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Diahorrea Flashcards

1
Q

How does the patient present?

A 
Terrible diarrhoea
6 weeks but it has gotten much worse
Tummy pain
Could not wait to see GP
3-4 a day for a month
8x recently
Bad overnight
Liquid, brown, sometimes blood from wiping
Sample all clear from GP
Weight loss - 7kg
Tired - no energy
Adopted 
Smokes 5 a day
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2
Q

How does she describe the pain?

A

Comes and goes
Left side
No change after opening bowels

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3
Q

How can diarrhoea be defined?

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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4
Q

How can diarrhoea be classified?

A

Acute (≤14 days)
Persistent (>14 days), or
Chronic (>4 weeks)

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5
Q

Describe the basic pathophysiology of diarrhoea?

A

10L of fluid enters GI tract daily

Small intestine responsible for reabsorbing (99%)

0.1L excreted in faeces

In diarrhoea there is decreased reabsorption or increased secretion

Or increase in bowel motility

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6
Q

From where is fluid secreted into the GI tract?

A 
Food 
Drink
Salivary glands
Stomach
Pancreas
Bile ducts
Duodenum
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7
Q

What are the two types of diarrhoea?

A

Inflammatory

Non-inflammatory

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8
Q

What can cause inflammatory diarrhoea?

A

Material
Viral
Parasitic

Or early bowel ischaemia, radiation injury or IBD

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9
Q

What are the associated symptoms of inflammatory diarrhoea?

A

Mucoid and bloody stool
Tenesmus
Fever
Severe crampy abdominal pain

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10
Q

What are the main features of the diarrhoea in inflammatory diarrhoea?

A

Small in volume

Frequent bowel movements

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11
Q

What are the most common causes of inflammatory diarrhoea?

A

Campylobacter, Salmonella, Shigella, Escherichia coli, or Clostridium difficile

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12
Q

In who is virus related diarrhoea common in?

A

Children who attend day care centres

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13
Q

What are the most common causes of acute diarrhoea in developing countries?

A

Protozoa and Parasites

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14
Q

What findings might be found in inflammatory diarrhoea?

A

Examination of the stool may show leukocytes, and tests for faecal occult blood may be positive.

The test for faecal leukocytes is plagued by a high rate of false-negative results leading to low sensitivity, but a positive test is very informative.

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15
Q

What are the main features of non-inflammatory diarrhoea?

A

watery, large-volume, frequent stool (>10 to 20 per day).

Volume depletion is possible due to high volume and frequency of bowel movements.

There is no tenesmus, blood in the stool, fever, or faecal leukocytes.

Histologically the GI architecture is preserved.

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16
Q

What can non-inflammatory diarrhoea be further divided into?

A

Secretory

Osmotic

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17
Q

What happens in secretory diarrhoea?

A

Altered transport of ions across the mucosa

which results in increased secretion and decreased absorption of fluids and electrolytes from the GI tract

especially in the small intestine

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18
Q

What causes secretory diarrhoea?

A 
Enterotoxins
Hormonal agents 
Laxative use
Intestinal resection
Bile salts and fatty acids
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19
Q

Where can enterotoxins be from?

A

Vibrio cholerae,

Staphylococcus aureus

enterotoxigenic E coli

and possibly HIV and rotavirus.

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20
Q

What hormonal agents can cause secretory diarrhoea?

A

Vaso-active intestinal peptide
Small-cell cancer of the lung
Neuroblastoma

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21
Q

What conditions can secretory diarrhoea be seen in?

A

Coeliac sprue
Collagenous colitis Hyperthyroidism
Carcinoid tumours

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22
Q

What are the features of osmotic diarrhoea?

A

Smaller stool volume

Improves or stops with fasting

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23
Q

What does osmotic diarrhoea result from?

A

presence of unabsorbed or poorly absorbed solute (magnesium, sorbitol, and mannitol)

in the intestinal tract

that causes an increased secretion of liquids into the gut lumen

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24
Q

What tests are done with osmotic diarrhoea?

A

Measuring stool electrolytes shows an increased osmotic gap (>50), but the test has very limited practical value. Stool (normal or diarrhoea) is always isosmotic (260 to 290 mOsml/L).

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25
Q

What can osmotic diarrhoea be subdivided to?

A

Maldigestion

Malabsorption

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26
Q

What does maldigestion refer to?

A

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

It can be seen in pancreatic exocrine insufficiency and lactase deficiency

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27
Q

What does malabsorption refer to?

A

Impaired absorption of nutrients.

It can be seen in small bowel bacterial overgrowth, in mesenteric ischaemia, post bowel resection (short bowel syndrome), and in mucosal disease (coeliac disease)

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28
Q

How much fluid is secreted into GI tract?

A

6-7 litres

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29
Q

How much fluid is lost in faeces?

A

0.1L

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30
Q

What happens to the fluid that is not excreted?

A

Gets absorbed via the walls of the small and large intestine

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31
Q

Why does fluid enter enterocytes?

A

There are lots of solutes in enterocytes

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32
Q

What happens in inflammatory diarrhoea (enterocytes)?

A

Destruction of the epithelium due to inflammation

Enterocytes cannot absorb fluids

Excess fluid in lumen

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33
Q

What happens in secretory diarrhoea (enterocytes)?

A

Ion channels become wrongly activated so solutes moves into the lumen

E.g. Cholera - chloride channel on enterocyte membrane becomes activates

Fluid follows the chloride

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34
Q

What happens in maldigestion diarrhoea (enterocytes)?

A

Solutes are not able to digest

Products remain in lumen - high solute concentration

Fluid moves to lumen

E.g. lactose intolerance

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35
Q

What happens in malabsorption diarrhoea (enterocytes)?

A

Solutes not absorbed by enterocytes

E.g. prunes

Sorbitol is not absorbed by enterocytes

Water is retained

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36
Q

What drug could help inflammatory?

A

Anti-cytokines e.g. Anti-TNF

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37
Q

What drug could help secretory?

A

Block dysregulated channel

38
Q

What drug could help maldigestion?

A

Enzyme replacement to facilitate reabsorption

39
Q

What do you acutely want to do for all types of diarrhoea?

A

Rehydration

e.g. Oral rehydration solution

40
Q

How does ORS work?

A

SGLT-1 = sodium glucose linked transporter

Give 1 glucose and 2 sodium takes both in

Pump into enterocytes

41
Q

Why does diarrhoea kill?

A

Dehydration

ORS essential especially in children

42
Q

What is chronic diarrhoea?

A

Symptoms for more than 6 weeks

43
Q

What is IBS?

A

Functional cause of diarrhoea

No known structural changes

Symptoms are unexplained

Non-progressive and will not kill patient

44
Q

What are the symptoms of IBS?

A 
Tiredness
Stomach pain
Bloating
Diarrhoea
Constipation 
Mucus in stool
45
Q

What are the symptoms of IBD?

A

Abdominal pain
Diarrhoea
Fatigue

Weight loss
Fever
Blood in stool

46
Q

What are some organic causes of diarrhoea?

A

IBD
Coeliac
Bowel Cancer

Organic = we can find a cause

47
Q

What are the two types of blood in stool?

A

Blood on toilet paper

Blood mixed in stool

48
Q

What was found on the patients abdo exam?

A

Soft abdomen
Tenderness particulary in LLQ
No masses

49
Q

What investigations does the A&E doctor want to conduct?

A

FBC - anaemia and signs of inflammation
U+E’s - check renal function and electrolyte status
CRP- look for infection/inflammation

50
Q

What further investigation should be conducted?

A 
Faecal Occult Blood 
Stool antigen 
Faecal calprotectin
Colonoscopy 
LFTs
51
Q

What further bloods should be conducted?

A

LFTs - includes albumin level which if low can indicate acute inflammation or malnutrition
Thyroid function tests
Ferritin, B12 and Folate
Antibody assay for coeliac disease

52
Q

What stool tests should be conducted?

A

Eggs + Cysts (associated with parasites) shed intermittently in the stool
3 separate stool samples, 2 days apart

Faecal calprotectin

53
Q

What stool tests should be conducted?

A

Eggs + Cysts (associated with parasites) shed intermittently in the stool
3 separate stool samples, 2 days apart

Faecal calprotectin - indicated migration of neutrophils into intestinal mucosa

Non-specific but looks for evidence of inflammation

54
Q

What are the patients results?

A

Raised CRP
Raised WBC
Elevated faecal calprotectin

55
Q

Now, what are the top differentials?

A

IBD

Colon Cancer

56
Q

What does the A&E doctor do?

A

Refer to Gastroenterologist

57
Q

What does the specialist do?

A

Conduct colonoscopy

58
Q

What were the colonoscopic findings?

A

Non continuous areas of linear ulcers with cobblestone appearance are seen extending from the caecum through to the splenic flexure.

When examined under a microscope, changes are seen in the mucosa, submucosa and muscularis propria.

Numerous non caseating granulomas and increased goblet cells noted.

59
Q

What is Ms Allen’s diagnosis?

A

Crohn’s disease

60
Q

What tells us it is Crohn’s disease?

A 
Non- continuous 
Cobbelstone appearance
Caecum to splenic flexure
Granulomas - collection of neutrophils 
Changes to mucosa, submucosa, muscularis and serosa (transmural changes)
61
Q

What would ulcerative collitis look like on a colonscopy?

A 
Continuous areas of inflammation
Starts at rectum and continues 
Does not extend beyond large bowel (illeum potentially in severe disease)
Crypt processes 
Affects only mucosa and submucosa
62
Q

What are some complications of Crohn’s?

A

Can get a whole (fistula) forming due to transmural involvement

63
Q

What are some complications of UC?

A

High predisposition to Colon Cancer

64
Q

What treatments can be used for Crohn’s? (conservative)

A

Stopping smoking - referral to cessation clinic
Exercise
Dietary advice to prevent malnourishment
Psychological support - groups

65
Q

What treatments can be used for Crohn’s? (medical)

A

Corticosteroids to induce remission

Azothiprine or bilogica (Mabs) long term to dampen down immune system

66
Q

What treatments can be used for Crohn’s? (surgical)

A

Bowel resection
May need ileostomy for a few months post-op

Mainly due to strictures and fistulas

Leave as late as possible due to the chance of further surgeries

67
Q

When should you see a GP re crohn’s?

A

blood in your poo
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

68
Q

What causes Crohn’s disease?

A

your genes – you’re more likely to get it if a close family member has it
a problem with the immune system

smoking

a previous stomach bug

an abnormal balance of gut bacteria

69
Q

What are the other symptoms of Crohn’s?

A 
a high temperature
feeling and being sick
joint pains
sore, red eyes
patches of painful, red and swollen skin – usually on the legs
mouth ulcers
children grow more slow than usual
70
Q

What would your GP ask you about?

A

your symptoms
your diet
if you’ve been abroad recently – you might have an infection
any medicines you’re taking
if you have a family history of Crohn’s disease

71
Q

What investigations might your GP do?

A

feel and examine your tummy
take a sample of blood
ask you to provide a poo (stool) sample

72
Q

What investigations might a specialist do?

A

Colonoscopy
Biopsy
MRI/CT Scan

73
Q

How can steroids help with Crohn’s?

A

can relieve symptoms by reducing inflammation in your digestive system – they usually start to work in a few days or weeks

are usually taken as tablets once a day – sometimes they’re given as injections

may be needed for a couple of months – do not stop taking them without getting medical advice

74
Q

What are the side effects of steroids?

A 
weight gain
indigestion
problems sleeping
an increased risk of infections
slower growth in children
75
Q

What can be helpful in children and young adults?

A

Liquid diet
Drinks containing all the nutrients
Avoids the risk of slower growth that happens with steroids

76
Q

What are the side effects of enteral nutrition?

A

Nausea
Diarrhoea
Constipation

77
Q

What immunosuppressants might be taken with Crohn’s?

A

azathioprine, mercaptopurine and methotrexate

78
Q

What can immunosuppressants do in Crohn’s?

A

can relieve symptoms if steroids on their own are not working

can be used as a long-term treatment to help stop symptoms coming back

are usually taken as a tablet once a day, but sometimes they’re given as injections

may be needed for several months or years

79
Q

What are the side effects of Immunosuppressants?

A

feeling and being sick, increased risk of infections and liver problems

80
Q

What biological medicines are used in Crohn’s?

A

adalimumab, infliximab, vedolizumab and ustekinumab

81
Q

What can biological medicines do in Crohn’s?

A

can relieve symptoms if other medicines are not working

can be used as a long-term treatment to help stop symptoms coming back

are given by injection or a drip into a vein every 2 to 8 weeks

may be needed for several months or years

82
Q

What are the side effects of biological medications?

A

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

83
Q

When might surgery be recommended?

A

the benefits outweigh the risks or that medicines are unlikely to work

84
Q

What does a resection involve?

A
  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.
85
Q

What might you need to careful about with Crohn’s?

A

Triggers

e.g. certain foods
pharmacy medicines

86
Q

What’s the deal with Crohn’s and vaccinations?

A

Flub jab yearly

Avoid live vaccines e.g. MMR

87
Q

What might be more difficult during a flare up?

A

Getting pregnant

88
Q

What might not work as well when you have Crohn’s?

A

Some contraceptives

e.g. the Pill

89
Q

What are possible complications of Crohn’s?

A

Damage to bowel e.g. scarring, narrowing, ulcers, fistulas

Difficulty absorbing nutrients - osteoporosis, iron deficiency anaemia

Bowel cancer

90
Q

How does the risk of bowel cancer change with Crohn’s?

A

after 10 years the risk is about 1 in 50
after 20 years the risk is about 1 in 10
after 30 years the risk is about 1 in 5

91
Q

What should people with Crohn’s do?

A

Have regular colonoscopies

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