Diarrhoea Flashcards
Describe the Bristol Stool Chart
-1= Hard lumps or pellets
-2= Lumpy and sausage shaped
-3= sausage shaped but with cracks on the surface
-4= smooth and sausage shaped
-5= separate, soft blobs with well defined edges
-6= Mushy with pieces of poo that have ragged or fluffy edges
-7= loose and watery- no solid pieces
What is diarrhoea?
Diarrhoea is the passage of three or more loose or liquid stools per day (or more frequently than is normal for the individual).
-Acute diarrhoea is defined as lasting less than 14 days.
-Persistent diarrhoea is defined as lasting more than 14 days.
-Chronic diarrhoea is defined as lasting for more than 4 weeks.
Presenting complaint
-What is normal for them
=Frequency?
=Consistency?
-Appearance
=Steatorrhea (fat malabsorption)
=Green/brown/orange- small bowel bacterial overgrowth
-How has this changed
=Duration?
=Progressive?
-How has this affected them- what is a bad day like?
=Urgency
=Nocturnal activity (inflammation)
=Housebound?
Further history of presenting complaint
-Bleeding
=Fresh, mixed in, clots
=NB haemorrhoids (wiping)
=Tenesmus (incomplete emptying- colorectal cancer)
-Weight loss
-Diet
=Energy drinks, additives, FODMAPS, caffeine, liquorice= alter gut transit
-Abnormal defecation behaviour
=Straining
=time on toilet
=manual evacuation
Past history and social history
-Occupation (primary school teachers- parasite)
-Family history (colorectal cancer- Amsterdam criteria, IBD, Coeliac)
-Past medical
=Vascular (mesenteric ischaemia), diabetes (autonomic neuropathy, nerve supply damage)
-Previous surgery
=gastrectomy
-Travel
=Counties visited in last 2 years
=Ever lived abroad
-Drug history
-Incontinence
Common culprit drugs with diarrhoea side effects
-Antibiotics
-Antidepressants
-NSAIDs
-Antihypertensives
-Diuretics
-Anticonvulsants
-Lipid lowering drugs
-Anti-diabetic treatment (metformin)
-PPIs/H2-blockers
-Alcohol
-Magnesium supplements
-Colchicine (anti-gout)
Definition of acute diarrhoea
-Change in stool consistency for <4 weeks
Common causes of acute diarrhoea
-INFECTION
-Campylobacter
-Norovirus
-Salmonella
-E. Coli
-Shigella
-Giardia, amoebiasis
-NB immunodeficiency/ HIV
-Drugs
-Gastroenteritis (abdo pain, nausea/vomiting)
-Diverticulitis (classically causes LLQ pain, diarrhoea, fever)
-Abx therapy (broad spectrum, c.diff)
-Constipation causing overflow (faecal incontinence)
-Medication
-Anxiety
-Food allergy
-Acute appendicitis
Definition of chronic diarrhoea
-Change in stool consistency for >4 weeks
Common causes of chronic diarrhoea
-Coeliac disease
-Irritable Bowel Syndrome (Rome criteria)
-Overflow diarrhoea
-Drugs
-Diet
-Colon cancer
-Thyroid disease
-Inflammatory bowel disease (UC bloody diarrhoea, cramps, weight loss, urgency and tenesmus vs Crohn’s: crampy, diarrhoea, ulcers, perianal, obstruction)
Less common causes of chronic diarrhoea
-Infection
-Microscopic colitis
-Ischaemic colitis
-Diabetes
-Small intestinal bacterial overgrowth (SIBO)
-Pancreatic insufficiency
-Bile acid malabsorption
-Post-Radiotherapy enteritis
-Small bowel lymphoma
-Thyrotoxicosis
-Appendicitis
Rare causes of chronic diarrhoea
-Vasculitis
-Laxative abuse
-Neuro-endocrine tumours
-Post-gastric surgery
Faecal calprotectin
-Calprotectin= protein released by immune cells (neutrophils)- shed into stool
-Correlates with small and large inflammation
-Altered bowel habits
-Monitoring inflammatory disorders
-Less than 20-50 microgram/g
IBS diet
-Exclude gluten
-FODMAP containing foods= exacerbate
Coeliac disease diagnosis
-Anti tTG >2000
-Low haemoglobin and ferritin (iron deficiency anaemia)
-Autoimmune conditions
-Dermatitis herpetiformis rash
=gluten free diet
=dexa bone scan for long-standing malabsorption, osteopenia (significant weight loss)
IBD presentation
-Erythema nodosum rash on shins/legs (painful purple lesions and raised)
-Elevated faecal calprotectin
-Weight loss
-Urgency, incontinence, nocturnal
-Biopsy and colonoscopy
Overflow diarrhoea
-Due to constipation
-Explosive watery diarrhoea, maybe incontinence
-Impacted stool on PR
-Faecal loading in large intestine
-Ondanstron= slows gut transit
-Opiates slows gut transit
Pancreatic insufficiency/ pancreatitis
-Faecal elastase low (released by pancreas, 200-500micrograms/g)
-Malabsorption on vitamins
-History alcohol abuse
-Atrophic pancreas, high density areas of calcium deposits
-Change in colour and consistency, steatorrhea (exocrine)
-High BM- insulin insufficiency (endocrine)
-Control blood sugar
-Replace enzymes taking capsule with every meal
Overview of Ischaemic colitis
Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage. It is more likely to occur in ‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
-Progressive abdominal pain
-Blood when pain is bad
-Worse 1-2hrs after eating
-Previous vascular disease
-X-ray: ‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
-CT contrast= narrowing coeliac axis= mesenteric angina/ ischaemia (plaque)
-Vascular MDT
-Optimising risk factors
Bloods investigations
-FBC
-U&E (dehydration with significant diarrhoea, CKD)
-LFT (GGT)= biliary/pancreatic causes
-High platelet count= inflammatory element
-CRP= inflammatory
-ALB= inflammatory, nutritional marker (lower= inflammation)
-TFTs (thyrotoxicosis)
-BM/lab glucose (diabetes/ pancreatic insufficiency/ endocrine dysfunction)
-HbA1c
-Anti-tTG-IgA (coeliac)
-B12/Folate/Ferritin (if anaemic- blood loss?)
-HIV
-Calcium/magnesium (chronic electrolyte loss)
-7a-cholestonone (bile acid malabsorption)
Stool investigations
-MC&S x3
-Enteric parasites
-Calprotectin (IBS vs IBD)
-Elastase (low= pancreatic insufficiency)
the patient is systemically unwell and needs hospital admission, +/- antibiotics
blood or pus in the stool
immunocompromised
recently received antibiotics, a proton pump inhibitor (PPI) or been in hospital
recent foreign travel
public health indication: diarrhoea in high-risk people (for example food handlers, healthcare workers, elderly residents in care homes), suspected food poisoning (for example after a barbeque, restaurant meal, or eating eggs, chicken, or shellfish)
Imaging investigations
-CT colonoscopy
-CT CAP (pancreatic lesions, cancer, bile)
-SB MRI (vascular supply, flow limiting ischaemia)
-AXR
Endoscopy
-Colonoscopy (cancer)
-Upper GI endoscopy
-Capsule endoscopy
Investigations of colorectal cancer/ IBD suspected
-Colonoscopy
-+/- ileoscopy and biopsies
-Consider flexible sigmoidoscopy in younger patients
Investigations in suspected coeliac
-Upper GI endoscopy and biopsy
Investigations for suspected small bowel IBD
-MRI enterography or capsule endoscopy
-CT if MRI or VCE not possible
Red flag features
-Weight loss
-Significant progressive change in bowel habit
-Urgency nocturnal
-Persistent PR bleeding
ROME IV criteria for IBS
-ROME IV criteria: Recurrent abdominal pain, on average, at least 1 day per week in the last 3 months (with symptom onset at least 6 months prior to diagnosis) which is associated with two or more or the following:
=Related to defaecation;
=Change in frequency of stool;
=Change in stool form.
-Patients are sub-grouped according to predominant Bristol stool type to help direct treatment:
=IBS with diarrhoea (IBS-D).
=IBS with constipation (IBS-C).
=IBS with mixed bowel habits (IBS-M).
=IBS unclassified (IBS-U) where symptoms meet the criteria for IBS but do not fall into one of the three subgroups above according to Bristol stool type.
Diagnosis of IBS
For at least 6 months:
-Abdominal pain, and/or
-Bloating, and/or
-Change in bowel habit
A positive diagnosis of IBS should be made if the patient has 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)
=abdominal bloating (more common in women than men), distension, tension or hardness
=symptoms made worse by eating
=passage of mucus
Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis
=Red flag features should be enquired about:
=rectal bleeding
=unexplained/unintentional weight loss
=Positive FIT, raised faecal calprotectin, IDA
=family history of bowel or ovarian cancer
=bowel habit change onset after 60 years of age, persistent or frequent bloating in females
Suggested primary care investigations are:
-full blood count
-ESR/CRP
-coeliac disease screen (tissue transglutaminase antibodies)
-Assess for bowel cancer, ovarian cancer, IBD
Blood tests for IBS
-Full blood count (FBC) — to assess for anaemia, and a raised platelet count.
-Inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) — may be raised if there is active inflammation or infection.
-Coeliac serology — to exclude coeliac disease, particularly if there is diarrhoea-predominant IBS or mixed symptoms.
-Faecal calprotectin — in particular if the person has diarrhoea and is aged 45 years or younger to exclude inflammatory bowel disease.
-Local and national referral guidelines for suspected colorectal or ovarian cancer should be followed, where indicated.
Treatment for IBS
NICE/BDS IBS advice sheet
Food diary
Trial of GFD (bloating)
Symptom guided approach
FODMAP exclusion diet
Transit studies
Pro-kinetics (linaclotide/prucalpride)
First-line pharmacological treatment - according to predominant symptom
=pain: antispasmodic agents
=constipation: laxatives but avoid lactulose
=diarrhoea: loperamide is first-line
-For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:
=optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
=they have had constipation for at least 12 months
-Second-line pharmacological treatment
=low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
-Other management options
=psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy
=complementary and alternative medicines: ‘do not encourage use of acupuncture or reflexology for the treatment of IBS’
-General dietary advice
=have regular meals and take time to eat
=avoid missing meals or leaving long gaps between eating
=drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
=restrict tea and coffee to 3 cups per day
=reduce intake of alcohol and fizzy drinks
=consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
=reduce intake of ‘resistant starch’ often found in processed foods
=limit fresh fruit to 3 portions per day
=for diarrhoea, avoid sorbitol
=for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
Differential Diagnosis for IBS
-Malignancy
-Functional or drug-induced constipation
-Hypothyroidism
-IBD
-Coeliac
-GI infection and secondary lactose intolerance
-Antibiotic associated diarrhoea
-Microscopic colitis
-Bile acid malabsorption
-Hyperthyroidism
-Laxative misuse
-Diverticular disease
Discussing IBS diagnosis
-Context of the gut-brain axis and explain that IBS is a chronic condition with recurrent fluctuating symptoms which can be triggered by stress, intercurrent illnesses, medications and eating.
-Reassure the person that IBS is not associated with an increased risk of cancer or mortality.
-Explain that the aim of management is to improve symptoms (it may not relieve them completely) and quality of life — treatments are likely to be needed long term.
Treatment for Coeliac
OGD D1 and D2 biopsies
DEXA scan if significant weight loss
GFD (gluten free diet)
Dietician review
GI review if ongoing/refractory symptoms
IBD treatment
Colonoscopy (+OGD if <17yo)
SBMRI
Biologic screening
Polymeric diet (CD)
5’ASA (UC)
(steroids)
Immunomodulators
-AZA, 6-MP
-methotrexate
Biologic drugs
-anti-TNF (infliximab, adalimumab)
-anti-α4β7 (vedolizumab)
-anti-IL-12/23p40 (ustekinumab)
-tofacitinib (JAK inhibitor)
Treatment for bile acid malabsorption
Questran
Treatment for SIBO
-Trial of antibiotics (e.g. rifaximin)
Treatment for pancreatic insuffiency
-Creon
-DM control
Treatment for ischaemia colitis
-Vascular MDT
