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NME > Functional and Infective Pathology of the Lower GI Tract > Flashcards

Functional and Infective Pathology of the Lower GI Tract Flashcards

1
Q

Diarrhoea definition

A

the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual)

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2
Q

acute diarrhoea last for

A

0-14 days

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3
Q

Persistent diarrhoea lasts for

A

14 days-4 weeks

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4
Q

Chronic diarrhoea lasts for

A

4+ weeks

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5
Q

Why worry about diarrhoea?

A
  • significant amount of morbidity (but little mortality)
  • dehydration:
    • increases risk of life threatening disease in
      young/old
    • electrolyte imbalance (NA,K,HCO3)
    • can lead to acidosis
  • chronic diarrhoea can negatively affect: wellbeing,
    mental health, activity, limited diet, social isolation
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6
Q

Diarrhoea

A
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7
Q

how infections cause diarrhoea

A
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8
Q

4 categories of causes of acute diarrhoea:

A
  • infection
  • medication
  • acute presentation of chronic pathology
  • other
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9
Q

Causes of acute diarrhoea: infection:

A
  • viral (norovirus, rotavirus)
  • bacterial (salmonella, clostridum difficile, cholera)
  • parasites (giardia lamblia)
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10
Q

Causes of acute diarrhoea: ,edications:

A
  • laxatives
  • antibiotics (macrolides)
  • allopurinol
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11
Q

Causes of acute diarrhoea: other:

A
  • anxiety
  • food allergy
  • GI inflammation (acute appy, intestinal ischaemia)
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12
Q

Most cases of infectious diarrhoea are ——- and ——-/ 50% of cases last

A
  • viral and self-limiting
  • <1 day
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13
Q

typically viral untreated infectious diarrhoeas last

A

2-3 days

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14
Q

typically bacterial untreated infectious diarrhoea last

A

3-7 days

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15
Q

typically protozeal untreated infectious diarrhoea lasts

A

weeks-months

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16
Q

Assessing acute diarrhoea: history:

A
  • onset, duration, severity
  • character (watery, fatty, blood stained, mucous)
  • triggers (infective contacts, diet, travel)
  • associated features: vomiting, fever, abdo pain, med
    changes, stress, surgery
  • Red flags: blood, recent antibiotics, weight loss,
    dehydrationn, nocturnal symptoms
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17
Q

Assessing acute diarrhoea: examination:

A
  • assess fluid status: tachycardia, reduced skin turgor,
    dryness of mucous membrane, delayed capillary refill,
    decreased urine output, hypotension, confusions
  • abdominal exam: pain, tenderness, distension, mass,
    increased or decreased bowel sounds
  • DRE: tenderness, stool consistency, mass,
    blood/mucous
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18
Q

Investigating acute diarrhoea

A
  • not always needed if the patient is well and the length
    of symptoms are short/quickly resolving
  • stool testing: exclude infections, pt vulnerable
  • blood tests: FBC, ESR. CRP,LFTs, U&Es, iron) to rule out
    other causes
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19
Q

Managing acute diarrhoea:

A
  • usually nothing: hydration, hypertonic saline/glucose
    sol
  • if unwell, hospital:
    • subsequent diagnostics once acute episode settles
    • even with proven infection, antibiotics rarely used
    • dehydration most common concern
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20
Q

5 categories of chronic diarrhoea causes:

A
  • diet
  • bowel disease
  • constipation and impaction
  • drugs
  • others
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21
Q

Chronic Diarrhoea Causes: Diet:

A
  • malabsorption
  • artifical sweeteners
  • excessive sorbitol
  • caffeine
  • alcohol
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22
Q

Chronic Diarrhoea Causes: Bowel Disease:

A
  • IBS
  • IBD
  • microscopic colitis
  • coeliac disease
  • etc
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23
Q

Chronic Diarrhoea Causes: Constipation and Impaction:

A

…

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24
Q

Chronic Diarrhoea Causes: Drugs:

A
  • macrolides
  • ACE inhibitor
  • NSAIDs
  • metformin
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25
Q

Chronic Diarrhoea Causes: other:

A
  • infection
  • endocrine
  • CF
  • lymphoma
  • hormone secreting tumours
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26
Q

Assessing chronic diarrhoea: history:

A
  • onset, duration, frequency, severity of symptoms
  • character (watery, fatty, blood stained, mucous)
  • triggers (infective, diet, const, drugs, IBS, IBD)
  • associated features: vomiting, fever, abdominal pain,
    changes in medication, stress, past surgery
  • red flags: blood in stool, Abx, weight loss,
    dehydration, nocturnal symptoms
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27
Q

Assessing chronic diarrhoea: examination:

A
  • assess fluid status: tachycardia, reduced skin turgor,
    dryness of mucous membranes, delayed capillary
    refill time
  • abdo exam: pain, tenderness, distension, mass,
    increased or decreased bowel sounds,, organomegaly
  • DRE: rectal tenderness, stool consistency, masses,
    blood/mucous
28
Q

Investigating chronic diarrhoea:

A
  • stool MC&S: add in parasitology, infection
  • blood tests: FBC, B12/folate, CA, ferretin, hormones)
  • qFIT: faecal calprotectin, feacal elastase
  • imaging: USS, CT/MRI, endoscopy
29
Q

qFIT stands for

A

Quantitative faecal immunohistochemical test

30
Q

qFIT:

A
  • 1st line investigation for changes in bowel habits (rule
    out bowel cancer)
  • contra-indicated for rectal bleeding
    • if normal (<10 micrograms Hb/g faeces) risk of
      bowel cancer is 0.4%
    • if >10 risk of bowel cancer 6%
    • if >150 risk of bowel cancer 31%
  • reduces need for invasive investigations
31
Q

Managing chronic diarrhoea:

A
  • treat the underlying cause
  • supportive care for patient
32
Q

Irritable Bowel Syndrome (IBS) definition

A

abdo pain which is either releated to defecation and/or associated with altered stool frequency or appearance

AND there are at least two of the following:
- altered stool passage (straining, urgency,
incomplete evacuation)
- bloating or distension
- worsened by eating
- passing rectal mucous

AND:
- alternative conditions are excluded

33
Q

IBS management:

A
  • rule out alternative causes and REASSURE
  • dietary manipulation:
    • diarrhoea:
      • reduce insoluble fibre intake
      • reduce food triggers (caffeine, alcohol,
        carbonated drinks)
        - constipation:
        - soluble fibre supplements or food high in
        soluble fibre
        - maintain adequate fluid intake
        - low FODMAP diet, fermentable oligosaccharide,
        disaccharides, monosaccharides, polyols)
  • probiotics may help
34
Q

IBS medical therapies:

A

Diarrhoea:
- Loperamide (antimotility)
- most common side effect is constipation, cardiac
arrhythmias in higher doses
- antispasmodic drugs for abdo cramps
Constipation:
- Laxatives
- bulk forming
- avoid lactulose
Low dose tricyclic antidepressant amytriptyline 4 weeks, >90% will respond to varying levels of success

35
Q

Constipation definition:

A
  • bowel movements less than 3 times a week
  • excessive straining
  • associated abdominal pain or bloating
  • change in intrinsic pattern
36
Q

Constipation can be categorised by either

A

Time:
- acute: 0-3 months
- chronic 3+ months

Causes:
- Primary (functional)
- Secondary (organic)

37
Q

Why worry about constipation?

A
  • distressing
  • concerns over underlying cause
  • increased morbidity (especially in elderly/frail)
38
Q

Consequences of constipation:

A
  • nausea/appetite loss
  • confusion
  • functional decline
  • overflow diarrhoea
  • urinary retention
  • haemorrhoids
  • anal fissures
39
Q

Assessment on Constipation: History:

A
  • how long?
  • speed of onset?
  • getting worse/better?
  • triggers: lifestyle, stress, meds, surgical changes)
  • associated symptoms (bleeding, loss of weight, abdo
    pain)
  • PMHx of GI disease
40
Q

Assessment of constipation: examination:

A
  • well/unwell
  • general exam: pyrexia, jaundice, cachexia
  • abdominal examination: tenderness, distention,
    masses
  • rectal exam: masses, empty rectum v impacted stool
41
Q

Investigations for Constipation:

A
  • blood tests: FBC, inflamm markers, iron, liver function,
    thyroid, HbA1c, Ca, B12 and folate)
  • stool tests: qFIT, calprotein
  • imaging: abdo X ray, CT scan
  • endoscopy
  • special investigations: bowel transit study, pelvic floor
    investigations
42
Q

3 categories of acute constipation causes:

A
  • functional: dehydration, diet, stress
  • medication: opiates, loperamide, iron
  • acute presentation of chronic pathology: bowel
    obstruction
43
Q

Opiates and Constipation:

A
  • 5 classes: kappa, delta, mu, zeta, nociception
  • all G coupled protein receptors
  • opiod receptors inhibit calcium channels leading to
    decreased neurotransmitter release
  • activation of mu and delta receptors, leading to
    reduced GI motility and increased sphincter tone
    leading to constipation
  • GI Tract can develop a tolerance ot opiods
  • loperamide acts by binding specifically to mu
    receptors promoting constipation
44
Q

Acute constipation Management:

A
  • remove the insult
  • support the patient
  • may need laxatives
45
Q

Chronic Constipation 6 categories of causes:

A
  • functional constipation
  • medication
  • colonic
  • pelvic floor/defecator disorders
  • endocrine
  • neurological
46
Q

Chronic Constipation Causes: Functional Constipation:

A
  • dehydration, diet, stress, IBS, pregnancy, withholding
47
Q

Chronic Constipation Causes: Medication:

A
  • opiates, loperamide, iron, calcium channel blockers
48
Q

Chronic Constipation Causes: colonic:

A
  • cancer
  • IBD
  • diverticular disease
49
Q

Chronic Constipation Causes: Pelvic Floor/Defecator disorders:

A
  • rectal prolapse
  • recocele
  • pelvic floor dyssynergia
50
Q

Chronic Constipation Causes: Endocrin:

A
  • hypothyroidism
  • hypercalcaemia
  • diabetes mellitus
  • porphyria
51
Q

Chronic Constipation Causes: ENurological:

A
  • MS
  • spinal cord lesions
  • Parkinson’s
52
Q

Management of Chronic Constipation:

A
  • remove the insult where possible
  • make the environement as facourable for bowel
    opening as possible:
    - adequate fibre and fluid intake, removing
    constipating meds
  • resolve faecal impaction first if present:
    enemas/suppositories
  • laxatives
  • neuromodulation (sacral nerve stimulation)
  • surgery: total colectomy, stoma
53
Q

Important causes of constipation:

A
  • diverticulitis
  • bowel obstruction
  • bowel cancer
54
Q

Diverticular disease

A
  • protrusion of mucosal pouches through bowel wall
    musculature
  • intimately linked with constipation:
    - cause or effect
    - poor dietary fibre implicated
  • > 90% have no symptoms
55
Q

Proximal bowel obstruction

A

bowels may still be functional despite obstruction; history can be misleading

56
Q

Absolute constipation

A

no passage of stool or passing of flatus: often indicates distal mechanical obstruction of colon

57
Q

Important to establish the cause of bowel obstruction quickly:

A
  • determination if spontaneous resolution possible
  • adhesional small bowel obstruction; will settle with
    surgery in >90% cases
58
Q

Causes of Bowel Obstruction: Extrinsic:

A
  • abdominal masses
  • adhesions.sar tissue
  • hernias
59
Q

Causes of Bowel Obstruction: Bowel wall problem:

A
  • neoplasia
  • inflammatory stricture
60
Q

Causes of Bowel Obstruction: Luminal:

A
  • bezoar/foreign body
61
Q

Management of Suspected Bowel Obstruction:

A
  • immediate resuscitation if unwell
  • early investigation essential: CT highly sensitive and
    specific for bowel obstruction
  • decision to make: will this settle or is intervention
    needed
  • closed loop lasege bowel obstruction is an
    emergency:
    - competent ileocaecal valve (50%) prevents reflux
    into ileum
    - beware the obstructed colon with right lower
    abdominal pain
62
Q

Bowel Cancer:

A
  • can have very vague or no GI symptoms
  • iron deficiency anaemia and qFIT increases concerns
    of bowel ca
63
Q

Laxatives

A
64
Q

Other laxatives:

A
65
Q

Side effects: Laxatives:

A

NME (52 decks)

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