Diarrhoea Flashcards
A **24 **year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known PMHx and is usually fit and well.
Blood pressure 110/65
Heart Rate 96 bpm
Saturations 96% on room air
Temperature: 37.4 degrees
Respiratory rate 22
ABCDE
A
- Ensure patent airway
B
- Monitor SpO2, give high flow oxygen if necessary
- Check RR
- Look, listen, feel chest
C
- Check HR, BP
- 12-lead ECG
- IV access & take bloods
- Assess fluid status: JVP, mucosa, CRT (peripherally & centrally)
- Give IV fluids if dehydrated
- Monitor UO, if pt drowsy > catheter
D
- AVPU/GCS
- Temperature, glucose
E
- Examine abdomen and limbs for signs of infection or the cause of PC
What further info would you like to know from this pt’s history?
I would like to know more about the patient’s history
This episode:
* Any abdominal pain
* Recent travel? (important)
* Any PR bleeding?
* Recent weight loss / night sweats?
* Obstructive symptoms - vomiting?
* Any similar symptoms?
* Has she eaten anything different or new prior to the onset?
* * Any close contacts with someone with the same Sxs?
Any PMHx? Any medications?
Any FHx of note?
SHx - alcohol/smoking?
Quick system review
The patient has not travelled anywhere recently. She does remember having persistent bouts of loose stool over the last 5 days but tended to put it down to her diet. She has in the past noticed blood when opening her bowels as well as mucous. Her mother has inflammatory bowel disease, but she doesn’t know which type. None of her close contacts have been ill with diarrhoea recently. She is currently a student in her last year of university.
What is your differential diagnosis?
Infective - Viral or bacterial gastroenteritis
Inflammatory - IBD, diverticular disease
Increased bowel motility - Irritable bowel syndrome, anxiety, hyperthyroidism
Malabsorption - coeliac disease, pancreatic insufficiency
Obstruction overflow - constipation, colon cancer, ovarian cancer
Medications - laxatives, colchicine, metformin, some ABx,
How will you investigate this patient?
Bedside
- HR, SpO2, BP
- VBG (lactate & K+)
- 12-lead ECG
Bloods
- FBC, CRP, U&E & Mg, LFTs, TFTs
- Blood cultures, urine MC&S
- Stool MC&S
- Faecal calprotectin could be useful to differentiate between IBD and IBS
Imaging
- AXR if colonic dilatation (toxic megacolon)
- Erect CXR (infection cause + pneumoperitoneum)
- Colonoscopy could be necessary (IBD, malignancy)
How will you manage this patient?
Supportive therapy is the main goal
- Fluid management - if dehydrated or signs of AKI > fluid resuscitation
- She may be severely fluid deplete
- Correct electrolyte abnormalities (low potassium)
Medical Mx
- Antibiotics only indicated if a positive culture result
- ABx would not be routeinly started in pts presenting with diarrhoea
What clinical signs O/E may suggest an underlying diagnosis of IBD?
A PIE SAC
I would look for extra-intestinal manifestations of IBD:
* Apthous ulcers
* Pyoderma gangrenosum
* Iritis (uveitis, conjunctivitis, episcleritis)
* Erythema nodosum
* Sacroillitis / Sclerosing cholangitis
* Ankylosing spondylitis / Arthritis/arthropathy
* Clubbing
What markers would suggest a severe attack of IBD?
Markers of a severe attack of IBD include:
- > 6 bloody stools a day
- Systemically unwell: pyrexia and tachycardia
- Hb <10 g/dL
- Albumin <30g/L
- Toxic dilatation
How would you manage an acute flare of IBD?
- Fluid resuscitation still the key point of treatment
- Monitor for acute electrolyte derangement
- Discuss the pt with my surgical colleagues if signs of severe disease activity
- Send samples to exclude infective colitis and other tests to exclude systemic infection
- If IBD likely > IV corticosteroids this would be discussed with nmy senior or the gastro team
What findings on sigmoidoscopy/colonoscopy would differentiate Crohn’s disease from Ulcerative Colitis?
Ulcerative Colitis
Location: Affects only the large bowel; the rectum is always involved.
Distribution: Inflammation is continuous and extends proximally.
Appearance:
- Uniform inflammation confined to the mucosa.
- Loss of vascular pattern, friability, and pseudopolyps.
Histology:
- Granulomas absent.
- Inflammation confined to the mucosa and submucosa.
Crohn’s Disease
- Location: Can affect any part of the GI tract (mouth to anus); rectum is frequently spared.
- Distribution: Inflammation is discontinuous (skip lesions).
Appearance:
- Cobblestone appearance due to deep ulcers and tissue swelling.
- Thickened bowel wall.
- Strictures and fistulae may be present.
Histology:
- Granulomas present.
- Inflammation extends through the full thickness of the bowel wall (transmural inflammation).
Does surgery have a role in the Mx of IBD?
- ~ 30% of pts with UC will require a colectomy at some stage
- Colonic perforation, uncontrollable bleeding, toxic megacolon and fulminating disease require urgent proctocolectomy
- Surgery in Crohn’s is not curative and only indicated for perforation, obstruction, abscess formation and fistulae.
- High recurrence rate after surgery
You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.
S – I am handing over a 24 year old woman with a likely first presentation of inflammatory bowel disease.
B – She has a history of 5 days of bloody diarrhoea with no other features of infection and a family history of inflammatory bowel disease.
A – I have sent investigations to check for electrolyte imbalance and dehydration. I have started fluid resuscitation. I have sent stool cultures to rule out infection but have not started antibiotics pending the results of this.
R – I would recommend admitting this patient and an urgent referral to the gastroenterology team to give advice on further management and investigations which may include starting steroids and arranging a sigmoidoscopy.
