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Gwen - GI and General surgery > GI: Diarrhoea > Flashcards

GI: Diarrhoea Flashcards

1
Q

What is diarrhoea?

A

Increased frequency and volume of stool and decreased consitency

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2
Q

What would you want to establish in the history in someone who is presenting with acute diarrhoea?

A

Acute (<2 wks)

  • Contact with D+V
  • Fever/systemic upset
  • Pain
  • Blood/mucus
  • Travel
  • Diet change
  • Contact with animals
  • Associated symptoms
  • Medications
  • Social - drugs, alcohol
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3
Q

What would you want to ask in the history in someone who is presenting with chronic diarrhoea?

A
  • Fever/systemic upset
  • Pain
  • Blood/mucus
  • Travel
  • Diet change
  • Weight loss
  • Nocturnal diarrhoea
  • Symptoms of anaemia
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4
Q

What are causes of bloody diarrhoea?

A
  • Campylobacter
  • Shigella
  • Salmonella
  • E. Coli
  • AMoebiasis
  • IBD
  • Colorectal cancer
  • Colonic polyps
  • Pseudomembranous colitis
  • Ischaemic colitis
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5
Q

What are causes of diarrhoea with mucus?

A
  • IBS
  • Colorectal cancer
  • Polyps
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6
Q

What are causes of diarrhoea with franck pus?

A
  • IBD
  • Diverticulitis
  • Fistula/abscess
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7
Q

What are causes of “explosive” diarrhoea?

A
  • Cholera
  • Giardia
  • Yersinia
  • Rotavirus
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8
Q

What is steatorrhoea?

A

Increased stool fat, pale, float, smelly

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9
Q

What are causes of steatorrhoea?

A
  • Pancreatic insufficiency
  • Biliary obstruction
  • Coeliac disease
  • CF
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10
Q

What are non-GI causes of diarrhoea?

A
  • Thyrotoxicosis
  • Autonomic neuropathy
  • Addison’s Disease
  • Amyloidosis
  • Pellagra
  • Drugs
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11
Q

What are the common causes of diarrhoea?

A
  • Gastroenteritis
  • Traveller’s diarrhoea
  • C. dioff
  • IBS
  • Colorectal cancer
  • IBD
  • Coeliac
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12
Q

What drugs can cause diarrhoea?

A
  • Antibiotics
  • Propranalol
  • Cytotoxics
  • Laxatives
  • PPI’s
  • NSAIDs
  • Digoxin
  • Alcohol
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13
Q

What bacteria can cause diarrhoeal illness?

A
  • Salmonella
  • Campylobacter
  • E. coli 0157
  • Shigella
  • Clostridium Difficile
  • Cholera
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14
Q

How long after onset do symptoms of Salmonella associated Diarrhoea present?

A

<48hrs

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15
Q

How long does Salmonella associated diarrhoea normally last for?

A

<10 days

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16
Q

What are the different types of diarrhoea?

A
  • Osmotic Diarrhoea
  • Secretory Diarrhoea
  • Inflammatory Diarrhoea
  • Abnormal motility
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17
Q

What can prolonged carriage of Salmonella be associated with?

A

Gallstone formation

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18
Q

What can be a common problem post-infection for someone who has had Salmonella?

A

Irritable Bowel Syndrome

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19
Q

What species of campylobacter is the main pathogen in diarrhoeal infection?

A

Campylobacter jejuni

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20
Q

What are the most common sources of campylobacter infection?

A
  • Contaminated Milk
  • Chickens
  • Puppies
  • Water
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21
Q

What is the incubation time for Campylobacter?

A

2-5 days

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22
Q

What are the main symptoms of Campylobacter infection?

A
  • Severe Abdominal Pain - often becomes continuous and radiates to right iliac fossa
  • Watery Diarrhoea
    • Can become bloody
  • Fever
  • Nausea and Vomiting
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23
Q

How long does it normally take for Campylobacter infection to clear?

A

3 weeks

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24
Q

How long does it take stools to become negative in Campylobacter infections?

A

6 weeks

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25
Q

What are some of the long term post-infective sequelae of Campylobacter infection?

A
  • Guillain Barre Syndrome
  • Reactive Arthritis
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26
Q

What is secretory diarrhoea?

A

Both active intestinal secretion of fluid and electrolytes as well as decreased absorption

Cholera toxin is regarded as the classic model of this

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27
Q

What are common causes of secretory diarrhoea?

A
  • Enterotoxins
  • Hormones
  • Bile salts (in the colon) - following ileal resection
  • Fatty acids (in the colon) - following ileal resection
  • Some laxatives
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28
Q

What is the pathophysiology of diarrhoea caused by cholera?

A
  • Increases cAMP levels
  • Increases protein kinases
  • Inhibit Na+ and Cl- absorption
  • Cl- secretion
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29
Q

What bacteria cause secretory diarrhoea?

A
  • Cholera
  • E. Coli
  • C. Difficile
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30
Q

How do you distinguish between secretory and inflammatory diarrhoea?

A

Inflammatory diarrhoea is accompanied by PAIN AND FEVER

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31
Q

What is osmotic diarrhoea?

A

Gut mucosa acts as a semipermeable membrane and fluid enters the bowel if there are large quantities of non-absorbed hypertonic substances in the lumen

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32
Q

What is inflammatory diarrhoea?

A

Damage to the intestinal mucosal cell so that there is a loss of fluid and blood

In addition, there is defective absorption of fluid and electrolytes

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33
Q

What can cause osmotic diarrhoea?

A
  • Non-absorbable substance
  • Malabsorption so that high concentrations of solute remain in the lumen
  • Specific absorptive defect - coeliac disease
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34
Q

How can you distinguish between osmotic diarrhoea and other types of diarrhoea?

A
  • Remove the malabsorptive substance
  • Bloating?
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35
Q

What are the causes of inflammatory diarrhoea?

A
  • Infection (Shigella)
  • Inflammatory conditions (UC, Crohn’s)
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36
Q

What is the reservoirs of E. Coli O157?

A

Cattle

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37
Q

What can cause diarrhoea due to abnormal motility?

A
  • Diabetic (arse)
  • Post-vagotomy
  • Thyrotoxicosis
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38
Q

What are the clinical features of Salmonella infection?

A
  • Diarrhoea
  • Vomiting
  • Fever
  • Septicaemia
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39
Q

What is Haemolytic Uraemic Syndrome (HUS)?

A

Shiga-Like Toxin (SLT) binds to globotriaosylceramide -> platelet activation stimulated -> microangiopathy

Platelets bind to endothelial, glomerular, tubular and mesangial cells

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40
Q

What type of E. Coli causes Enterohaemorrhagic E. Coli infection?

A

E. Coli O157:H7

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41
Q

What are the clinical features of E. Coli O157?

A

Frequent Bloody Stools

42
Q

What can E. Coli O157 cause?

A

Haemolytic Uraemic Syndrome

43
Q

Who does HUS most commonly occur in, if it does occur?

A

Children and the Elderly

44
Q

How long after the onset of diarrhoea can it take for HUS to develop in E. Coli O157 infection?

A

5-9 days

45
Q

What is the definition of Food Poisoning?

A

Illness caused by eating contaminated foodstuffs

46
Q

What bacteria can cause food poisoning?

A
  • Staphylococcus Aureus
  • Bacillus cereus (re-fried rice)
  • Clostridium Perfringens
47
Q

What is Dysentery?

A

Infection of the intestine causing severe diarrhoea with blood and mucus

48
Q

What causes bacillary dysentery?

A

Shigella

49
Q

What are the symptoms of bacillary dystentery?

A
  • Abdominal pain
  • Small volume Bloody diarrhoea + mucus
  • Sudden fever
  • Nausea
50
Q

What is the incubation period for bacillary dysentery?

A

1-6 days

51
Q

How is bacillary dysentery spread?

A

Faecal-Oral

52
Q

How is cholera spread?

A

Faecal-Oral route

53
Q

Can you name the organism which causes cholera?

A

Vibrio Cholerae (Gram -ve rod)

54
Q

How long does it take cholera to incubate?

A

A few hour to 5 days

55
Q

What are the clinical features of Cholera?

A
  • Profuse watery stools (1L/h)
  • Fever
  • Vomiting
  • Rapid dehydration
    • Associated Metabolic Acidosis
56
Q

What can be a complication of Shigella Infection?

A
  • HUS
  • Seizures
57
Q

What is the definition of Colitis?

A

Inflammation of the colon

58
Q

What are colitic symptoms?

A
  • Recurring bloody diarrhoea +/- pus
  • Lower Abdominal Pain
  • Faecal Incontinence
  • Fatigue
  • Unexplained Weight loos
59
Q

What is Gastroenteritis?

A

Inflammation of the stomach and intestine

60
Q

What can cause Gastroenteritis?

A

Usually due to viral, bacterial infection or food-poisoning toxins

61
Q

How do you objectively determine if someone has developed Gastro-enteritis?

A

3+ stools in 24 hrs, plus one of

  • Fever
  • Vomiting
  • Pain
  • Blood/mucus in stools
62
Q

How long does gastroenteritis normally last?

A

3-5 days

63
Q

What are the main features of gastroenteritis?

A

Dirrhoea +/- vomiting

64
Q

What are the 4 main pathogenic mechanisms of bacterial gastroenteritis?

A
  • Mucosal adherence - effacement of intestinal mucosa
  • Mucosal invasion - Penetration and destruction of mucosa
  • Toxin production enterotoxin - Fluid secretion without mucosal damage
  • Cytotoxin - Damage to mucosa
65
Q

For each of the 4 pathogenic mechanisms of bacterial gastroenteritis, describe their clinical presentations

A
  • Mucosal adherence - Moderate watery diarrhoea
  • Mucosal invasion - Dysentery
  • Toxin Production - Profuse Watery diarrhoea
  • Cytotoxin - Dysentery
66
Q

What bacteria can cause gastroenteritis?

A
  • Salmonella
  • Campylobacter
  • Shigella
  • EHEC
  • ETEC
  • Cholera
67
Q

What organism causes pseudomembranous colitis?

A

C. Difficile

68
Q

How does C. diff cause diarrhoea?

A
  • Toxin A - enterotoxin
  • Toxin B - cytotoxic
69
Q

How does C. diff infection present?

A
  • Severe Bloody Diarrhoea
  • Abdominal Pain
  • Gut perforation
  • Pyrexia
  • Toxic Megacolon
70
Q

What are the 4 C’s which put a patient at risk of C. diff colonisation?

A
  • Cephalosporins
  • Clindomycin
  • Ciprofloxacin
  • Co-Amoxiclav
71
Q

How would you manage someone with C. diff infection?

A

Stop causative ABx

10 days of treatment

  • Non severe - Metranidazole - 400 mg 8hrly
  • Severe - Oral Vancomycin - 125 mg 6 hrly
72
Q

What parasites can cause diarrhoea?

A
  • Cryptosporidium parvum
  • Giardia lamblia
  • Entamoeba histolytica
73
Q

What can be a complication of Entamoeba Histolytica?

A

Amoebic Liver Abscess

74
Q

How does amoebiasis present?

A
  • Amoebic dysentry - Similar to ulcerative colitis
    • Profuse Diarrhoea +/- blood
    • Can have fever
    • Abdo pain
  • Amoebic colonic abscess
  • Amoebic liver abscess
    • High, swinging fever
    • Sweats
    • RUQ pain/tenderness +/- chest pain
75
Q

How does giardia infection present?

A
  • Explosive Diarrhoea
  • Malabsorption
  • Bloating
  • Flatulence
  • Weight loss
76
Q

Where does giardia colonise in the gut?

A

Duodenum and jejunum

77
Q

How would you treat giardia infection?

A
  • Metranidazole
  • Tinidazole
78
Q

How does Rotavirus cause diarrhoea?

A

Infects mature enterocytes of villous body and tip (not crypts) with cell death and lactose intolerance

79
Q

How would you clinically assess someone with acute diarrhoea?

A
  • Assess hydration - postural BP, skin turgor, pulse, mucus membranes, CRT
  • Features of infection - fever, raised WCC, rashes
  • Consider PR exam
80
Q

How would you investigate someone with suspected gastro-enteritis?

A
  • Stool culture
  • Blood culture
  • Renal function
  • Blood count - neutrophilia, haemolysis
  • Abdominal X-Ray - if abdomen distended, tender
81
Q

What would make you suspect a non-infectious cause for diarrhoea?

A

>2 weeks duration

82
Q

How would you clinically assess someone with chronic diarrhoea?

A
  • Assess hydration - postural BP, skin turgor, pulse, mucus membranes, CRT
  • Features of infection - fever, raised WCC, rashes
  • Signs of underlying cause - WL, clubbing, anaemia, oral ulcers, rashes, abdo mass/scars, thyroid status
  • Consider PR exam
83
Q

What investigations would you consider doing in someone with diarrhoea?

A
  • Bedside - Basic observations
  • Bloods - FBC, ESR, CRP, U+E’s, TFTs, Coeliac serology
  • Other - stool cultures, faecal elsatase, Lower GI endoscopy
84
Q

What might decreased MCV on FBC in someone with diarrhoea suggest?

A
  • Bleeding
  • Iron deficiency - coeliac, colon cancer
85
Q

What might increased MCV on FBC investigation indicate in someone with diarrhoea?

A
  • Alcohol abuse
  • B12 deficiency due to coeliac/crohn’s
86
Q

What might increased ESR/CRP indicate in someone with diarrhoea?

A
  • Infection
  • Crohn’s
  • UC
  • Cancer
87
Q

What might you see on U+E’s in someone with diarrhoea?

A
  • Hypokalaemia - if severe
  • Features of dehydration
88
Q

If someone presented with what you deemed to be infective diarrhoea, when would you consider symptomatic treatment without further investigation?

A

No systemic signs

89
Q

If someone presented with what you deemed to be infective diarrhoea with systemic features (fever, dehydration, visible blood), how would you manage them?

A

Admit:

  • Oral fluids
  • Consider empirical Abx unless non-infectious cause found
  • Faecal culture
90
Q

How would you manage diarrhoea?

A
  • Treat cause
  • Oral rehydration initially, unless severe -> IV
91
Q

What is toxic megacolon?

A

Usually a complication of inflammatory bowel disease, such as ulcerative colitis and, more rarely, Crohn’s disease, and of some infections of the colon, including C. diff infections (pseudomembranous colitis).

Other forms of megacolon exist and can be congenital (present since birth, such as Hirschsprung’s disease). It can also be caused by Entamoeba histolytica and Shigella.

92
Q

What is the major cause of traveller’s diarrhoea?

A

Enterotoxigenic E. Coli

93
Q

How would you detect c. diff?

A
  • FBC - WBC
  • Stool PCR followed by specific ELISA immunoassay for toxins
  • Consider AXR - significant distention
94
Q

What imaging would you consider in someone with c. diff infection?

A

AXR - look for toxic megacolon

95
Q

What are infective causes of non-bloody diarrhoea?

A
  • Norovirus
  • Rotavirus
  • Anteric Adenovirus
  • Enterotoxigenic E. Coli
  • Enteropathogenic E. Coli
  • Toxin-producing s. aureus
  • Cholera
  • C. perfingens
  • Giardia
  • Cryptosporidium
96
Q

How would you manage someone with cholera?

A
  • Oral rehydration salts - may need 1L/hr initially
  • Consider IV fluids if severly dehydrated + ORS
  • Consider Abx - doxycycline/tetracycline
97
Q

How would you investigate suspected amoebiasis?

A
  • Bloods - LFT’s, U+E’s, serum antiamoebic antibody
  • Orifices - Stool culture/microscopy, Faecal antigen
  • Imaging - Abdo USS, CT +/- aspiration (abscess), sigmoidoscopy
  • Specific - Stool/Liver pus PCR
98
Q

What features might you see on sigmoidoscopy in amoebiasis?

A
  • Friable mucosa
  • Mucosal ulceration
  • Amoebomas
  • Colonic abscesses
99
Q

How would you treat amoebiasis?

A
  • Metranidazole, then diloxanide fuorate - to destroy gut cysts
  • Consider tinidazole - severe infection or liver abscess
100
Q

What might you see on microscopy of stool culture in amoebiasis?

A

Cysts and trophozoites

101
Q

What might serology for amoebiasis show?

A

Antibody titres elevated

102
Q

Key investigations diarrhoea

A
  • FBC: raised WCC, anaemia
  • U+E: hypokalaemia, dehydration
  • Raised ESR: IBD, cancer
  • Raised CRP: IBD, infection
  • Coeliac serology: anti-TTG or anti-endomysial antibodies

Stool: MCS and C diff toxin

Gwen - GI and General surgery (44 decks)

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