Diarrhoea And Constipation

Question 1

What is diarrhoea characterised by

Answer 1

IV stool frequency and volume and dec consistency

Patient perspective may vary

Question 2

What do you need to determine in the history

Time scale

Answer 2

Acute

Chronic

Question 3

What springs to mind if it is acute

Answer 3

Gastroenteritis

• travel
• diet change
• contact with D&V
• any fever pain
• HIV
• achlorhydria

Question 4

Diff diag of chronic diarrhoea

Answer 4

Does it alternate with constipation suggest IBS

Dec weight, nocturnal diarrhoea, anaemia require close follow up for crohns coeliac or UC

Question 5

Bloody diarrhoea causes

Answer 5

Shigella
Campylobacter 
Salmonella
E.  Coli
Amoebiasis
UC
Crohns
Colorectal cancer
Colon polyps 
Pseudo membraneous colitis
Ischaemic colitis
Fresh PR bleeding

Question 6

Mucus in the diarrhoea

Answer 6

IBS
colorectal cancer
Polyps

Question 7

Frank pus in diarrhoea

Answer 7

Suggest IBD
Diverticulitis
Fistula/abscess

Question 8

Explosive diarrhoea

Answer 8

Cholera
Giardiasis
Yersinia
Rotavirus

Question 9

Steatorrhoea

What is it like and what causes it

Answer 9

Inc has
Offensive smell
Floating hard to flush faeces

Pancreatic insufficiency
Biliary obstruction

Question 10

Common causes of diarrhoea

Answer 10

Gastroenteritis
Travellers diarrhoea
C diff
IBS
Colorectal cancer
Crohns, UC, coeliac

Question 11

Less common causes of diarrhoea

Answer 11

Microscopic colitis
Chronic pancreatitis
Bile salt malabsorption 
Laxative abuse
Lactose intolerance 
Ileal /gastric resection
Overflow diarrhoea
Bacterial overgrowth

Question 12

Non GI or rare causes of diarrhoea

Answer 12

Thyrotoxicosis
Autoimmune neuropathy 
Addison’s disease
Ischaemic colitis
Tropical sprue
Gastroinoma
Carcinoid
Pellagra
VIPoma
Amyloid

Question 13

Drugs that cause diarrhoea

Answer 13

Antibiotics
Propranolol
Cytotoxic
Laxatives
PPI
NSAIDS
Digoxin
Alcohol

Question 14

Signs to look for in a patient with diarrhoea

Answer 14

Dehydrated - dry mucous membranes, dec skin turgor,cap refill less than 2 seconds
Look for infective signs
Fever, clammy, BP low high HR
Cancer signs
Fever, night sweats, loss weight, clubbing, anaemia
IBD
Weight loss clubbing oral ulcers, rashes erythema nodosum
Prev Surgeries - scars, bags, masses
Goitre hyperthyroid signs

Question 15

What exam must you do in diarrhoea

Answer 15

DRE

Masses or impacted faeces

Question 16

What blood investigations are you going to do in diarrhoea

Answer 16

Blood tests - FBC, dec MCV iron def anaemia, inc MCV in alcohol abuse or dec B12 absorption in coeliac or crohns
Eosinophilia if parasites 
Inc CRP infection, UC, crohns , cancer 
Dec k+ severe diarrhoea 
Metabolic acidosis in severe diarrhoea 
Dec TSH in thyrotoxicosis
Coeliac serology

Question 17

What stool tests are you going to do in diarrhoea

Answer 17

MC&S
Bacterial pathogens, ova cysts, parasites, c diff toxin,
Viral PCR
Fecal elastase - if suspect chronic pancreatitis
Fecal cal protection - UC not acute in case infective cause skew results

Question 18

Management of diarrhoea

Answer 18

Depends on cause
Infective no work for food handlers till stool clear
Hospital outbreak wards may need closing
Oral rehydration if poss and better than IV
Severe IV fluids with electrolyte replacement
Anti diarrhoea loperamide after each loose stool not given in colitis risk of toxic megacolon
Avoid antibiotics unless systemic illness dec risk of c diff
Antibiotics associated diarrhoea may respond to probiotics

Question 19

Investigations diarrhoea Lower GI endoscopy

Answer 19

Malignancy colitis in question
If acutely unwell, limited flex sig with biopsy
Full colonoscopy can assess more proximal disease if normal consider radiology or video capsule

Question 20

What does c diff cause

Answer 20

Pseudomembraneous colitis

Question 21

Signs of c diff

Answer 21

Inc temp
Colic
Diarrhoea with systemic upset 
Inc CRP, WCC
Dec albumin
Colitis

Question 22

What type of colitis is seen in c diff

Answer 22

Yellow adherent plaques on non ulcerated inflamed mucosa - the pseudo membrane

Question 23

What can c diff progress to

Answer 23

Toxic megacolon

And multi organ failure

Question 24

Predictors of fulminant c diff

Answer 24

>70 year 
Prev c diff 
Anti peristalsis drugs used 
Severe leucocytosis
Haemodynamic instability

Question 25

Detection of c diff

Answer 25

Urgent test of suspicious stool
2 stage process
Rapid screening test for c diff protein or PCR
Followed by specific ELISA for toxins, AXR for toxic megacolon.

Question 26

What makes you suspicious about a patients having c diff

Answer 26

The characteristic smell of the faeces

Question 27

Treatment of c diff

Answer 27

Stop causative antibiotic if possible
Mild disease:metronidazole
Severe : vancomycin
Urgent colectomy maya be needed in toxic megacolon or if deteriorating

Question 28

Recurrent disease treatment of c diff

Answer 28

Fecal transplant

Fidaxomicin minimally absorbed antibiotic

Question 29

Constipation definition

Answer 29

Reflects pelvis dysfunction
Or inc transit time
Passage of 2 or less motions a week
Often passed with difficulty, pain, straining, and a sense of incomplete evacuation

Question 30

What does constipation + rectal bleeding give concern for

Answer 30

Cancer

Question 31

What does constipation + distension + active bowel sounds give concern for

Answer 31

Stricture / GI obstruction

Question 32

What does constipation + menorrhagia give concern for

Answer 32

Hypothyroidism

Question 33

Important history questions in those with constipation

Answer 33

Frequency 
Nature
Consistency of stools
Blood or mucus
Diarrhoea alternating with constipation IBS
recent change in bowel habit
Is she digitalising the rectum or vagina to pass stool - rectocele front wall of the rectum bulges into the back wall of the vagina 
Diet 
Drugs
Weight loss
Pain 
Known anaemia

Question 34

What is an important examination to do in constipation

Answer 34

PR

Question 35

What tests are done in those with diarrhoea

Answer 35

Non in the young and mildly affected
More tests done with inc age
Blood FBC, ESR/CRP, U&E, +a2+, TFT.
Colonoscopy: if suspected colorectal malignancy
Transit studies, anorectal physiology, biopsy for Hirschorungs occasionally needed

Question 36

What are the triggers that initiate tests

Answer 36

Weightloss
Abdominal mass
+PR blood
Iron def anaemia

Question 37

Treatment for constipation

Answer 37

Conservative
Reassure, lifestyle diet, drink more water, exercise
Medical
Bulking agents, stimulant laxative,stool softener, osmotic laxative
Second line Prucalopride 5HT4 agonist with prokinetic properties, lubiprostone chloride channel activator inc intestinal fluid secretion

Question 38

General chases of constipation

Answer 38

Poor diet +- lack of exercise 
Poor fluid intake/dehydration
IBS
Old age
Post op pain
Hospital environment

Question 39

Anorectal disease cause of constipation

Answer 39

Anal or colorectal cancer
Fissures, structures, herpes
Rectal prolapse
Proctalgia fugax
Mucosal ulceration/neoplasia
Pelvic muscle dysfunction / Levator ani syndrome

Question 40

Intestinal obstruction causes of constipation

Answer 40

Colorectal carcinoma 
Stricture - crohns
Pelvic mass - fetus fibroids
Diverticulitis - rectal bleeding common 
Pseudo obstruction

Question 41

Metabolic endocrine causes of constipation

Answer 41

Hypercalcaemia
Hypothyroidism 
Hypokalaemia
Porphyria
Lead poisoning

Question 42

Drugs that cause constipation

Answer 42

Opiates 
Anticholingerics 
Iron
Some antacids
Diuretics frusemide
Calcium channel blocker

Question 43

Neuromuscular causes of constipation

Answer 43

Slow transit from dec propulsive activity
Spinal or pelvic nerve injury
Aganglionosis - Chagas’ disease, hirschprungs
Systemic sclerosis
Diabetic neuropathy

Question 44

Other causes

Answer 44

Chronic laxative abuse

Idiopathic slow transit idiopathic megarectum/colon