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Acutely Ill Patient > Diarrhoea > Flashcards

Diarrhoea Flashcards

1
Q

Definition of diarrhoea

A

No universally agreed definition.
Abnormal passage of loose or liquid stools (types 6+7) with increased frequency (more than 3 times daily) and/ or volume of stool (more than 200g/day)

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2
Q

Definition of Acute diarrhoea

A

Lasts for less than 2 weeks

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3
Q

What are the features of mild dehydration?

A
  • Lack of energy
  • Anorexia
  • Nausea
  • Light-headedness
  • Postural hypotension
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4
Q

What are the features if moderate dehydration?

A
  • Apathy
  • Tiredness
  • Dizziness
  • Muscle cramps
  • Dry tongue/ sunken eyes
  • Reduced skin turgor
  • Postural hypotension
  • Tachycardia
  • Oliguria
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5
Q

What are the features of severe dehydration?

A
  • Profound apathy
  • Weakness
  • Confusion (leading to coma)
  • Shock
  • Tachycardia
  • Peripheral shut down
  • SBP less than 90
  • Anuria
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6
Q

How would you initially assess someone with diarrhoea?

A

A to E (as can cause dehydration)

Stabilise airway and breathing as required

Assess circulation

  • IV access and fluids
  • Bloods to send: FBC, U&Es, CRP, LFTs, TFTs, VBG and if there are signs of sepsis blood cultures
  • Catheterisation if very unwell

History and Examination

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7
Q

What to ask in the history?

A

Nature of stool

  • Bloody
  • Mucus (IBS, colorectal cancer, polyps, IBD)
  • Pus (IBD, diverticulitis, abscess)
  • Watery
  • Steatorrhoea
  • Stool frequency

Other Sxs

  • Fever
  • Abdo pain
  • Nausea
  • Vomiting

Recent travel? (did you drink tap water/ eat anything funny?)
Contact with people with similar Sxs?
Possible sources of food poisoning?
Recent changes in medication, or use of Abx?
Immunocompromised?
SH - job not a public health risk e.g. chef

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8
Q

How long are viruses usually incubated for?

A

Around 1 day

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9
Q

How long are bacteria usually incubated for?

A

A few hours to a few days

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10
Q

How long are parasites usually incubated for?

A

Up to 2 weeks

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11
Q

What symptoms associated with diarrhoea may warrant admission?

A
  • Persistent vomiting
  • Painless, watery, high volume diarrhoea as this is a risk of dehydration
  • Severely dehydrated, shocked or unable to retain oral fluids
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12
Q

What are the lower GI red flags?

A
  • Age over 50
  • Rectal bleeding
  • Recent change in bowel habit
  • Nocturnal Sxs
  • Unexplained or unintentional weight loss
  • IDA
  • FH of colorectal cancer or IBD
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13
Q

What is important to assess for on examination?

A

Abdo and PR:

  • Assess for masses, PR bleeding or impacted faeces
  • Oral ulcers, clubbing and signs of anaemia
  • Signs of dehydration (cap refill, BP, pulse, tongue/ mucous membranes, skin turgor, JVP)
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14
Q

What are the features of acute diarrhoea without blood?

A

Tends to be from the small bowel.

It is generally larger in volume and typically painless

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15
Q

List the causes of acute diarrhoea without blood

A
  • Infection (gastroenteritis)
  • Medications
  • Hyperthyroidism
  • Malabsorption
  • IBS
  • Crohn’s disease
  • Lymphocytic colitis
  • Constipation with overflow diarrhoea
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16
Q

What are the common pathogens that cause acute diarrhoea without bleeding?

A
  • C diff (often follows Rx with clindamycin or broad spectrum Abx. it can cause pseudomembranous colitis)
  • Cholera (Px with profuse watery diarrhoea without abdo pain or fever)
  • Parasites such as giardia, entamoeba, cyclospora and cryptosporium (cause prolonged diarrhoea for more than 14 days usually without vomiting)
  • Rotavirus (common in young children and is self limiting within 1 week)
  • Norovirus (predominantly a vomiting illness but is accompanies with watery non-bloody diarrhoea for 1-2 days)
17
Q

What medications can cause diarrhoea as a SE?

A
  • Magnesium antacids
  • NSAIDs
  • PPIs
  • Abx
  • Metformin
  • Thyroxine
18
Q

What are the features of Lymphocytic colitis? (who it is associated with, clinical features and management)

A

Associated with medications, coeliac disease and older people

Leads to profuse non-bloody diarrhoea with a normal mucosal appearance but intraepithelial lymphocytes on biopsy

It responds well to budesonide or other systemic steroids

19
Q

What are the features of acute bloody diarrhoea?

A

Tends to be from the large bowel

It is usually smaller in volume and painful

20
Q

What are the causes of acute bloody diarrhoea?

A
  • Infection (gastroenteritis)
  • Diverticulitis
  • Ischaemic colitis
  • Ulcerative colitis
21
Q

What are the common pathogens that cause acute bloody diarrhoea?

A
  • Campylobacter jejuni (causes profuse watery bloody diarrhoea with fever and cramps. often a 24 hour prodromal flu-like illness)
  • Salmonella (particularly serogroup D. causes bloody diarrhoea with fever and cramps that lasts from 4-7 days)
  • E coli 0157 (usually causes a mild self limiting diarrhoea for less than 72 hours. VTEC E coli can lead to haemorrhagic colitis and haemolytic uraemic syndrome)
  • Shigella (causes acute watery diarrhoea that may be accompanied by mucus, pus or blood for around 3 days)
  • Schistomiasis
22
Q

What investigations would you do for acute diarrhoea?

A

Bedside:
Obs
Stool cultures, foecal elastase (pancreatitis), foecal calprotectin (IBD)
Urine dip

Bloods:
FBC, U&Es (dehydration/ hypokalaemia), CRP, LFTs, TFTs, VBG, Anti-TTG (coeliac) and if there are signs of sepsis blood cultures

Imaging:
AXR (if systemically unwell to rule out toxic megacolon)
Flexi sig if high suspicion of IBD
Biopsies if indicated

23
Q

What are the indications for sending a stool sample for MC&S and OCP (3 samples on 3 different days)?

A
  • Systemically unwell
  • Immunocompromised
  • Diarrhoea is prolonged
  • Foreign travel
  • Blood/ pus in stool
24
Q

What are the pathogens routinely looked for on stool sample MC&S?

A
  • Campylobacter
  • Cryptosporidium
  • E. Coli
  • Salmonella
  • Shigella
25
Q

When might there be red or white blood cells in the stool?

A

Particularly in Shigella and Campylobacter

26
Q

How do we manage someone with acute diarrhoea?

A
  • Treat cause
  • Rehdration (oral better than IV. IV: 0.9% saline with KCl)
  • Reduce gut motility (only give if clear Dx of underlying cause and avoid if infective)
  • Avoid Abx (unless confirmed infection or sepsis)
27
Q

What anti-motility agents can you give?

A

Loperamide 2mg PO after each stool - max 16mg/ day

Codeine phosphate 30mg TDS

28
Q

When should anti-motility agents be avoided?

A
  • If no cause has been found

- If cause is infectious

29
Q

Give some examples of antispasmodics and when they would be given?

A

Given for Sx relief

Mebeverine, hyoscine butylbromide

30
Q

When should advice be sought from the local health protection unit regarding the need for investigations?

A
  • The patient is suspected public health hazard e.g. food handlers, healthcare workers, elderly residents in care home
  • There is an outbreak of diarrhoea where isolating the organism may help pinpoint the source of the outbreak
  • The patient is infected with certain organisms that may cause serious clinical sequelae e.g. E.Coli 0157
31
Q

Is food poisoning a notifiable disease?

A

Yes

32
Q

Why is E.Coli 0157 so important to identify?

A

Can cause haemolytic uraemic syndrome.
(Causes anaemia, low platelets and kidney failure)

E.Coli is most common travellers infection

33
Q

What is the definition of chronic diarrhoea?

A

The passage of abnormally large volumes of loose stools for more than 14 days

34
Q

Persistent diarrhoea is more likely infectious or non-infectious pathology?

A

Non-infectious

35
Q

What are the differentials for chronic diarrhoea?

A

Colonic:

  • diverticular disease
  • colon cancer
  • colitis (UC, Crohn’s, microscopic colitis, ischaemic colitis)

Small bowel:

  • malabsorptive conditions (coeliac, bile salt malabsorption - ileal resection cholecystectomy, whipple’s disease, tropical sprue, small bowel overgrowth, chronic pancreatitis, CF
  • Lactulose intolerance
  • IBS

Endocrine:

  • hyperthyroidism
  • autonomic neuropathy from DM
  • addison’s

Chronic infections:

  • cryptosporidium
  • giardiasis
36
Q

What are the red flags for chronic diarrhoea?

A
  • Weight loss
  • Rectal bleeding
  • Diarrhoea persisting more than 6 weeks in patients over 60
  • FH of bowel or ovarian cancer
  • Abdo or rectal mass
  • Anaemia in a man or post-menopausal woman
  • Raised inflammatory markers
37
Q

What should you do if colorectal cancer is suspected?

A

Urgent 2 week wait referral

38
Q

What Investigations would you do for chronic diarrhoea?

A

Bloods:
FBC, LFTs, TFTs, U&Es, ESR/CRP
Tests of malabsorption - calcium, B12, folate, iron studies
Antibody tests for coeliac e.g. EMA, TTG

Stool for MC&S and OC&P
also for foecal elastase, chymotrypsin and fat

Flexi sig or colonoscopy if colonic or ileal disease suspeted

Acutely Ill Patient (8 decks)

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