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Year 3 - Met3a > Diarrhoea > Flashcards

Diarrhoea Flashcards

1
Q

how serious can diarrhoea be

A
  • Common, often mild and self-limiting but potentially serious and life threatening
  • second commonest cause of death in children under 5
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2
Q

What do patients sometimes mean by diarrhoea

A
  • irregular bowel habit

- change in bowel habit

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3
Q

What are the red flags for cancer relating to diarrhoea

A
  • change in bowel habit
  • bleeding
  • weight loss
  • FH bowel or ovarian cancer
  • aged over 50 and for longer than 6 weeks
  • anaemia
  • abdominal or rectal mass
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4
Q

What is the definition of diarrhoea

A
  • 3 and more stools a day and loose
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5
Q

How much fluid is cycled in the intestinal tract

A

9L of fluid is cycled from the intestinal tract

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6
Q

How much fluid is produced in the intestinal tract

A
  • 1L of saliva
  • 1l of intestine
  • 1L of bile
  • 2L of pancreas
  • 2L of gastric
  • 2L of diet
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7
Q

How much fluid leaves the intestinal tract

A
  • 1.5L in colon
  • 3.4 in ileum
  • 4 in Jejunum
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8
Q

what is absorbed and secreted

A

Absorption

  • nutrients
  • water
  • electrolytes

secretion

  • water
  • electrolytes
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9
Q

How do you take a history of diarrhoea

A
  • duration
  • type of stool and frequency
  • organic features - BO at night, fever, blood
  • systemic disease = diabetes, thyrotoxicosis, systemic sclerosis
  • H/O pancreatic disease or abdominal surgery
  • family history: IBD, malignancy, coeliac
  • travel
  • dietary indiscretion (include alcohol)
  • medication: NSAIDs, antibiotics, PPIs laxatives
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10
Q

How do you classify diarrhoea

A
  • Acute - less than 2 weeks

- chronic - last longer than 4 weeks

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11
Q

What does acute diarrhoea look like

A
  • watery
  • bloody
  • usually mild and self-limiting
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12
Q

What does chronic diarrhoea look like

A
  • watery
  • bloody
  • steatorrhoea
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13
Q

What is the most common cause of diarrhoea

A
  • infection
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14
Q

what can cause acute diarrhoea

A
  • Look for fever/pain
  • dietary indiscretion (few hours)
  • viral infection (24-48 hours)
  • food poisoning
  • travellers diarrhoea (2-5) days
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15
Q

How do you treat acute diarrhoea

A
  • usually sit it out
  • oral rehydration therapy is it is severe
  • usually gets better on its own accord
  • occasionally consider IV fluids/antibiotics
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16
Q

What is acute travellers diarrhoea caused by

  • viruses
  • parasites
  • other bacteria
A

Viruses

  • rotavirus
  • adenovirus
  • noravirus
  • Ecoli

Parasites

  • G, intestinalis
  • C parvum
  • I belli
  • cyclospora

other bacteria

  • Shingella spp
  • salmonella spp
  • campylobacter spp
  • EHEC
  • EIEC
  • V cholerae
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17
Q

what is the most common cause of acute traveller diarrhoea

A

E.coli

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18
Q

What is oral rehydration made out of

A
  • 1L of water
  • 3.5g of sodium chloride
  • 2.5g of sodium bicarbonate
  • 1.5g potassium chloride
  • 20g of glucose
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19
Q

How should you consider using IV fluids/antibiotics in in acute diarrhoea

A
  • elderly or immunocompromised
  • frequent bloody stools
  • severe abdominal pain
  • temperature - greater than 38.5 degrees
  • hypovolaemia
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20
Q

Persistent and chronic daiarrhoea needs ..

A

always needs accurate diagnosis and treatment

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21
Q 
describe what 
- bloody 
- water 
- fatty 
mean in chronic diarrhoea and what can cause them
A

Watery

  • secretory
  • osmotic

blood

  • colonic disease
  • infection
  • neoplasia

fatty

  • pancreatic
  • small bowel
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22
Q

What are the two causes of fatty diarrhoea

A
  • Pancreatic insufficiency

- small intestinal disease

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23
Q

How do you check to see if pancreatic insufficiency is causing fatty chronic diarrhoea

A

Normal red cel folate

  • faecal fat - greater than 20g/24 hours
  • faecal elastase - measure pancreatic enzyme in the stool
  • plain abdominal radiograph/US
  • abdominal CT, EUS, MRI, MRCP
  • ERCP
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24
Q

How do you check to see if small intestinal disease is causing fatty chronic diarrhoea

A
  • Low red cell folate
  • anti-TTG antibodies
  • duodenal/jejunal/TI biopsy
  • small bowel imaging - CT, MRE
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25
Q

What are clues to infective causes of diarrhoea

A

Rapid onsent of symptoms are food - greater than 6 hours
- toxin producing organisms = B cerus, S aureus

fever

  • invasive bacteria - salmonella, shigella, campylobacter
  • enteric viruses
  • cytotoxic organisms - c.difficle, E histolytica

blood diarrhoea

  • invasive bacteria - salmonella, shigella, campylobacter, E.coli
  • amoebic dysentery - travel history

Antibiotics
- C.difficile

26
Q

What drugs can cause chronic diarrhoea

A
  • Alcohol
  • antibiotics
  • anti-depressants
  • anti-hypertensives
  • cholesterol lowering agents
  • NSAIDs
  • oral hypoglycemics - (Biguanides)
  • propanol
  • laxatives
  • PPIs
  • Digoxin
27
Q

what can cause osmotic diarrhoea

A
  • non absorbable substance
  • high concentration of solute in malabsorption
  • specific defect - e.g. disaccharidase deficiency
28
Q

What can cause secretory diarrhoea

A
  • inflammation e.g. IBD
  • infection e.g. salmonella
  • enterotoxins from e.g. E coli, V cholera
  • hormones e.g. neuroendocrine tumours
  • bile salts and fatty acids
29
Q

What can cause motility diarrhoea

A
  • thyrotoxicosis
  • iBS
  • DM
  • autonomic neuropathy
30
Q

what is the commonest cause of maldigestion

A

lactose intolerance

31
Q

what is FODMAP related diarrhoea

A
  • Some patients with IBS type symptoms
  • osmotic diarrhoea
  • pain and bloating from fermentation of these
F - fermentable 
O - oligosaccharides 
D - disaccharides (e.g. lactose) 
M - monosaccharides (e.g. fructose) 
P - polyols
32
Q

What is Clostridum difficile associated with

A
  • use of broad spectrum antibiotics - (clindamycin, cephalosporins, penicillins, fluoroquinolones)
  • use of PPIs
33
Q

Describe Clostridium difficile

A
  • anaerobic gram positive
  • spore forming
  • made out of toxins A and B
  • life threatening infection
34
Q

How is Clostridium difficile transmitted

A

Faecal - oral route

35
Q

Describe who is affected by C.difficile the most

A
  • associated with antibiotic use
  • elderly
  • more prominent with patients with IBD
36
Q

What are the severities of C Difficile

A
  • Mild
  • moderate
  • severe
  • complicated
  • life threatening
37
Q

Describe the severity of disease C difficile

A 
Mild 
- 3 stools a day
- normal WCC
treatment 
- Oral metronidazole 400mg/8h PO for 10-14d
Moderate 
- 3 -5 stools a day
- raised WCC
treatment 
- Oral metronidazole 400mg/8h PO for 10-14d
severe 
- WCC raised 
- temperature greater than 38.5 degrees 
- raised CR 
- abdominal pain or XR acute colitis 
Treatment 
- oral vancomycin 125mg/6hr PO
complicated
- hypotension 
- partial ileus 
- evidence of severe disease on CT
Treatment 
- Oral vancomycin and IV metronidazole 
life threatening
- complete ileus or toxic megacolon 
Treatment 
- oral vancomycin and IV metranidazole 
- faecal microbiota transplant 
- consider colectomy if toxic megacolon, raised LDH or deteriorating
38
Q

How do you investigate diarrhoea (bloods and stool)

A

Blood tests

  • FBC - anaemia
  • Inflammatory markers - WCC, Platelets, CRP all raised
  • U and Es - dehydration/AKI
  • albumin/Ca/P - nutritional status
  • haematinics
  • TTG antibodies and IgA - coeliacs disease
  • TFTs

Stool and other tests

  • stool weight
  • MC&S, CDT, Cysts, ova, parasites
  • faecal calprotectin
  • FIT - faecal immunochemical test for Hb) - test for blood in the stool
  • faecal elastase
  • stool pH/electrolytes/reducing substances
39
Q

How do you investigate diarrhoea with imaging

A
  • Colonoscopy and biopsies

Other imaging

  • duodenal biopsy
  • small bowel MRI
  • video-capsule endoscopy
  • cross-sectional imaging
40
Q

How do you prevent diarrhoea

A
  • Hand washing with soap and water
41
Q

Name the common causes of diarrhoea

A
  • Gastroenteritis
  • traveller’s diarrhoea
  • C.Difficile
  • IBS
  • colorectal cancer
  • Crohn’s disease
  • ulcerative colitis
  • coeliac disease
42
Q

Name the less common causes of diarrhoea

A
  • microscopic colitis
  • chronic pancreatitis
  • bile salt malabsorption
  • laxative abuse
  • lactose intolerance
  • illeal/gastric resection
  • overflow diarrhoea
  • bacterial overgrowth
43
Q

Name the non GI causes of diarrhoea

A
  • thyrotoxicosis
  • autonomic neuropathy
  • Addison’s disease
  • ischaemic colitis
  • tropical sprue
  • gastronome
  • carcinoid
  • pellagra
  • VIPoma
  • amyloidosis
44
Q

Name the causes of bloody diarrhoea

A
  • campylobacter
  • shigella/salmonella
  • E.coli
  • amoebiasis
  • colorectal cancer
  • UC
  • Crohn’s
  • colonic polyps
  • pseudomembranous colitis
  • ischaemic colitis
45
Q

Name the cause of mucus diarrhoea

A
  • IBS
  • UC
  • colorectal cancer
  • polyps
46
Q

What can cause frank pus in diarrhoea

A
  • IBD
  • diverticulitis
  • fistula/abscess
47
Q

What can cause explosive diarrhoea

A
  • cholera
  • giardia
  • yersinia
  • rotavirus
48
Q

What is steatorrhoea

A
  • characterised by flatulence, offensive smell, and floating, hard to flush stools
49
Q

What conditions can cause steatorrhoea

A
  • pancreatic insufficiency
  • biliary obstruction
  • coeliac disease/malabsorption
50
Q

What should be included the assessment of someone with diarrhoea

A
  • Dehydration
  • fever, weight loss, clubbing, anaemia, oral ulcers, rashes, abdominal mass or scars
  • goitre or hyperthyroid signs
  • DRE for masses or impacted faeces
51
Q

What are the signs of dehydration

A
  • dry mucus membranes
  • reduced skin turgor
  • capillary refill is greater than 2 seconds
  • shock
52
Q

What does faecal elastase test for

A
  • if suspected chronic pancreatitis (malabsorption, steatorrhoea)
53
Q

Why do you use lower GI endoscopy

A
  • look for malignancy and colitis
54
Q

name some lower GI endoscopy that you can use

A
  • flexible sigmoidoscopy and biopsies - if acutely unwell
  • full colonoscopy - if more proximal disease
  • if normal consider radiology or video capsule
55
Q

What is the management of diarrhoea

A
  • Treat the cause
  • if there is a hospital outbreak wards might need closing
  • Oral rehydration, better than IV but if there is sustained diarrhoea and vomiting, IV fluids with electrolyte replacement might be needed
  • Codeine phosphate 30mg/8h PO or loperamide 2mg PO after each loose stool (max 16mg/d) this reduces stool frequency
  • avoid antibiotics unless infective diarrhoea is causing systemic upset
  • antibiotics associated diarrhoea may be response to probiotics
56
Q

What medication can you give a patient to reduce diarrhoea

A
  • Codeine phosphate 30mg/8h PO or loperamide 2mg PO after each loose stool (max 16mg/d) this reduces stool frequency
  • Should avoid in colitis, may precipitated toxic megacolon
57
Q

How do you manage infective diarrhoea

A

If no systemic signs -stool culture is not needed

Systemic illness -
- fever greater than 39 degrees, dehydration
- diarrhoea and visible blood for >2 weeks
Then you should admit to hospital
- oral fluids
- direct faecal smear

If polymorphs seen

  • Likely - shigella, or camplylobacter or E.coli
  • more rarely - C.diff, yersina enterocolitica, salmonella

If non polymorphs seen

  • likely - salmonella, E.coli,, C.diff
  • culture negative causes - noravirus

special circumstances

  • food poisoning outbreak
  • travel
  • recent antibiotic use
  • rectal intercourse
  • immunocompromised
  • raw seafood ingestion
58
Q

What are the signs of C.difficile

A
  • Fever
  • Colic
  • Diarrhoea with systemic upset (↑↑CRP, ↑WCC, ↓albumin)
  • Colitis (with yellow adherent plaques on inflamed non-ulcerated mucosa – the pseudomembrane) progressing to toxic megacolon and multi-organ failure
59
Q

How do you detect C.difficile

A
  • Urgent testing of suspicious stool (characteristic smell)
  • Two-stage process with rapid screening test for C. diff protein (or PCR) followed by specific ELISA for toxins
  • AXR for toxic megacolon
60
Q

How do you treat recurrent C.difficile

A
  • fidaxomicin (minimally absorbed oral antibiotics) associated with lower relapse rates
  • faecal transplantation

Year 3 - Met3a (43 decks)

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