CBL 12 - A patient with diarrhoea Flashcards
Q1. What is the differential diagnosis?
UC
Crohns
Diverticulosis
Coeliac disease
Ischaemic colitis
Bowel cancer
Infective colitis
IBS
Haemorrhoids
Fistula
Giardia infection
Pancreatic enzyme insufficiency
Haemorrhoids vs fistula presentation
Blood in stool - how do you differentiate?
look up more
Mixed with stool?
Frank red bood
What does mucus in the stool indication? [1]
Inflammation (of the stool)
On examination, he looked a little pale, pulse rate 98 bpm and BP 110/70 mmHg. Abdomen is distended with slight tenderness throughout.
Q2. What were the abnormal findings you identified on general physical examination and abdominal examination?
- little pale
- BP 110/70 mmHg
- Abdomen is distended with slight tenderness throughout.
Q3. What investigations should be requested? [+]
FBC
U&E
LFTs
Calcium, B12, RBC folate, ferritin levels
TFTS
ESR
CRP
antiTTG IgA levels
Faecal calprotectin
Stool culture - MCS (esp. C-diff)
Faecal elastase (pancreatic insufficiency)
How do you specifically investigate stool cultures? [2]
Send three cultures, two days apart
What the typical infective organisms that cause bloody diarrhoea? [5]
- Non-typhoidal salmonellosis (e.g. S. typhimurium, S. enteritidis)
- Campylobacter spp. (e.g. C. jejuni, C. coli)
- Shigella spp. (S. dysenteriae, S. flexneri, S. boydii, S. sonnei)
- Yersinia enterocolitica
- Enterohaemorrhagic Escherichia coli (EHEC)
[] is the most common cause of gastroenteritis in children.
Rotavirus is the most common cause of gastroenteritis in children.
[] is the most commonly implicated bacterial cause of gastroenteritis.
Campylobacter is the most commonly implicated bacterial cause of gastroenteritis.
[] commonly causes a vomiting illness after reheating starchy food (e.g. rice).
Bacillus cereus commonly causes a vomiting illness after reheating starchy food (e.g. rice).
[] is a classic cause of dysentery in young children.
Shigella is a classic cause of dysentery in young children.
[] is commonly implicated in Travellers’ diarrhoea.
Giardia lamblia is commonly implicated in Travellers’ diarrhoea.
A sigmoidoscopy is performed in clinic and reveals a friable, spontaneously haemorrhagic granular mucosa to the limit of view and a biopsy was taken. He is admitted to hospital from the clinic.
Q4. What is the differential diagnosis based on above?
UC [?]
Early in the disease, the mucous membrane is erythematous, finely granular, and friable, with loss of the normal vascular pattern and often with scattered hemorrhagic areas.
Q5. List the abnormal findings on blood tests, and what do these abnormal results indicate regarding the underlying disease?
Low HB
- Anaemia
Raised white blood count - inflammation
Raised Platelets - active bleeding
Low Potassium - from diarrhoea
CRP - inflammation
Indicates active inflamation occurring.
What imaging do you perform for UC? [2]
- flexible sigmoidoscopy
- full colonoscopy
A colonoscopy must be avoided in acute severe disease due to the increased risk of bowel perforation
What are the macroscopic [5] and microscopic [2] changes seen in UC?
Macroscopic findings:
* Continuous, uniformly inflamed mucosa
* Erythematous, friable mucosa
* Abnormal vascular pattern
* Ulceration
* Inflammatory polyps (‘pseudopolyps’)
Microscopic findings (biopsy):
* Crypt abscesses
* Decreased goblet cell abundance
Describe Truelove & Witt criteria of mild, moderate and severe to grade UC, based off:
- Bowel movements per day
- Blood in stool
- Pyrexia
- Pulse (>90BPM)
- Anaemia
- ESR
Q6. Why was this patient admitted from the clinic?
He’s presenting with severe UC, which requires admission
Which autoimmune antibody is associated with UC? [1]
pANCA (if PSC is suspected)
Q7. Which is the next most appropriate investigation for this man while in ED and why?
Additional imaging modalities such as plain abdominal X-ray (AXR) and computed tomography (CT) may be important for the exclusion of UC complications in an acute presentation (e.g. toxic megacolon, bowel perforation).
Q8. What does the XR abdomen show?
Toxic megacolon
This patient’s colon is very dilated and there are extensive ‘mucosal islands’ indicating bowel wall inflammation.
What size toxic megacolon should you be concerned about? [1]
Diameter > 6cm
Stool cultures return as negative. The gastroenterology team comes to review him.
Q9. Mr. R had given up smoking recently. Is that relevant to his clinical presentation?
Yes - smoking is protective in UC
? It has been reported that nicotine increases the thickness of colonic mucus, thus enhancing the protection of the intestinal mucosa [14], but this remains to be confirmed.
It is possible that nicotine may increase the production of this mucus
