of a suspected notifiable disease. Don’t wait for laboratory confirmation of a suspected infection or contamination before notification. Consult the PHE Notifiable Diseases poster for further information.
-Send the form to the proper officer within 3 days, or notify them verbally within 24 hours if the case is urgent by phone, letter, encrypted email or secure fax machine.
what drugs can cause constipation?
Opiates Antimuscarinics Calcium channel blockers Antidepressants iron
what are the functional causes of constipation?
Irritable bowel syndrome
Idiopathic slow transit
what are the metabolic/endocrine causes of constipation?
Diabetes mellitus
Hypercalcaemia
Hypothyroidism
Porphyria
what are the psychological causes of constipation?
Depression
Anorexia nervosa
Repressed urge to defecate
what are the neurological causes of constipation?
Spinal cord lesion
Parkinsons disease
what are some general causes of constipation?
Pregnancy
Inadequate fibre intake
Immobility
what gastrointestinal disease can cause constipation?
- Intestinal obstruction and pseudo-obstruction
- Colonic disease eg carcinoma, diverticular disease
- Aganglionosis eg Hirschsprungs disease, Chagas disease
what defecatory disorders can cause constipation?
- Rectal prolapse, mucosal prolapse intussusception and solitary rectal ulcer syndrome
- Large rectocele
- Pelvic flood dyssynergia/anismus
- megarectum
what would be the investigation in recent change in bowel habit with other symptoms such as bleeding?
colonoscopy
CT pneumocolon
to exclude colorectal cancer and diverticular disease
what are the 3 categories of constipation?
- normal transit through colon (59%)
- defecatory disorders (25%)
- slow transit (13%)
describe normal transit constipation?
- Travels through colon at normal rate and stool frequency is normal yet patient feels constipated due to perceived difficulties of evacuation or passing hard stools
- Abdominal pain or bloating
- Marker studies of colonic transit can be used to distinguish it from slow transit
describe slow transit constipation?
- Predominantly in young women who have infrequent bowel movement.
- Often starts at puberty
- Infrequent urge to defecate, bloating, abdominal pain and discomfort.
describe defecatory disorders?
- Paradoxical contraction rather than normal relaxation of external anal sphincter.
- Due to dysfunction of anal sphincter and pelvic floor
- Characterised by performing proctography and tests of anorectal physiology
what are the common causes of constipation?
anal fissure medicine induced constipation hypercalcaemia hypothyroidism diabetes mellitus spinal cord lesion colonic stricture colon cancer parkinson's disease
what are the signs and symptoms of anal fissures?
Rectal pain, bleeding, excessive straining
what are the signs and symptoms of medicine induced constipation
Temporal relationship of onset of symptoms with medicine use
what are the signs and symptoms of hypercalcaemia
Tiredness, nausea, vomiting, loss of appetite
what are the signs and symptoms of hypothyroidism
Weight gain, dry skin, depression, fatigue, changes in voice
what are the signs and symptoms of diabetes mellitus
Polyuria, polydipsia, polyphagia
what are the signs and symptoms of spinal cord lesion
Motor and/or sensory changes in affected areas of body
what are the signs and symptoms of Parkinsons disease?
Rigidity, akinesia, tremor
what investigations would be performed in a patient with anal fissures?
Digital rectal examination
what investigations would be performed in a patient with medicine induced constipation?
Withdraw medicines and see if symptoms improve
what investigations would be performed in a patient with hypercalcaemia?
Corrected serum calcium level >2.75
what investigations would be performed in a patient with hypothyroidism?
Thyroid stimulating hormone level elevated in primary hypothyroidism, low in central hypothyroidism
what investigations would be performed in a patient with diabetes mellitus?
Fasting blood sugar, random plasma glucose, abnormal oral glucose tolerance test
what investigations would be performed in a patient with spinal cord lesion?
Imaging of spinal cord with CT of MRI
what investigations would be performed in a patient with colonic stricture?
Endoscopic diagnosis by direct visualisation or by barium enema
what investigations would be performed in a patient with colon cancer?
Endoscopy or barium enema/CT
what investigations would be performed in a patient with Parkinson’s disease?
Clinical diagnosis
what investigations would be performed in a patient with Parkinson’s disease?
Clinical diagnosis
what is the treatment of acute constipation?
treat underlying cause
diet + lifestyle advice + laxatives or prunes
constipation with faecal impaction-evacuation measures
opioid induced constipation-methylnaltrexone
what is the treatment of acute constipation?
treat underlying cause
diet + lifestyle advice + laxatives or prunes
constipation with faecal impaction-evacuation measures
opioid induced constipation-methylnaltrexone
when would you consider IBS as a diagnosis?
Consider IBS if patient has had 6 month history of
- abdominal pain, and/or
- bloating, and/or
- change in bowel habit
- IBS is a diagnosis of omission, must rule out other conditions such as IBD before making diagnosis of IBS
what are some other symptoms of IBS?
-abdominal bloating (more common in women than men), distension, tension or hardness
-symptoms made worse by eating
passage of mucus
-abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:altered stool passage (straining, urgency, incomplete evacuation)
-Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis
What are the red flags for IBS?
rectal bleeding
unexplained/unintentional weight loss
family history of bowel or ovarian cancer
onset after 60 years of age
what primary care investigations can be performed on a patient with suspected IBS?
full blood count
ESR/CRP
coeliac disease screen (tissue transglutaminase antibodies
what conditions cause loose stool habits?
IBS coeliac colorectal cancer IBD diverticular hyperthyroidism
what conditions cause constipation?
hypothyroidism bowel obstruction (no movement)
describe the joint aetiopathology of IBS, IBD, coeliac and colorectal cancer?
Virtually any GI condition that is inflammatory mediated damages the mucosa (including the brush border) and therefore impairs normal digestion, absorption, bowel movements etc. less things that should be absorbed will be absorbed so more passes straight through.
describe the aetiopathology of thyroid disease and altered bowel habit?
The thyroid gland controls the activity of many organs. In hypothyroidism there is reduced everything including digestion, absorption and GI movement and in hyperthyroidism the opposite is the case
what is the aetiopathology of diverticular disease?
Inflamed mucosa impairs normal digestion, absorption etc
what is the aetiopathology of bowel obstruction?
Any form of blockage will completely stop bowel movement because the GI tract is a glorified tube. If things can only move in one direction and there’s a blockage, there’s nowhere else to go (until pressure builds up and you get a ruptured viscous)
why is cancer staging important?
Curability of a tumour is usually inversely proportional to the tumour burden. Staging is the evaluation of the extent of disease via invasive and non-invasive diagnostic test.
what is clinical staging?
based on examination, radiographs, isotopic scans, CT, and other imaging
What is pathologic staging?
takes into account information from surgical procedures such as intraoperative palpation, resection of regional lymph nodes and/or tissue adjacent to tumour, biopsy
what are the different aspects of the TMN staging system?
TNM=Tumour, Node, Metastasis
T1-4 = size of tumour (higher the number larger the tumour)
N0-N3 = nodal involvement
M0-M1 = absence or presence of metastases
With increased staging the tumour burden increases and curability decreases
what does T1 indicate?
T1 = limited to mucosa and submucosa
what does T2 indicate?
T2 = extension into but not through muscularis propria
what does T3 indicate?
invasion of perirectal fat
what does T4 indicate?
invasion of adjacent structures
what does N0 indicate?
no involved lymph node
what does N1 indicate?
fewer than 4 regional nodes involved
what does N2 indicate?
more than four regional lymph nodes involved
what does N3 indicate?
distant nodes involved
what does M0 indicate?
no metastasis
what does M1 indicate?
Distant metastasis
what is the epidemiology of colonic cancer?
Third most common cancer in males (risk is 1 in 15), second in females (1 in 19) but incidence is higher in men.
More common with age (peaks in over 80s), incidence has increased since the 1970s
30% present with advanced disease (defined as mets/ locally invasive so resection can’t happen)
what are the usual characteristics of colonic cancer?
- Majority found in sigmoid colon & at rectosigmoid junction
- Usually small, annular and ulcerated
- Polyps:
what are the types of polyps seen in colonic cancer?
villous adenoma
hamartomatous polyps
hyperplastic
what type of polyp has the greatest chance of malignant transformation?
villous adenoma
what is the risk with hamartomatous polyps?
syndromes are high risk for malignancy, but the polyps aren’t that serious
what type of polyps have low risk of becoming malignant?
hyperplastic
what investigations would be perfomed in a patient with suspected colonic cancer?
Bloods – FBC, WCC, CEA, CRP + ESR
Foecal occult (as part of screening programme/ in suspected bowel cancer)
Colonoscopy (with biopsy) – has been viewed as the reference standard for years; patients shouldn’t have major co-morbidities
Barium enema/ flexible sigmoidoscopy – offered to patients with major co-morbidities
CT colonography – doesn’t require sedation and is still somewhat sensitive but if a lesion is found, they’ll need colonoscopy anyway
PET CT? – looking for metastasis
what are the clinical features of colonic cancer?
- Significant, unintentional weight loss
- Anorexia
- Malaise
- Blood in/ with stools
- Mucous in stools (from tumour secretion)
- Intestinal obstruction (can be acute, chronic or acute on chronic)
- Bowel perforation
- Evidence of mets: Jaundice/ abdominal distension from ascites/ hepatomegaly
describe features of ascending colon cancer?
- more likely to grow beyond mucosa
- no bowel obstruction-> grows large, late diagnosis
- can ulcerate and bleed->anaemia
- unexplained weakness
describe the features of descending colon cancer?
- More likely to be ring-shaped infiltrating masses -> napkin-ring constriction
- Napkin-ring constriction -> colicky pain
- Constriction -> blood streaked stools = haematochezia
- Change in bowel habit (can be diarrhoea, constipation or the two alternating)
Who are the members of the MDT involved in cancer care?
Surgeon Medical oncologist Clinical oncologist Haematologist Pathologist Clinical nurse specialist Radiologist Physiotherapist Dietitian occupational therapist (OT) Radiographer doctor or nurse who specialises in symptom control Counsellor psychologist.
what is stage A in dukes classification of colon cancer?
tumour confined to mucosa
90-95% 5yr survival
what is stage B1 in dukes classification of colon cancer?
tumour growth into muscularis propria
75-80% 5 yr survival
what is stage B2 in dukes classification of colon cancer?
Tumour growth through muscularis propria and serosa (full thickness)
60% 5 year survival
what is stage C1 in dukes classification of colon cancer?
tumour spread to 1-4 regional lymph nodes
25-30% 5 yr survival
what is stage C2 in dukes classification of colon cancer?
Tumour spread to more than 4 regional lymph nodes
25-30% 5 yr survival
what is stage D in dukes classification of colon cancer?
distant metastases to liver, lung, bones
<1% 5 yr survival
