Diarrhoea in a Young Man

Question 1

Define diarrhoea

Answer 1

Change in consistency +/- frequency

Question 2

Important questions to ask about diarrhoea

Answer 2

Food
Travel
Sick contacts
Recent antibiotics
Diabetes
Nocturnal diarrhoea (red flag)
Dark blood or blood mixed in with stool is sinister until proven otherwise (red flag)

Question 3

Causes of tenesmus

Answer 3

Proctitis
Rectal cancer
IBS/IBD

Question 4

Clinical presentations of diarrhoea

Answer 4

Small bowel: large volume, lower frequency
Large bowel: small volume, higher frequency
Steatorrhoea: diagnosed on faecal fat microglobulins

Question 5

Factors determining whether stool is firm or loose

Answer 5

Water content
Transit time (Ca2+, thyroid, blood glucose, brain-gut axis, osmotic effects of intake, etc)

Question 6

Rectal bleeding

Answer 6

Anorectal: anal fissures, haemorrhoids, rectal cancer, proctitis, anal cancer
Colonic: IBD (esp UC), diverticulosis, colorectal cancer or polyps, angiodysplasia

Question 7

Factors suggestive of organic (not functional) disease

Answer 7

Rectal bleeding
Nocturnal diarrhoea
Constitutional symptoms

Question 8

Factors suggestive of functional disease

Answer 8

Passage of flatus

Bloating (but can occur with organic disease)

Question 9

Albumin

Answer 9

Negative acute phase reactant (not in isolation; look at CRP and ESR; marker of significant inflammation)

Question 10

ESR

Answer 10

Up in inflammation

Can be up in anaemia (why - how does this work based on what you know about how the test is performed)

Question 11

Pattern of bowel involvement in UC

Answer 11

Continuous inflammation starting distally (must involve rectum) and extending proximally

Question 12

Pattern of bowel involvement in Crohn’s

Answer 12

Skip lesions

Terminal ileum/ileocaecal junction common site of involvement

Question 13

Pentasa

Answer 13

Topical 5ASA tablet; only really work in colon (not small bowel)
Settles inflammation in setting of mild-moderate disease

Question 14

PSC and IBD risk

Answer 14

Risk of bowel cancer much higher with PSC and IBD

Question 15

5ASA

Answer 15

No longterm risks

Question 16

Steroid SEs

Answer 16

Immune: immunosuppression
Metabolic: HTN, impaired glucose tolerance, weight gain, proximal myopathy

Question 17

Surgical options for UC

Answer 17

Ileoanal pouch

?

Question 18

Methotrexate for IBD

Answer 18

No evidence for use in UC

Question 19

Thiopurines

Answer 19

Take about a month to work

Question 20

Risk of bowel cancer with IBD

Answer 20

Less risk with well controlled disease

Question 21

1st line treatment for rescue therapy (few days of IV steroids not helping)

Answer 21

Infliximab (TNF-a antagonist)

2nd line: consider cyclosporine in short term (more cumbersome to use)