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CSI 16- Diarrhoea Flashcards

1
Q

Define diarrhoea?

A

Three or more loose or liquid stools per 24 hours, and/or

Stools that are more frequent than what is normal for the individual lasting <14 days, and/or

Stool weight greater than 200 g/day.

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2
Q

Based on duration how can you further classify diarrhoea ?

A

Acute (less than 14 days)

Persistent (more than 14 days), or

Chronic (more than 4 weeks).

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3
Q

How much fluid do we reabsorbe each day and how does diarrhoea affec this?

A

10 L of fluid

Mostly reabsorbed at small bowel.

overall (in both small and large bowel) 99% of fluid is reabsorbed leaving 0.1 L in feaces

Diarhheoa interferes with this process which can result in :

  • Decreased absorption of fluid or
  • Increased secretion of fluid and electrolytes or
  • increase in bowel motility
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4
Q

what are the origins of the 10L of fluid entering the GI tract everyday

A

salivary glands, stomach, pancreas, bile ducts, and duodenum

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5
Q

Extensiviely classify diarrheoa

A

Inflammatory - can be infectious or non infectious

Non-inflammatory

  • Secretory or
  • Osmotic
    • Mal digestion
    • Mal absorption
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6
Q

what is inflammatory diarrhoea? what causes it and what are the symptoms nornmally associated with it

A

Inflammatory process going on it could be due to :

  • bacterial, viral or parasitic infection or develop early in the course of bowel ischeamia/ radiation injury/ IBD

Associated symptoms are:

  • Mucoid and bloody stool
  • Tenesmus (feeling like you need to pass stool)
  • fever
  • severe crampy abdominal pain
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7
Q

What are the features of infectious inflammatoruy diarrhoea

A

Small in volume with freqent bowel movements

Does NOT reuslt in volume depletion in adults but maybe for kids or older people

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8
Q

what are the causes of infectious inflammatory diarrheoa?

A

Bacterial infections like:

  • Campylobacter
  • Salmonella
  • Shigella
  • Escherichia coli
  • C.difficile

Virus more common in kids who go to day care

Protozoa and parasites - common casuse of acute diarrheoa in developing countries

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9
Q

what are the examination results for inflammatory diarrhoea?

what should you be wary of?

what will the histology of GI tract show?

A

Stool culture- show leukocytes

Feacel occult blood may be postiive.

Feacal occult has a high chance to be false negative (low sensitivity) but positive is very informative.

Histology is abnormal

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10
Q

what are the features of non-inflammatory diarhoea?

A

Very large volume, watery stool

Frequent stool like between 10 and 20 a day

Volume depletion very possible

NO tenesmus, blood in stool, fever or feacal leukocytes

Histology of GI tract is preserved

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11
Q

what are the features of secretory diarhhoea and what causes it?

A

Due to altered transport across mucosa leading to increased secretion and decreased absorption of fluids and electrolytes from the GI tract (small bowel mainly)

Not improved by fasting

Causes could be :

  • enterotoxins
  • Hormonal agents
  • Laxative use
  • intestinal resection
  • bile salts
  • fatty acids
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12
Q

The causes of secretory diarrhoea are enterotoxins and hormonal agents.

what are the sources of these causes

A

Enterotoxins - infection from:

  • Vibrio cholerae
  • S.aureus
  • enterotoxigenic E.coli
  • Possibly HIV and rotavirus

Hormonal agents :

  • VIP
  • small- cell lung cancer
  • neuroblastoma
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13
Q

what other conditions would you see secretory diarrheoa

A

chronic diarrhoea with coeliac disease

collagenous colitis

hyperthyroidism

carcinoid tumours

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14
Q

what are the features of osmotic diarrhoea?

A

Stool volume lower than secretory diarrhoea

DIarhhoea improves or stops with fasting

Results from presence of unabsorbed or poorly absorbed solutes like Mg, sorbitol and mannitol. This leads to in increased secretion of fluids into GI tract

Stool electrolyte shows increased osmotic gap of more than 50 but the test isn’t very useful

Stool whether normal or diarrheoa is always isosmotic (260-290 mOsm/L)

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15
Q

what are the fesatures and causes of maldigestion (osmotic diraahoea)

A

refers to impaired digestion of nutrients within the intestinal lumen or at the brush border membrane of mucosal epithelial cells.

can be seen in:

  • pancreatic exocrine insufficiency
  • lactase deficiency
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16
Q

what are the features and casues of Malabsorption (osmotic diarrhoea)

A

refers to impaired absorption of nutrients.

Can be seen in:

  • Small bowel bacterial overgrowth
  • mesenteric ischeamia
  • post bowel resection (short bowel syndrome)
  • mucosal disease- celiac
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17
Q

what are the main symptoms of Crohns disease and when does it come

A

The symptoms usually start in childhood or early adulthood.

The main symptoms are:

  • diarrhoea
  • stomach aches and cramps- often in lower right quadrant
  • blood in your stool
  • tiredness (fatigue)
  • weight loss

The symptoms may be constant or may come and go every few weeks or months. When they come back, it’s called a flare-up

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18
Q

when is it a good time to see a GP? what symptoms are pre-requisite for it.

A

See a GP if you or your child have:

  • blood in your stool
  • diarrhoea for more than 7 days
  • frequent stomach aches or cramps
  • lost weight for no reason, or your child’s not growing as fast as you’d expect.

GP will try to determine cause of symtpoms to see if it’s Crohns

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19
Q

what are the treatments for Crohns

A

No cure for it but there are other meds:

medicines to reduce inflammation in the digestive system – usually steroid tablets

medicines to stop the inflammation coming back – either tablets or injections

surgery to remove a small part of the digestive system – sometimes this may be a better treatment option than medicines.

GP, specialist nurse or doctors over see this

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20
Q

what are the causes of Crohns

A

Exact cause is unknown but several factors play a role:

  • genes – you’re more likely to get it if a close family member has it
  • a problem with the immune system that causes it to attack the digestive system
  • smoking
  • a previous stomach bug
  • an abnormal balance of gut bacteria

NO PARTICULAR DIET causes it

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21
Q

Crohns is hard to diagnose - similar symptoms to other disease. what Diagnostic will the GP carry out

A

Full history

  • HPC
  • DHx, FHx
  • Travel

Abdo exam

IXs:- blood and stool sample tested for signs of inflammation or infection

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22
Q

what are the other less common symptoms of Crohns

A
  • pyrexia
  • feeling and being sick
  • joint pains (arthritis)
  • sore, red eyes (uveitis or episcleritis)
  • patches of painful, red and swollen skin – usually on the legs (pyoderma gangronosum or erythema nodosum)
  • mouth ulcers.
  • Kidney stones

Children with Crohn’s disease may grow more slowly than usual.

23
Q

if your GP suspects crohns and refers you to a gastroenterologist ; what tests could they do?

A

Colonoscopy

Colonscopy with biopsyu

MRI or CT- drink a contrast to help see it

24
Q

what is involved in a colonoscopy

A

You have list of waht to eat (junk food only)

Take laxative the day before

Sedative is given to you (remifentanil)]

Dont drive for 24 hrs after sedative

Any polyps found will be removed swiftly

After colonoscopy, you will be looked after in recovery room

25
Q

How are steroids given? How does it work and give S/Es

A

Reduce inflammation

Take once a day as a tablet (maybe IV)

May need to be taken for couple of months but it’s usually taken during a flare-up. for acute relief

S/Es are: weight gain, indigestion, problems sleeping, an increased risk of infections and slower growth in children

26
Q

what type of diet may help in Crohns and explain why.

Give S/Es

A

liquid diet (enteral nutrition) may help reduce symptoms for kids or young adults

it contains all nutrients you’ll need for a few weeks

Avoids risk of slower growth with steroids.

S/Es: some people may feel sick or have diarrhoea or constipation while on the diet.

27
Q

what immunosuppresants may help with crohn’s disease and explain how they help.

how do you take them?

A

azathioprine, mercaptopurine and methotrexate.

Can releive symptoms if steroids on their own isn’t working

Can be used as long term treatment - Several months or yrs

Tabelt- once a day; sometimes (injections) IV

S/E: Nausae and vomiting, liver porblems and increased risk of infection

28
Q

when are biologics used for crohn’s? what are they and how do they help.

A

Stronger meds given when other meds haven’t worked

e.g. adalimumab, infliximab, vedolizumab and ustekinumab.

They:

  • relieve symptoms
  • used as long term treatment to stop symptoms comiong back (several months or yrs)
  • given by injection or drip into vein every 2 to 8 wks
  • S/E are:

increased risk of infections and a reaction to the medicine leading to itching, joint pain and a high temperature

29
Q

when is surgery considered for crohn’s and what are the effects

A

Recommedned if they think the benefits outweigh risks or that meds are unlikely to work

they can relieve symptoms and help stop them from coming back for a while but they will return eventually

30
Q

what are the features of a surgical resection

A

it involves:

  1. Making small cuts in your tummy (keyhole surgery).
  2. Removing a small inflamed section of bowel.
  3. Stitching the healthy parts of bowel together.

hospital stay is a week and it takes a month to fully recover

you may need ileostomy until bowel recovers

May still need to take meds after surgery to stop symptoms coming back

31
Q

Living with Crohns

what are the diet and lifestyle measures that can help you

A

No special. diet, kids may need liquid diet

Have a healthy balanced diet

if you think a particular food triggers symptoms, see if avoiding it helps

Do not make any big diet changes without talking to GP

32
Q

Living with Crohns

what pharm meds can help you/ make it worse and explain

A

In some ppl, NSAIDs like Ibuprofen makes symptoms worse so avoid

Ask pharmacist or GP for advice if you’re taking a new med like loperamide

33
Q

Living with Crohns

what are the vaccination measures that can help you

A

Biologics and immunosuprresant can increase flu risk

take flu jab every year and the one off pnuemococcal vaccines

Avoid live vaccines like MMR; make you ill

34
Q

What advice should pregnant women with crohns recieve

A

Most ppl have normal pregnancy and healthy baby

Some meds can harm baby so

  • Tell GP ASAP if you accidnetally get pregnant
  • tell GP if you’re planning one- they may chnage treatment

it may be harder to get pregnant during crohns flare up but fertility should return to normla in between

Some crohns meds can temporarily reduce fertility in men

35
Q

How does crohns affect contraception

A

Make sure you use contraception if you do not want to get pregnant.

Ask your GP or care team about the best contraception to use because some types, such as the pill, may not work as well as usual if you have Crohn’s disease.

36
Q

what are the possible complications of Crohns

A

Increases risk of:

damage to your bowel that may require surgery – such as scarring and strictures, ulcers and fistulas

difficulty absorbing nutrients from food – this can lead to problems like osteoporosis or iron deficiency anaemia

bowel cancer – you may need regular cancer screening to check for this

37
Q

what are the risks of bowel cancer after certain time passes? what will the team do?

A

Low at first but increases as time passes. e.g.

  • after 10 years the risk is about 2%
  • after 20 years the risk is about 10%
  • after 30 years the risk is about 20%

if you have it for more than 10 yrs or Crohns affect multiple parts of bowel, care team may screen you (colonoscopies)

38
Q

Crohn flare up are unpredictable, how can you do to get help and support to cope with it emotionally and practically

A

tell your friends and family about your condition – so they can understand the effect it has on your life

talk to your GP or care team – they can offer support, treatment and referral to a specialist such as a counsellor if needed

use support groups like Crohn’s and Colitis UK

39
Q

Give examples and features (from f2f) of the following types of diarrhoea

Inflammatory

Secretory

Osmotic:

A

Inflammation- exudation of serum and destruction of epithelium. it has many causes

Swecretory- ion channels secrete excess ions into lumen. e.g. cholera enterotoxin

Osmotic (Maldigested)- lactose intolerance- cant digest lactose and hence cannot absorb it and hence there will be more wtaer in lumen

Malabsorptive- e..g substances that can’t be absorbed like prunes (Sorbitol)

40
Q

what are the acute and long term treatment for diarhoea ?

A

Acute- Oral rehydration solution ( it gives one glucose molecule and 2 Na+ to SGLT1)- reestablished water potential needed for reabsorption to prevent dehydration/volume depletion

Long term- treat underlying cause- very relevant for IBD

41
Q

Contrast the functional and organic causes of diarhoea?

A

Functional- IBS

  • No structural change in GI tract
  • No cause of symptoms we can measure

Organic:

  • Can see and measure casue of symptoms
  • e.g. celiac disease, cancer, IBD
42
Q

Compare and contrast the symptoms of IBD and IBS.

which one does our pt have

A

Mucus in stool ALONE- IBS

Our pt had weight loss hence has IBD features

43
Q

Explain the nuances and associated symptoms of blood in stool

A

Colour

  • Bright red- shsows lower GI tract bleeding
  • Brown- upper GI bleeding as the blood has been digested. Can present with haemetemesis also

Toilet paper (red)- problem with anus or rectum like haemorrhoids and anal fissures

if it’s mixed in stool- it could suggest cancer or IBD

44
Q

what are the possible blood tests one should order if a pt comes in with diarrhoea and abdominal pain

A
  • FBC- anaemia
  • Urea & Electrolytes- check renal function and electrolyte balance
  • CRP- inflammation
  • LFT
  • Thyroid- hyper can cause diarrhoea
  • Ferrtin
  • Vit B12/folate
  • celiac serology for tissue transglutaminsae antibody
45
Q

what possible stool test should be ordered for diarrhoea and blood in stool

A

Feacal occult- if blood can’t be seen visibly

Microbiology- looking for bacterial pathogens such as Cholera

Ova and cysts- (can be caused by parasite) 3 specimens 2 days apart as ova sheds intermittently

Feacal calprotectin- marker for inflammation in the bowel. Indicates migration of neutrophils to the intestinal mucosa. Inflammation could be due to cancer, celiac or IBD

46
Q

what are the results of a colonoscopy and biopsy for Crohns

A

Non-continuous inflammation

Cobblestone appearance - due to interspersed deep ulceration

Deeper ulceration (transmural- goes through all the layers of the gut)

Non-caseating granulomas and increased goblet cells

47
Q

what will the histology for crohns show

A

Granuloma

48
Q

what are the features of UC and what will the gross pathology show?

what will colonoscopy show?

A

Continuous circumferential mucosa inflammation- may also affect submucosa

Always involves rectum

Gross: show pseudopolyps if UC has occurred for a long time- scarring has occurred

only affects colon- except in rare occasion affect distal ileum (UC is severe and colonic content has backwash into ileum)

49
Q

what are the major complications of Crohn’s and UC

A

Crohns- more likely to get fistulas, ulcers and strictures

UC-

  • more predisposed to colorectal cancer than Crohn’s
  • Severe GI bleeding
  • Fulminant colitis and Toxic megacolon (severe UC)
50
Q

what does the histology for UC show?

A

crypt abscess are more typical for UC

51
Q

what are the treatments for UC and Crohns

A

Lifestyle advice and conservative treatments

  • Stop smoking and alcohol
  • Dietary advice and refer to dietician
  • Psychological support- long term (lifelong) condition.
  • Acute setting:*
  • Steroids are used to induce remission (short sharp way to settle it down)
  • Long term:*
  • Aziathoprine
  • 5 ASA
  • Methotrexate
  • Biologics- antibodies against TNF-a like infliximab
  • Surgical resection to reduce fistulas and strictures ( crohns )- last resort
52
Q

what are the first line treatment for mild UC

A

Give rectal depositories (anti-inflammation)

Start with 5-ASA

53
Q

what is the abdominal x-ray sign for structure and circumferential inflammation in ulcerative colitis?

A

Stricture- String sign (sting like appearance of bowel due to severe narrowing)

UC circumferential- Lead pipe sign due to loss of Haustra

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