Diarrhoea

Question 1

What is diarrhoea?

Answer 1

Increased stool frequency?

Increased stool volume?

Change in stool consistency?

All of the above?

What is normal for the patient- change from their baseline. Eg. IBS or faecal incontinence

Question 2

What questions would you ask during a history?

Answer 2

How often? 
Normal?
Blood?
Abdo-pain? 
Weight loss?
Fatigue?

Question 3

What is acute diarrhoea?

Answer 3

Less than 4 weeks
Mostly infectious and self limiting
Investigate after 1 week

Question 4

What is chronic diarrhoea?

Answer 4

More than 4 weeks
Chronic pathology
Always investigate

Question 5

Give examples of causes of acute diarrhoea

Answer 5

Viral:
Rotavirus
Norovirus
Enteric adenovirus

Bacterial:
Salmonella 
Shigella
Campylobacter
Staph.aureus

Parasitic:
Cryptosporidium parvum
Can be chronic -
Giardia lamblia
Entamoeba histolytica

Question 6

Give some examples of chronic diarrhoea

Answer 6

Pancreatic:
Chronic pancreatitis
Pancreatic cancer
Cystic fibrosis
Endocrine:
Hyperthyroidism
Diabetes
Addison’s disease
Hormone secreting tumours (e.g. Carcinoid, VIPoma)
Other:
Drugs
Alcohol
Factitious

Colonic:
Ulcerative & Crohn’s colitis
Microscopic colitis
Colorectal cancer
Small bowel:
Coeliac disease
Crohn’s disease
Bile salt malabsorption
Lactose intolerance
Small bowel bacterial overgrowth

Question 7

List some mechanisms of diarrhoea

Answer 7

Osmotic e.g. lactose intolerance
Steatorrhoea
Secretory e.g.Cholera, E. Coli, gut hormones
Inflammatory e.g. UC, Crohn’s, infections
Neoplastic
Ischaemic
Post irradiation

Question 8

Describe ulcerative colitis

Answer 8

Continuous mucosal inflammation of the
colon without granulomas on biopsy, affecting
the rectum and a variable extent of the colon in
continuity and characterised by a relapsing
and remitting course.
Inflammation of the rectum and maybe extending up

Question 9

Describe Crohns disease

Answer 9

Discontinuous and often granulomatous
transmural inflammation affecting any area of
the gastrointestinal tract.

Question 10

What symptoms are common in ulcerative colitis?

Answer 10

Bloody diarrhoea, rectal bleeding, mucus, faecal urgency, abdo pain, nocturnal defecation
Often insidious onset
Extraintestinal manifestations (arthritis, uveitis, erythema nodosum, pyoderma gangrenosum)
Primary sclerosing cholangitis

Question 11

What tests must be carried out when diagnosing ulcerative colitis?

Answer 11

History and examination
Stool cultures + CDT
Faecal calprotectin
CRP
FBC
Albumin
Flexible sigmoidoscopy/colonoscopy

Question 12

Who does Ulcerative colitis affect?

Answer 12

Any age (peak teens/early adulthood)
M:F 1:1
Relapsing/remitting course
Positive effect of smoking! (ex-smokers 70% increased risk of UC)
Appendicectomy protective
10-15 fold risk in 1st degree relatives (2% lifetime risk)

Question 13

How would you treat ulcerative colitis?

Answer 13

Admit
Hydrocortisone 100mg iv qds (prednisolone given when flare ups in community )
Heparin s.c. (prevent DVT and PE)
Stool chart
AXR (baseline and exclude toxic megacolon)
Daily CRP

Question 14

What drugs would you avoid in ulcerative colitis?

Answer 14

NSAID’s, opiates, antimotility agents

Question 15

What is the treatment to severe UC?

Answer 15

Infliximab

(Cyclosporin)

Colectomy

Question 16

What is the treatment for mild-moderate ulcerative colitis?

Answer 16

Mesalazine (5 ASA)
Oral
Topical: suppository, enema
Prednisolone – reducing course 
Azathioprine
Biologics:
Anti-TNF agents e.g. Infliximab, adalimumab
a4b7 integrin blocker: Vedolizumab
(Surgery)

Question 17

Who may crohn’s disease affect?

Answer 17

Any age (peak teens/early adulthood)
M:F 1:1
Relapsing/remitting course
Smoking
Previous appendicectomy
Family history
Infectious gastroenteritis (increase risk in following year)

Question 18

Give the symptoms of crohn’s disease

Answer 18

Chronic diarrhoea most common
IBS type symptoms
Abdo pain (in 70%)
Weight loss (in 60%)
Anaemia
Growth failure in children
 Blood +/- mucus in stools (40-50% of Crohn’s colitis)
Perianal disease
Extraintestinal manifestations (e.g. arthritis, uveitis, erythema nodosum

Question 19

Give the different categories of crohn’s disease

Answer 19

Inflammatory disease
Stricturing disease: infammatory/fibrotic
Fistulating disease
Perianal disease

Question 20

Give the treatment for crohn’s disease

Answer 20

5 ASA preparations
Prednisolone/Budesonide (corticosteroids)
Azathioprine/6-Mercaptopurine (purine analogue)
Methotrexate (inhibits folic acid metabolism)
Nutritional therapy (elemental diet)
Antibiotics
Biologics, e.g. Infliximab, adalimumab (anti-TNF), Vedolizumab (a4b7 integrin blocker)
Surgery