Case 15- Gut Disorders Flashcards
Symptoms suggesting IBS
Abdominal pain/ discomfort
Pain relieved on opening bowels
Associated with a changed in bowel habit
Abnormal stool passage
Bloating
PR mucus
Pain worse after eating
NB- may also have nausea, lethargy, backache, bladder symptoms
Investigations for IBD
Stool sample- faecal calprotectin, OCP, microscopy culture and sensitivity
FBC, CRP, TFT, LFT, Fe studies, serum vitamin B12, folate
Endoscopy (OGD/ colonoscopy) with biopsy- diagnostic (swallow capsule is alternative)
Imaging- look for complications (CT/ MRI)
Investigations for coeliac
FBC UE calcium magnesium haemantics etc.
IgA levels
Raised IgA antibodies- anti TTG, anti endomyseal antibodies
Endoscopy with small intestine biopsy- gold standard
NB- if patient on gluten free diet, must reintroduce gluten 6 weeks before testing
Differentials for IBS
Chrons, UC, coeliac, colon cancer, lactose intolerance, ovarian cancer
General appearance in certain gut disorders
IBS- healthy, no weight loss
Chrons- weight loss, malnourishment
UC- weight loss in severe cases
CRC- weight loss
Pain in certain gut disorders
IBS- alleviated by defecation, diffuse, no nighttime pain
Chrons- constant, right lower abdomen, may occur at night
UC- left lower abdomen, may occur at night
CRC- often no pain
Stool habits in certain conditions
IBS- diarrhoea, constipation, no blood, no nighttime diarrhoea
Chrons- non bloody, watery diarrhoea, increased frequency, can occur at night
UC- bloody diarrhoea with mucus
CRC- right sided: melaena, diarrhoea, left sided: constipation
Extraintestinal findings UC
Arthritis
Spondylitis
Erythema nodosum
Finger clubbing
Iritis
Extraintestinal features of Chrons
Perianal lesions
Erythema nodosum
Arthropathy
Pyoderma gangrenosum
Aphthous ulcers
Clubbing
Iritis
Gall stones
Gastroenteritis
Abdominal pain, fever, n and v, lethargy, either watery diarrhoea or bloody diarrhoea, volume depletion
Management of suspected gastroenteritis
Isolate patient and PPE
FBC UE
Stool sample for microscopy, culture and sensitivities and OCP
Fluids and loperamide/ metoclopramide if needed
Antibiotics if causative agent found and patient at high risk
Coeliac symptoms
Diarrhoea, bloating, abdominal discomfort, abdominal distension, anaemia (iron folate or B 12), fatigue, weight loss, failure to thrive, dermatitis herpetiformis (can b across abdomen),mouth ulcers, steatorrhea, angular stomatitis
C diff infection investigations
Stool test for c diff toxin (antigen only shows exposure to bacteria, not current infection)
FBC UE- raised WCC, electrolyte disturbance (diarrhoea)
Investigations for IBS
Bloods- FBC, ESR, CRP
Faecal calprotectin- exclude IBD (perhaps diarrhoea predominant)
Anti TTG antibodies- exclude coeliac (anti endomyseal also)
Over 60 and mild symptoms
Think cancer
Management of Crohn’s disease
Lifestyle- diet, exercise, smoking and alcohol
Crohns- IV steroids (induce remission) azathioprine and merctopurine (maintain remission)- assess TMPT activity first
Surgical resection (typically ileoceacal resection, or stricture/adhesiolysis/fistula correction)
IBD Common Extra Intestinal Sx
Clubbing
Iritis
Arthropathy (joint pain)
Erythema nodosum
NB- dermatitis herpetiformis is coeliac
IBS Management
Lifestyle advice- fluids, regular small meals, reduce processed foods, smoking & alcohol etc., reduce fizzy drinks
Medical- Loperamide for diarrhoea, laxatives for constipation (not lactulose), buscopan for cramps
Safety net- red flags/things get worse
NB- if symptoms aren’t managed with the above, TCA (amitriptyline), SSRI, and CBT can be trialled
UC Sx
Abdominal pain (LLQ), tenderness, diarrhoea, blood in stool, faecal urgency, tenesmus
IBD differentials
Crohns, diverticulitis, IBS, mesenteric ischaemia, infective colitis, ectopic pregnancy, endometriosis, appendicitis
Chrons vs UC
Skip lesions, transmural inflammation, affects everywhere from mouth to anus (spares rectum), pANCA positive in UC but likely negative in Crohns
Crohn’s Sx
Abdominal pain (RLQ), diarrhoea, perianal lesions, blood in stool (LESS THAN UC), malnutrition, weight loss, anaemia, abdominal mass, mouth ulcers
Complications of Crohns
More prone to strictures fistulas and adhesions (transmural)
Where does UC Affect
Colon and rectum (always starts at rectum, and never spreads beyond the ileocecal valve)
Where does Crohns typically affect
Terminal ileum
Crohns on imaging
Kantor string sign
Proximal bowel dilation
Rose thorn ulcers
Fistulae
Comb sign
Carnetts sign
E. coli
Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis
Prolonged non bloody diarrhoea
Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.
Shigella
Bloody diarrhoea
Vomiting and abdominal pain
Staph aureus
Severe vomiting
Short incubation period
Campylobacter
Flu like prodrome with crampy abdominal pain, fever, and diarrhoea (can be bloody)
Mimic appendicitis
Complication- GBS
NB- Campylobacter infection is often self-limiting but if severe then treatment with clarithromycin (c for c) may be indicated
Bacillus cereus
Either vomiting within 6 hours (rice)
Diarrhoea after 6 hours
Amoebiasis
Gradual onset bloody diarrhoea, abdominal pain, tenderness which may last several weeks
Something to ask a patient with diarrhoea or cough
Any recent travel
Coeliac management
Gluten free diet life long
Iron, vitamin, calcium, and vitamin D supplementation (osteoporosis and anaemia are complications)
Management of c diff
First episode- Vancomycin 10 days (oral- get into colon) or oral fidaxomicin 2nd line (3rd line, oral vancomycin, IV metronidazole)
Recurrent episode- within 12 weeks, oral findaxomicin, after 12 weeks, oral vancomycin or oral findaxomicin
Life threatening- oral vancomycin and IV metronidazole
NB- fidaxomicin if recurrent episodes
NB- Bezlotoxumab may be used in conjunction with antibiotics to reduce the risk of recurrence in such patients. However, it is not currently recommended for the prevention of C.difficile infection by NICE due to it not being cost-effective.
Aminosalicylates (eg. Mesalazine and sulphalazine)
Colonic anti inflammatories
SE- headache, lung fibrosis, pancreatitis, agranulocytosis (always check FBC when someone taking them is unwell)
Causes of c diff
PPI’s
Cephalosporin eg, cefotaxime, cefuroxime
Then clindamycin
Features of c diff infection
Diarrhoea
Abdominal pain
Lymphocytosis
Severe- toxic megacolon
White cell count and C diff severity
Mild- normal WCC
Moderate- WCC below 15, loose stools
Severe- WCC above 15, creatinine 59% above baseline, raised temp, evidence of severe colitis
Life threatening- hypotension, partial or complete ileus, toxic megacolon, CT evidence of severe disease
Conditions associated with coeliac disease
Autoimmune thyroid disease
Dermatitis herpetiformis
IBS
T1DM
Histology of coeliac disease
Villus atrophy with crypt hyperplasia
Complications of coeliac disease
Anaemia- iron, folate, and vitamin B12
Hyposplenism
Osteoporosis and osteomalacia
Lactose intolerance
T cell lymphoma of the small intestine
Subfertility
Endoscopic findings supportive of coeliac disease
Villus atrophy
Crypt hyperplasia
Increased epithelial lymphocytes
Laminate propria infiltration with lymphocytes
Management of coeliac disease
Gluten free diet (bread, pasta, pastries, beer, oats)
Immunisations- yearly flu vaccine, pneumococcal vaccine very 5 years
Histology of Crohn’s disease
Inflammatory bowel disease- typically affects terminal ileum and colon but can be seen anywhere from mouth to anus in skip lesions (patchy, non continuous inflammation)
Transmural inflammation (from mucosa to serosa), goblet cells, granulomas
More likely to get deep ulcers, fistulae, strictures
Small bowel enema signs of Crohns
Kantors string sign (strictures)
Proximal bowel dilation
Rose thorn ulcers
Fistulae
Complications of Crohn’s disease
Small bowel and CR cancer
Osteoporosis
Diverticulosis
Outpouchings in bowel wall, commonly the sigmoid colon- reserved for asymptotic patients
Risks- increasing aged low fibre diet
Diverticula disease
Altered bowel habit, colicky left sided abdominal pain
High fibre diet can minimise symptoms
Diverticulitis
When a diverticula becomes infected
Left iliac fossa pain and tenderness
Anorexia, nausea, and vomiting
Diarrhoea (bloody)
Features of infection (pyrexia, raised WBC, CRP)
Management of diverticulitis
Mild- oral antibiotics at home
Severe (and if symptoms don’t settle over 72 hours)- IV antibiotics in hospital (cephalosporin with metronidazole), NBM, IV fluids
NB- low fibre diet recommended during diverticulitis recovery
Red flag symptoms in a suspected IBS case
Rectal bleeding
Unexplained or unintentional weight loss
Family history of bowel or ovarian cancer
Onset of age after 60 years
Features of UC
Bloody diarrhoea
Urgency
Tenesmus
Abdominal pain (LLQ)
Extra intestinal features
Histology of UC
No inflammation beyond submucosa
Pseudopolyps
Crypt abscesses
Depletion if goblet cells
Barium enema UC findings
Loss of haustrations
Superficial ulceration aka pseudo polyps
Drainpipe colon (long standing disease)
Causes of UC flares
Stress
Medications eg, NSAIDs, ABX, cessation of smoking
Classification of UC flare severity
Mild- fewer than 4 stools per day
Moderate- 4-6 with minimal systemic disturbance
Severe- more than 6, with blood, systemic disturbance eg. Fever, tachycardia, abdominal tenderness or distension, reduced bowel sounds, anaemia, hypoalbuminaemia
NB- severe disease- admit to hospital
Management of mild to moderate UC
Inducing remission
Proctitis/ sigmoiditis- topical (rectal) aminosalicylate (mesalazine), add oral corticosteroid if emission not achieved (oral mesalazine for sigmoiditis)
Extensive disease- topical (rectal) and oral aminosalicylate (mesalazine), add oral glucocorticoid and aminosalicylate (mesalazine) if emission not achieved
Management of severe UC (colitis)
Admit to hospital
IV steroids
Ciclosporin if steroids can’t be used
Maintaining remission in UC
Mild/moderate- aminosalicyate
Severe/2 exacerbations in a year-/oral azathioprine or mercaptopurine
Classification of diverticulitis
Hinchey system
1- para colonic abscess
2- pelvic abscess
3- purulent peritonitis
4- faecal peritonitis
Investigations for diverticulitis
Colonoscopy avoided whilst symptomatic to avoid risk of perforation
Other tests like erect CXR (air), FBC (WCC), CRP, AXR, CT
Investigations s for gastroenteritis
Bedside- abdominal examination, observations
Bloods- FBC UE LFT CRP
Specialist- stool sample fir microscopy culture and sensitive, and OCP
Enterohaemorrhagic E. coli
Avoid antibiotics- increase chance of HUS
also avoid antidiarrhoeals (also in shigella)
Management of coeliac disease
Life long gluten free diet
May require vitamin substitution eg. Iron, calcium, vitamin D
Antibodies and coeliac disease
Levels of IgA and tTG will drop 3-12 months after introduction of a gluten free diet
Odansetron
5HT3 antagonist, good for chemo/radio therapy induced nausea
Constipation in IBS
Bulk forming laxative- iphagea husk
Surgical management of UC
Removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
Imaging choice for Crohn’s patients with perianal fistulae
MRI
Perianal fistulae
MRI investigation of choice
patients with symptomatic perianal fistulae are usually given oral metronidazole
a draining seton is used for complex fistulae
Perianal abscess
requires incision and drainage combined with antibiotic therapy
