Diarrhoea Flashcards
What are the most common causes of gastroenteritis?
Eschericia coli
Campylobacter
Shigella
Salmonella
Clostridium difficult
Norovirus
Rotavirus
Staphylococcus aureus
What are the most common causes of bloody diarrhoea from gastroenteritis?
Camplyobacter
Shigella
What are the causes of non bloody watery diarrhoea due to gastroenteritis?
Escherchia coli
Cholera
What is the most common cause of bloody diarrhoea?
Campylobacter
What are some complications of gastroenteritis?
IBS
GBS (Guillian Barre Syndrome) = hyporeflexia/areflexia
What is GBS?
Guillian Barre syndrome is an autoimmune condition which antibodies attack the myelin sheath (schwann cells) of nerves
What are some differentials for chronic bloating and diarrhoea?
Crohn’s disease
Ulcerative colitis
IBS
Coeliacs disease
What are the similarities between IBS and IBD?
Both can cause:
-diarrhoea
-bloating
-crampy pain
-mucosal stool
What are the key differences between IBD and IBS presentation?
IBS = NO SYMPTOMS AT NIGT
IBD = SYMPTOMS AT ANY TIME
IBS = No weight loss
IBD = Weight loss
IBS = No other systemic affects
IBD = extra intestinal manifestations and general unwell symptoms
IBS = watery diarrhoea
IBD = often contains blood
What are the main indications in a patients history with diarrhoea that would make you think IBS over IBD?
NO SYMPTOMS AT NIGHT
No weight loss
No blood in stool
What investigations would you do for a patient with diarrhoea and spasmodic abdominal pain?
State why you’d do each investigation:
FBC (Gastroenteritis)
Faecal calprotectin (indicates IBD if positive)
Coeliac serology
Faecal elastase (chronic pancreatitis)
Stool culture (MCS)
Colonoscopy
Biopsy if required
How does UC present?
Bloody diarrhoea
Left lower quadrant abdominal pain
Weight loss
Fever
Extra intestinal manifestations
Stool urgency
Stool frequency
Tenesmus
Mucous discharge
What are some extra intestinal manifestations of ulcerative colitis?
Arthritis
Erythema nodosum
Uveitis
Pyoderma gangrenosum
Primary sclerosing cholangitis
What are some complications of ulcerative colitis?
TOXIC MEGACOLON
Bowel obstruction
Bowel perforation
Colorectal adenocarcinoma
What type of inflammation occurs with ulcerative colitis?
Superficial non granulomatous inflammation originating in rectum spreading proximally potentially up to the ileocaecal valve
How does Crohn’s disease present?
Episodic abdominal pain
Diarrhoea
Bloody stool
Mucos in stool
Systemic fever
PERIANAL DISEASE
Extra-intestinal manifestations
What is a key difference in the presentation between Crohn’s disease and ulcerative colitis?
Perianal disease occurs with Crohn’s
Mouth ulcers very commonly happens with Crohn’s
What are some Perianal diseases seen with Crohn’s?
Perianal fistulae
Perianal abscess
Perianal ulcers
What are some extra intestinal manifestations of Crohn’s disease?
Enteropathic arthritis
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Iritis
Primary Sclerosing cholangitis
What type of inflammation is seen with Crohn’s disease?
Skip like lesions that have transmural full thickness inflammation that can span the entire GI tract
Fissures, deep ulcers and fistulae
Granulomatous infalmmation
What are the complications of Crohn’s disease?
Fistulae
Strictures
GI malignancy
Recurrent Perianal fistulae
Malabsorption
Inc risk of gallstones
Inc risk of renal stones
What is the management of an acute severe flare of uclerative colitis?
IV corticosteroids (hydrocortisone)
Fluid resuscitation
Prophylactic heparin
TED stockings
What medication is given to treat a mild to moderate ulcerative colitis flare?
Aminosalicylates topical or rectal like mesalazine
Second line Prednisolone
What medication is given to treat a mild to moderate ulcerative colitis flare?
Aminsalicylates topical or rectal like mesalazine
If doesn’t work give corticosteroids (Prednisolone)
What is the management strategy once the acute ulcerative colitis flare has resolved?
What happens if theres a relapse??
Ween down the steroids but maintain the oral or rectal mesalazine
If relapse give Azathioprine (DMARD)
What are the side effects of azathioprine?
Pancreatitis
Myelosuppression
What happens if azathioprine fails to achieve remission for ulcerative colitis?
Try biologics
What are some side effects of steroids?
ACNE
Weight gain
Immunosuppression
Osteoporosis
Peptic ulcers
What are the general principles for managing uclerative colitis?
Fluids
Severe = IV corticosteroids (hydrocortisone) try ween down till nothing and maintain with mesalazine
Mild-moderate = mesalazine oral or rectally if relapse give steroids (prednisolone) then ween to azathioprine
What is the management for Crohn’s disease?
Fluid resus
Prophylactic hepatic
TED stockings
IV corticosteroids
Mesalazine or methotrexate/azathiprine if corticosteroids fail
What investigations are used to diagnose coeliac disease?
Colonoscopy with biopsy
Coeliac serology
What would be seen on biopsy for a patient with coeliac disease?
Villous atrophy
Crypt hyperplasia
Lymphocyte infiltration
What is tested for in coeliac serology?
Anti-TTG
Anti-Endomysial IgA
What is the management for coeliacs disease?
Gluten free diet
What are the differentials for a patient with diarrhoea, tender mass in right iliac fossa and mouth ulcers?
Appendiceal mass due to Crohn’s disease
Appendicitis
Appendiceal abcesses
Intestinal abscess
How do you differentiate between an Appendiceal mass and an abscess?
CT AP IV contrast
How does management differ between an Appendiceal mass and an abscess?
Steroids for Appendiceal mass/crohns
Abx and drainage for abscess
Why does coeliacs disease lead to weight loss?
Villous atrophy
Crypt hyperplasia
Leads to malabsorption in duodenum and jejunum
What causes of gastroenteritis occurs over a long period of time causing prolonged watery diarrhoea?
Giardiasis (Protozoa)
What are the stools like for gastroenteritis caused by giardia?
Long lasting
Profuse watery
Yellow and smelly
What antibiotic is given to treat gastroenteritis caused by giardia?
Metronidazole
What are some acute causes of gastroenteritis/food poisoning?
Staphylococcus aureus
Bacillus cereus
Viral
What is the pathophysiology of acute gastroenteritis/food poisoning?
Staphylococcus aureus and bacillus cereus produce toxins leading to diarrhoea and vomiting
What is the managing for food poisoning?
Supportive treatment (fluids)
What is the main differential if a patient is being treated for a chest infection with co-amoxicillin and clarithromycin?
Clostridium difficile (C.diff)
What is the main class of antibiotic that increases the risk of C.difficile infection?
Cephalosporins
What is an example of a cephalosporin that increases the risk of c.diff infection?
Ceftriaxone
What is an example of a macrolide that increases the risk of c.diff infection?
Clarithromycin
How do you diagnose C.diff?
Stool culture (MCS)
How do you treat a c.diff infection?
1st line = oral vancomycin 10days
2nd line = oral fidoxamicin
3rd line = oral vancomycin + IV metronidazole
How does a C.diff infection occur?
Depleted gut flora allows for the overgrowth of C.diff
What management would you do if a patient has a recurring c.diff infection?
If mild do nothing
Of serious give prophylactic vancomycin to get germinating spores
What are the main differentials if a patient is experiencing weight loss and bloating?
Coeliacs disease
Crohn’s disease
Chronic pancreatitis
What considerations might you make for a patient with wheezy breathlessness and a watery diarrhoea?
Carcinoid syndrome
What is carcinoid syndrome?
Neuroendocrine tumour that originates in the GI tract metastases to somewhere like the liver and become symptomatic due to the substances being secreted avoiding first pass metabolism by the liver
What commonly causes enlarged liver?
Polycystic livers
Glycogen storage disease
Carcinoid syndromes
What genotypes are commonly associated with coeliacs disease?
HLA-DQ2
HLA-DQ8
What is a skin condition caused by coeliacs disease?
Dermatitis herpetiformis
What is a cause of watery diarrhoea and bloating when all investigations come back normal:
-normal FBC
-negative coeliac serology
-negative faecal calprotecin
-negative faecal elastase
-stool culture negative
Overflow diarrhoea
What imaging is used to diagnose overflow diarrhoea?
Abdominal x-ray
What is the management for overflow diarrhoea?
Rectal examination
Laxatives
Stool softeners
Manual evacuation
What are some laxatives that can be given to treat overflow diarrhoea?
Macrogol (osmotic laxative)
Senna (stimulative laxative)
What are some stool softeners that can be given to treat overflow diarrhoea?
Glycerin
Phosphate enemas
What are some risk factors for developing overflow diarrhoea?
Low fibre diet
Immobile
Suppressing feeling to go
Dehydration
Stress
Why may a patient have normal investigations but have watery diarrhoea and colonoscopy revealing brown black pigmentation in the large bowel?
Patient chronically overuses laxatives
What is it called when a patient has a brown black pigmentation in their large bowel due to chronic use of laxatives?
Melanosis coli
What is the pathophysiology of melanosis coli?
Macrophages engulf the laxative compounds
How can diabetes lead to watery diarrhoea and weight loss?
Diabetic auto neuropathy
What is the pathophysiology of diabetic autoneuropathy?
Diabetic neuropathy affects the enteric nervous system leading to stagnation of small bowel contents which can lead to small bowel bacterial overgrowth leading to colitis
What Abx would be used to treat an infection due to diabetic auto-neuropathy?
Rifaxamine
Ciprofloxacin
Metronidazole
What is the primary differential if a patient has a cholecystectomy and is now suffering from watery diarrhoea with out pain?
Bile salt deficiency diarrhoea
What is the pathophysiology of bile salt deficiency causing diarrhoea?
Removed gall bladder
Bile acids not reabsorbed in the terminal ileum as efficiently since the gallbladder is not regulating the flow of bile into the bowel
Continuous flow overwhelms the bowel leading to the osmotic diarrhoea
How do you investigate bile salt deficiency diarrheoa?
Radioabbeled bile acids to see how much is retained
How do you treat diarrhoea due to bile slat deficiency?
Bile acid sequestrants
What is an example of a bile acid. Sequestrant?
Cholestyramine
What is used to maintain remission for Ulcerative Colitis following a severe flare or more than 2 exacerbations in a year?
Azithioprine (oral)
What is the first line medication used to treat pain caused by IBS?
Antispasmodics - Mebeverine or hyoscine butylbromide also called Buscopan
