Diarrhoea (oxford clin cases) Flashcards
Define diarrhoea
Increase in the amount of stool passed daily
What are some causes of diarrhoea
Bowel infection Bowel inflammation Increased gut motility Malabsorption Obstructive overflow Medications
What differentials are more likely when a young patient presents with diarrhoea (late teen early adult)?
Infectious diarrhoea
IBS
IBD
Coeliac’s disease
What differentials are more likely when an old patient presents with diarrhoea?
Cancer/polyps causing obstruction/ overflow obstruction
Diverticular disease
Ischaemic colitis
Bacterial overgrowth
At what age is IBD most commonly diagnosed?
Teen- early adulthood (15-25) Older ages (50-80)
What should you be concerned about when a patient presents with diarrhoea? How will you check for this?
Dehydration- assess volume status by checking BP (it might be low, narrow mean arterial pressure), check to see if tongue is coated in mucus/ lips are dry, ask the patient if they are thirsty, heart rate may be tachycardic
Electrolyte or pH disturbance- if the patient is acutely unwell and respiration looks impaired an arterial blood gas may be the best way to quickly assess them. If oxygen sats are normal and respiration is not impaired then do a venous blood gas to avoid discomfort
How do anxiety vs shock affect blood pressure and heart rate
They would both cause tachycardia
Anxiety would increase blood pressure
Shock would cause blood pressure to fall
What elecrolyte status likely to be in someone with diarrhoea?
They are likely to have low K+, HCO3-, Cl-, Na+ as they loose electrolytes in their faeces
What is the treatment for someone who is acutely dehydrated due to diarrhoea?
Put a cannula in so they can be given fluids
Take a set of bloods so you dont need to bleed them later
What do mucoid or jelly like stools suggest?
Infection
What do foul smelling or floating stools suggest?
Pancreatic obstruction or insufficiency
Malabsoprtion (eg coeliacs)
Biliary insufficiency
What do pale stools suggest?
Biliary insufficiency or obstruction
What do stools with blood on wiping suggest?
Anal fissure or haemorrhoids
What do stools with blood mixed in suggest?
Colonic pathology
What does nocturnal diarrhoea suggest?
An organic problem not a motility problem
What dies urgency with diarrhoea suggest?
Infection or IBD
What is tenesmus?
When someone defecates and feels they haven’t emptied their bowels properly
What does tenesmus suggest?
Space occupying lesion eg tumor
What do we mean by variable bowel habit?
Alternating diarrhoea and constipation
What does variable bowel habit suggest?
Cancer or IBD
What diagnosis does vomitting with diarrhoea suggest?
Infectious gastroenteritis
What does pain in the right iliac fossa with diarrhoea suggest?
Terminal ileum inflammation
What does pain in the left iliac fossa with diarrhoea suggest?
Diverticular disease
What does relief of pain on passing stools suggest?
IBS
What does significant weight loss with diarrhoea suggest?
Chronic pathology instead of acute
What clinical features may be present with IBD alongside diarrhoea/ abdo pain?
Uveitis- inflammation of the middle layer of the eye
Scleritis- painful red eye with no loss of vision
Episcleritis- uncomfortable red eye with no loss of vision
Pyoderma gangrenosum- ulcers with a purple halo
Erythema nodusum- dark red nodules on the shin
What type of diet is associated with IBS?
Low fibre
What medications are especially associated with C diff diarrhoea?
PPIs
Antibiotics
What questions might you ask in the history when someone presents with diarrhoea?
Character of stool- mucoid, bloody, foul smelling, floating, pale?
Is there urgency?
Do they wake up at night to poo?
Do they have any other clinical signs (uveitis, epi-scleritis, erythema nodosum, derma gangrenosum)?
Have they travelled abroad recently?
Have they eaten anything dodgy recently?
Has the diarrhoea been going on for long or has it just started?
Is there alternating diarrhoea and constipation?
Have they had significant weight loss?
What is their typical diet like?
What do they do for work/ where do they live- is there a cause of stress?
Is there family hx of IBD or cancer etc?
What medications do they take and has this changed recently changed?
Is there tenesmus?
Is there abdominal pain? Where exactly?
Has there been any vomiting
What is dermatitis herpetiformis and when is it seen? Where is it usually located?
A rash which is a feature of coeliacs disease- it is usually found all over the extensor surfaces and scalp and is very itchy so they patient may have scratched it a lot
What clinical signs will you look for in someone who has diarrhoea and what do they suggest?
Uveitis/ scleritis- features of IBD
Mouth ulcers- feature of IBD
Virchow’s node- feature of GI malignancy that has spread
Dermatitis herpetiformis- feature of coeliacs
Clubbing- caused by many GI pathologies
Abdominal masses- RIF= IBD, LIF= diverticular disease or cancer
Erythema nodosum- feature of IBD
Pyoderma gangrenosum
Where might you find an abdominal mass in someone with Crohn’s? Explain why
Right iliac fossa- it is due to inflammation of the terminal ileum
What investigations might you order in someone who has diarrhoea?
Bloods- FBC, CRP, ESR, thyroid function tests, blood glucose, TTG+IgA, UEs, albumin
Feaces tests- feaces microscopy and culture, feacal occult blood test, c diff toxin test
What blood test is highly specific to coeliac disease? What do you have to measure with it and why
TTG
IgA levels must be measured alongside it as if they are low it could cause a false negative
Is there more likely to be blood in the stool in UC or Crohn’s
UC
What is the difference between patients who have Crohn’s vs UC in between attacks?
Crohn's= patients are generally unwell in between attacks UC= patients are generally well in between attacks
What are second line investigations for IBD and why are they done?
Abdominal x ray- look for inflammation and rule out toxic megacolon in someone with UC
Colonoscopy- visualise inflammation and take biopsies
What is usually seen in Crohn’s when lesions are biopsied?
Non caseating granulomas
How is Crohn’s managed?
Non steroidal immunosupressants
Surgery to resect the affected parts of the bowel
Why are non steroidal immunosupressants used in IBD?
Long term use of steroids cause many side effects eg osteoporosis, diabetes, cataracts)
Steroids also don’t allow healing of the underlying mucosa
How is infectious diarrhoea/ food poisoning managed?
Rest at home and high fluid intake
Tell patients to practise good hygiene and isolate to avoid spread, wear apron and gloves when seeing them in hospital
How is IBS managed?
Reassurance
Antispasmodics to reduce gut motility
Antidepressants to slow bowel movements (given at a low dose)
Diet and herbal remedies
What is a common causative agent for infectious diarrhoea in the elderly and immunosupressed?
Clostridium difficile
How is C diff colitis managed?
Fluids if they are dehydrated
Isolate and maintain good hygiene
Antibiotics
Stop medications that predispose them to c diff is posible eg abx and PPIs
How do patients with UC usually present?
Painless, bloody diarrhoea
How does hyperthyroidism affect stools?
Increased frequency and softer
