GI Medicine - Vomiting and Diarrhoea Flashcards
what does acute mean?
sudden onset
in what animals is acute vomiting and diarrhoea seen commonly?
dogs
what may acute vomiting and diarrhoea start with?
vomiting and progress through small to large intestinal diarrhoea
how does acute vomiting and diarrhoea often resolve?
usually self limiting
define emesis
vomiting
define haematoemesis
vomiting blood
define haemtochezia
fresh blood in/on faeces/diarrhoea (originates in large intestine)
define melaena
faecal passage of digested blood (stomach or small intestine origin)
define diarrhoea
increase in faecal water content
define tenesmus
straining to pass faeces
define dyschezia
difficulty passing faeces
define emetic
substance which stimulates vomiting
define anti-emetic
substance that inhibits vomiting
what is vomiting?
a complex, coordinated reflex reaction
what are the events of vomiting coordinated by?
the brainstem
does vomiting involve gastric contraction?
no
what are the 4 stages of vomiting?
prodromal (nausea)
retching
expulsion
relaxation
what occurs in the prodromal phase of vomiting?
nausea restlessness and agitation hypersalivation gulping lip licking
what is inhibited during the retching phase of vomiting?
salivation
what happens during the retching phase of vomiting?
simultaneous, uncoordinated, spasmodic contractions of respiratory muscles
duodenal retroperistalsis
mixing of gastric contents
what happens during the expulsion phase of vomiting?
pyloric contraction and fundic relaxation to move food into upper stomach
relaxation of proximal stomach and lower oesophageal sphincter
airway is protected
abdominal contraction and descent of diaphragm
initially during the expulsion phase of vomiting what is the tone like in the upper oesophageal sphincter?
high so that it remains closed
how is the airway protected during the expulsion phase of vomiting?
inhibition of breathing
coordinated closure of the glottis and nasopharynx to protect both aspects of the airway
how does abdominal contraction and the descent of the diaphragm lead to vomiting in the expulsion phase of vomiting?
stomach is squeezed and vomitus forced up (heaves)
oesophageal retro-peristalsis
reduced upper oesophageal sphincter tone
what muscles relax during the relaxation phase of vomiting?
abdominal
diaphragmatic
respiratory
what happens during the relaxation phase of vomiting?
muscles relax
glottis and nasopharynx open
breathing returns
describe small intestinal diarrhoea
large volume watery normal frequency normal colour melaena
describe large intestinal diarrhoea
small volume increased urgency and frequency tenesmus dyschezia \+/- mucous \+/- blood
what does ‘itis mean?
inflammation
define gastritis
inflammation of the stomach
define enteritis
inflammation of the small intestine
define colitis
inflammation of the large intestine
define gastro-enteritis
inflammation of the stomach and small intestine
define entero-coliitis
inflammation of the small and large intestine
define gastro-entero-colitis
inflammation of the stomach, small and large intestines
what questions must you ask about vomiting and diarrhoea when completing phone triage?
is vomiting productive or non-productive frequency - try to gauge fluid loss foreign body/material risk haematemesis/melaena diarrhoea - small or large intestinal
what questions must be asked about the patient generally when completing phone triage?
pre exisiting medical or GI disease or medication
worming history (especially with puppies and kittens)
recent change in diet
known scavenger - dietary indiscretion or FB ingestion
clinical demenour
appetite
drinking
other systemic signs
when should you advise a patient receives consultation following phone triage?
unproductive vomiting large loss of fluid haematemesis / melaena suspect FB inappetant / hypodipsic other systemic signs neonate any other concerns
what are the 3 main categories of acute vomiting and diarrhoea?
non fatal, often trivial, may or may not require specific treatment
severe and potentially life threatening
surgical
what are the causes of vomiting and diarrhoea that is non fatal, often trivial and may or may not require specific treatment?
dietary indiscretion
parasitism
enteric infection
adverse drug event
what are the causes of vomiting and diarrhoea that is severe and potentially life threatening?
pathogenic and enteric infections (e.g. parvovirus or bacterial) acute haemorrhagic diarrhoea syndrome acute pancreatitis intoxications surgical disease
what are the causes of vomiting and diarrhoea that are surgical?
intusussception GDV incarceration stricture/partial obstruction foreign body
what is the major presenting complaint seen in surgical GI dieases?
vomiting
what is intusussception?
telescoping of one intestine loop into another
in what animals is intusussception commonly seen?
young rather than old
what must be investigated regarding intusussception?
underlying cuase
what is incarceration?
loop of intestine becomes strangulated by the mysentry
what are the possible consequences of vomiting and/or diarrhoea?
dehydration
hypovolaemia
acid base disturbance
aspiration pneumonia
when is aspiration pneumonia particularly a risk for vomiting patients?
if sedated
neuromuscular disease
upper airway incompetency (e.g. laryngeal paralysis)
what are the diagnostic tests used for acute gastroenteritis?
history and physical exam
laboratory diagnostics
imaging
response to surgery or symptomatic treatment
what laboratory diagnostics may be used for acute gastroenteritis?
bloods - haematology, biochem and electrolytes
faecal - infectious disease testing
specific tests as required (e.g. cPLI or fPLI)
what will a pooled faecal sample test for?
parasitology and culture
what will a swab/faecal sample test for?
CPV
what is the cornerstone of management of acute vomiting and diarrhoea?
maintaining hydration
how may hydration be maintained in acute vomiting and diarrhoea patients?
IV fluids
oral rehydration solutions
what fluids are best used to maintain hydration in acute vominting and diarrhoea patients?
hartmanns with potassium
what is found within rehydration solutions?
glucose, electrolytes and glutamine
when will oral rehydration solutions be used to treat acute V+D patients?
if able to manage at home
what is usually sufficent for re-hydrating acute V+D patients if at home?
water
what is the dietary advice if acute vomiting is seen?
rest the gut (free access to water) for 24-36 hours before reintroducing an bland diet little and often
when should animals with acute vomiting be transferred back onto their normal diet following resting the gut?
over 2-5 days once bland diet tolerated
is resting the gut suitable for all patients?
no - neonates and diabetics are at risk of hypoglycaemia if they go without food
what is glutamine and why is it useful for acute V+D patients?
amino acid which supports enterocytes and helps them to function well
what is the dietary advice if the patient has diarrhoea?
feed throughout to nourish enterocytes
what risk is reduced by feeding through diarrhoea?
sepsis
what is the issue with needing to feed through diarrhoea in dogs?
most have concurrent vomiting
cosmetic issue as will produce more diarrhoea when eating
what is the main supportive/symptomatic management of acute V+D?
antiemetics
antispasmodics
antidiarrhoeals
what must be ruled out before anti emetics given?
obstruction
how do anti diarrhoeals work?
bind toxins and excess water as well as modifiying GI motility and secretions
what is often found in anti-diarrhoeals?
clay (kaolin)
how is acute vomiting and diarrhoea treated?
anthelmintics (worming)
antibiotics rarely indicated
pre and pro biotics
when will anthelmintics be given?
if puppy or kitten
if adult and not recently wormed
when should antibiotic use for treatment of acute V+D be considered?
if haemorrhagic diarrhoea
if pyrexic
what is the benefit of giving pre and pro biotics?
safer than unnecessary antibiotics
what drugs are always contraindicated for patients with vomiting and diarrhoea?
NSAIDs
what should happen if patients with acute V+D have pre-exisiting NSAID use?
consider that they could be the cause
withhold for the duration of V+D episode and restart when resolved
why are NSAIDs contraindicated for V+D patients?
inhibition of prostaglandins which are needed for maintenance of GI mucosal integrity and renal blood flow during hypovolaemic stress
what are prostaglandins required for?
maintenance of GI mucosal integrity and renal blood flow during hypovolaemic stress
what are prostaglandins required for?
maintenance of GI mucosal integrity and renal blood flow during hypovolaemic stress
when should you consider than the cause of gastroenteritis may be infectious?
neonates unvaccinated animal haemorrhagic diarrhoea pyrexia raw fed patient
what should happen to potentially infectious patients until any alternative diagnosis confirmed?
barrier nurse and isolate
what are the nursing considerations for acute V+D?
patient hygiene
environmental hygiene
kennel signage
what are the areas of patient hygiene that must be considered in V+D patients?
clean/dry bottom
avoid patient over grooming/rubbing
tail bandage
what are the areas of environment hygiene that must be considered in V+D patients?
waste disposed of appropriately
appropriate washing/disinfection of contaminated items
PPE
what are the 2 main types of gastrointestinal foreign body presentations?
no obstruction
obstruction
if the foreign body is smooth/small and gastric and not causing obstruction how should it be treated?
induce emesis
what drug is used to induce emesis in dogs?
Apomorphine
what drug is used to induce emesis in cats?
Xylazine
if the foreign body is non obstructive and intestinal how should it be treated?
natural passage with radiographic monitoring
if the foreign body is gastric but larger and not smooth but not causing obstruction how should it be treated?
endoscopic retrieval or surgery depending on size
what will happen to bones in the stomach?
will be dissolved by gastric acid in a few days
what can be done if the FB is a needle in the intestine?
feed high fibre diet
monitor for passage
how is an obstructive gastrointestinal FB treated?
surgery
what is gastric dilation?
acute dilation of the stomach
what is GDV?
acute dilation of the stomach with torsion of the stomach and twisted splenic pedicle
what is the effect of GDV?
impaired venous return (pressure on caudal vena cava)
compromised gastric mucosa
leading to shock and death
what is a key sign of GDV?
unproductive vomiting
how quickly must GDV be treated?
ASAP - is life threatening
what dogs are more likely to get GDV?
deep chested breeds
what is the cause of GDV?
not really known but may be: diet aerophagia delayed emptying of stomach due to pyloric blockage timing of exercise very soon after meal
how is GDV treated?
aggressive IVFT
immediate decompression of stomach
IV antibiotics
surgical correction
what can a bandage be useful for during GDV treatment?
placed between cheek teeth so that the dog can bite on something while having stomach tubed conscious
how is the stomach decompressed in GDV patients?
stomach tube if possible
needle paracentesis if not
how long should the stomach tube for GDV treatment be?
from tip of nose to last rib
what diameter should stomach tubes be?
same as would be required for ET tube
what surgery is performed on GD or GDV patients?
gastropexy
+/- derotation if GDV
what is gastropexy?
stomach is tied to the abdominal wall in a normal position to prevent reccurance
what are the main parasitic causes of acute (or chronic) V+D?
roundworms
hookworms
whipworms
cestodes (do not cause GI signs)
do roundworms typically cause clinical GI signs?
rarely but may do in puppies/kittens
what is caused by hookworms?
GI bleeding
what is caused by whipworms?
inflammation and diarrhoea
what are the protozoal causes of acute or chronic V+D?
coccidia
giardia
Tritrichomonas foetus
when is coccidia problematic?
only in puppies and kittens
coinfections
what GI signs are caused by Giardia?
large and small intestine diarrhoea
in what animals is Giardia seen?
young dogs and cats
what is the risk associated with Giardia?
can be zoonotic
how is Giardia diagnosed?
3 pooled faecal sample (SNAP test)
in what animals is Tritrichomonas foetus infection seen?
young cats (less than 18 months)
what can be caused by Tritrichomonas foetus?
intractable diarrhoea
peri-anal oedema
faecal incontinence
how is Tritrichomonas foetus transmitted?
faeco-oral
how is Tritrichomonas foetus diagnosed?
colonic wash and PCR from sample
how is colonic wash performed?
10mls sterile saline into colon and then collected through a urinary catheter (usually foley)
how is Tritrichomonas foetus treated?
environmental management to reduce transmission
as maturity reached they have an adequate immune response
what causes acute pancreatitis?
idiopathic dietary indiscretion hyperlipaemia impaired perfusion trauma to pancreas handling of pancreas in surgery
what happens during acute pancreatitis?
local release of pancreatic enzymes
pancreatic autodigestion leading to severe local inflammation and pain
what can be caused by pancreatitis?
systemic inflammation and death
what are the systemic signs of acute pancreatitis?
mild to fatal inappetance lethargy severe abdominal pain V+D jaundice
why is jaundice caused in acute pancreatitis patients?
due to bile duct obstruction if pancreas swells
what position may dogs adopt when they have acute pancreatitis?
prayer position
how is acute pancreatitis diagnosed?
history and physical exam
imaging (x ray and ultrasound)
lab evaluation
what is involved in the laboratory examination for acute pancreatitis?
haematology
biochemistry
pancreatic lipase immunoreactivity (PLI)
what tests are available for pancreatic lipase immunoreactivity?
benchside or external lab species specific (cPLI or fPLI)
how is acute pancreatitis treated?
IVFT
nutritional support through feeding (oral or tube)
analgesia (NSAIDs contraindicated as V+D)
what is the prognosis of acute pancreatitis?
variable to guarded
death and recurrence are possible
what attitude to feeding pancreatitis patients has overtaken the fasting idea?
should be fed well throughout as it improves prognosis
when should acute pancreatitis patients be offered water?
frequent, small amounts once vomiting is controlled
how should food be introduced to acute pancreatitis patients once vomiting is controlled?
slowly (little and often)
what soft of diet should be fed to acute pancreatitis patients?
highly digestible
complex carbohydrate
low fat
what does chronic pancreatitis result from?
repeated attacks of acute pancreatitis
chronic low grade pancreatitis
what are the signs of chronic pancreatitis?
chronic, recurrent, grumbling GI signs
inappetance and lethargy
V+D
how is chronic pancreatitis managed?
at home
modified diet
manage nausea/appetite
analgesia (not NSAIDs)
define anorexia
a loss of desire to eat despite being physically able to
what may anorexia be due to?
a variety of GI and systemic disorders
define hyporexia
reduced appetite
define polyphagia
excessive appetitie
define pica
appetite for non-nutritional substrates (e.g. licking concrete or metal)
what is pica usually due to?
micro-nutrient deficiencies (e.g. iron or B12
what secondary complications does prolonged anorexia lead to?
weight loss
impaired immune function
increased risk of sepsis
poor wound healing and slow recovery
define borborygmi
gurgling
define flatus
passing wind
define ileus
reduced GI motility
when is V+D defined as chronic?
when it is greater than 3 weeks in duration
what are the main signs and findings of chronic GI disease?
altered appetite (quantity and substrate) dehydration vomiting (+/- blood) diarrhoea (+/- digested or fresh blood) weight and condition loss borborygmi/flatus abdominal discomfort
what are the uncommon signs of chronic GI disease?
ascites
oedema
what are the main causes of chronic V+D?
primary GI disease
secondary to extra-GI disease
what are the main primary GI diseases that cause chronic V+D?
gastric ulceration
dietary intolerance/sensitivity
inflammatory
neoplastic
what are the main causes of chronic V+D that are secondary to extra-GI diseases?
liver disease
kidney disease
chronic pancreatitis
endocrine disease (hyperthyroid in cats and hypoadrenocorticism in dogs)
how is the cause of chronic V+D diagnosed?
history and clinical exam lab diagnostics to eliminate extra-GI causes absorption tests imaging gastroscopy / laparotomy and biopsy
what lab diagnostics will be used to rule out GI disease?
haematology serum biochem basal cortisol total thyroxine pancreatic tests (f/cPLI and f/cTLI) faecal analysis
what are absorption tests used for?
to check amount of vitamin B9 (folate) and B12 (cobalamin) being absorbed from different areas of the GI tract
when is contrast radiography performed?
when lab results and imaging have not achieved a definite diagnosis and endoscopy is not available
what are the issues with contrast studies?
messy
time consuming
difficult to interpret
often done poorly
what is used for GI contrast studies?
barium
what are BIPS?
barium impregnated polyethylene spheres
what is shown by BIPS?
spheres vary in size so can give an indication of the size of the obstruction
what is the role of ultrasound in diagnosing the cause of chronic V+D?
identify masses, intussusceptions and measure GI wall thickness
evaluate lymph nodes for free fluid
what are the 2 main ways to perform intestinal biopsy?
laparotomy
endoscopy
what is the advantage of laparotomy for intestinal biopsy?
enables multiple full thickness biopsies (more detail)
what is the disadvantage of laparotomy for intestinal biopsy?
surgical risk of dehiscence is high (2-12%)
what is the advantage of endoscopy for intestinal biopsy?
minimally invasive
what is the disadvantage of endoscopy for intestinal biopsy?
small biopsies only
may not reflect jejunal disease (as scope cannot reach)
what are chronic enteropathies?
chronic disease of the small intestine
what is the most common form of chronic enteropathy?
inflammatory bowel disease (IBD) complex
what diseases make up the IBD complex?
food responsive diarrhoea (FRD)
antibiotic responsive disease (ARD)
true idiopathic inflammatory bowel disease (iIBD)
what is food responsive diarrhoea (FRD) caused by?
intolerance / hypersensitivity
what is antibiotic responsive disease (ARD) caused by?
abnormality in the gut flora of the GI tract that interacts poorly with the immune system
what breed is antibiotic responsive IBD seen in?
GSD
what is true idiopathic inflammatory bowel disease (iIBD) caused by?
inflammation caused by the immune system within the gut wall launching an auto immune response
what is protein losing enteropathy a form of?
chronic enteropathy
what is protein losing enteropathy?
severe (diffuse) SI disease resulting in severe malabsorption and loss of albumin and globulin
what are the signs of protein losing enteropathy (PLE)?
severe weight loss
oedema
ascites
risk of thromboembolytic events
what are the causes of PLE?
IBD
lymphangiectasia - dilation of lymph vessels
alimentary lympho(sarco)ma
how is PLE diagnosed?
endoscopy
how is chronic V+D treated?
treat underlying cause
what are the commonly used therapies for chronic V+D?
exclusion of parasitism dietary modification vitamin B12 steroids anti-emetics appetite stimulants
how should food intolerance/hypersensitivity be managed?
avoidance of allergen
novel or hydrolysed diets
what are hydrolysed diets?
all food broken down into constituents so that body doesn’t recognise where they originate and so will no launch allergic response
what are the general feeding principles for all GI disease?
highly digestible
restricted fat - prevent GOR and delayed gastric emptying
supplementary fibre - reduce LI diarrhoea (fermantable or non-fermentable)
little and often (3-4 times per day)
what must be considered with inappetant patients?
reasons for inappetance that are related and unrelated to GI disease
what are the reasons unrelated to GI disease that a patient may be inappetant?
pain
stress
what are the reasons related to GI disease that a patient may be inappetant?
dehydration hypokalaemia hypocobalaminaemic nausea delayed gastric emptying making them feel full due to impaired motility
what must not be introduced to patients in hospital?
new prescription diets
how can food intake in hospital be encouraged?
warm, wet and smelly food
ask owner about individual preferances
what individual eating preferences may patients have?
prefurred foods environment to eat in solitary or accompanied eating hand feeding owner encouragement . facilitation
what are the main aspects of medical therapy for inappetance?
control nausea
stimulate appetite
ensure patient is not receiving any drugs that may be supressing appetite
what drugs are used to control nausea?
maropitant
metaclopromide
what drug is used to stimulate appetite?
mirtazapine
what drugs may suppress patient appetite?
opioids - reduce motility
NSAID - contraindicated anyway as cause GI irritation
what nutritional support is available if patient is struggling to eat?
feeding tubes (N/O, oesophageal, percutaneous endoscopic gastrotomy)
what can feeding tubes be used for?
microenteral nutrition
liquid or blended feeding
medication admin
what is microenteral nutrition?
glucose, AA and electrolytes given to support enterocytes as only receive nutrition from intestinal lumen
why does cobalamin need to be supplemented?
B12 is needed for metabolism in almost all cells
will lead to inappetance and poor enterocyte health
how may cobalamin be supplemented?
SQ
oral
how is cobalamin administered SC?
weekly until normalised (4-6 weeks)
recheck serum levels 4-6 weeks after end of course to ensure levels are staying high
how is cobalamin administered orally?
daily in mage doses
remeasure serum levels after 4-6 weeks
what is exocrine pancreas insufficiency?
failure of normal exocrine (enzyme) pancreatic secretion
what does EPI lead to?
maldigestion and malabsorption
what may EPI be caused by?
pancreatic acinar atrophy (PAA)
recurrent pancreatitis
what is pancreatic acinar atrophy?
progressive atrophy of pancreas in dogs
what breeds in PAA most commonly seen in?
GSD
at what age does PAA usually begin?
young adult
why may recurrent pancreatitis cause EPI?
scar tissue forms after each bout and so functional aspects are lost
what are the key signs of EPI?
ravenous appetite
diarrhoea
typically fatty/greasy faeces
severe weight loss
why are EPI sufferers faeces usually greasy?
lipaze is not produced from the pancreas
how is EPI diagnosed?
trypsin like immunoreactivity (TLI) serum test (species specific)
what are the issues with EPI treatment?
expensive
lifelong
how is EPI treated?
oral pancreatic extract (either capsules or fresh (frozen) pancreas
how often should EPI patients be fed per day?
2-3 meals per day
what must be given with each meal for an EPI patient?
enzymes
what diet should be fed to EPI patients?
highly digestible high protein (quality) not low fat non-complex carbohydrates vitamin supplementation (cobalamin)
what is colitis?
colonic inflammation
what is used to treat colitis?
Sulphasalazine (Salazopryn)
what is Sulphasalazine (Salazopryn) contraindicated for?
SI disease
how does Sulphasalazine (Salazopryn) work?
sulfonamide bound to 5-ASA
link is cleaved by bacteria in colon
leads to local release of 5-ASA which acts as a local anti inflammatory
what drug type is Sulphasalazine (Salazopryn)?
NSAID
what is a major side effect of Sulphasalazine (Salazopryn)?
keratoconjunctivitis sicca (KCS) - dry eye
what must be measured before and during Sulphasalazine (Salazopryn) administration?
schirmer tear test (STT) to confirm normal
what is irritable bowel syndrome?
large intestinal pattern diarrhoea +/- occasional vomiting
in what dogs is IBS usually seen?
anxious / nervous small / toy breed dogs (potential for underlying physical or emotional disorder)
how is IBS diagnosed?
exclusion of all other causes of signs
what are some of the reasons that an animal may be vomiting blood that is not of GI origin?
coagulopathy
swallowed blood from respiratory tract (oral, nasal or pulmonary)
what is seen with gastric or small intestinal bleeding?
haematemesis
melaena
what is seen with large intestinal bleeding?
haematochezia
what may partially digested blood in vomit look like?
coffee grounds
what are the causes of GI ulceration?
drugs (NSAIDS, opioids) foreign body (direct trauma) neoplasia hypoadrenocorticism kidney or liver disease other rare causes
how are gastric ulcers treated?
evaluate for and remove/treat underlying cause acid blockers coating agents analgesia Misoprostol surgery if perforated
what are the main acid blockers used to treat gastric ulcers?
proton pump inhibitors - omeprazole
histamine receptor agonists
antacids
what is the role of misoprostol?
given after NSAID overdose as it is a prostaglandin analogue and so will help to overcome defecit
what is constipation?
impaction of the colon or rectum with faecal material including hair/bones etc
what is the consistency of faeces during constipation?
excessively dry or hard
what does prolonged constipation lead to?
irreversible changes to the colon wall which reduces motility an leads to obstipation
define obstipation
the inability to pass the accumulation of dry hard feces. This can cause impaction of the entire length of the colon and lead to permanent damage
what are the signs of constipation?
infrequent defecation dyschezia tenesmus pain associated with defecation (successful or not) vomiting anorexia lethargy
what are the causes of constipation?
dietary dehydration of electrolyte derangement drug related (reduced motility) environmental pain/orthopedic problems making posturing for defecation difficult spinal / neuromuscular disease pelvic canal obstruction perineal/perianal disease
what are the environmental causes of constipation?
stress
dirty or absent toileting opportunities
lack of exercise
how is constipation treated?
identify and correct the underlying cause
fluid therapy (with electrolyte correction if needed)
oral laxatives
enemas
motility modification
surgery (case dependent)
how is the cause of constipation identified?
full history
clinical, neurological, rectal and peri-anal exam
abdominal and pelvic x-rays
lab tests
what can be used to clear the colon in a constipated patient?
microlax enema
oral laxatives
enema
what are the main oral laxatives available?
lactulose
lax-a-past
katalax
how is an enema performed?
warm water
+/- lubricant
digital manipulation and manual evacuation
what type of enema must not be used in patients with constipation?
phosphate containing
how can constipation be prevented?
ensure adequate water intake control any underlying disease add fibre into diet ensure litter tray is in a good location, is clean and is large enough provide analgesia if needed increase exercise increase gut motility laxatives
why should fibre be added to the diet in constipated patients?
stimulates colonic motility
what drugs are used for motility modification?
Cisapride
what is megacolon?
loss of neuromuscular function of the colon producing weakened colonic contractions and faecal overload
what species is megacolon most often seen in?
cats
what causes megacolon?
idiopathic - neuromuscular dysfunction
chronic underlying disease
how is megacolon treated?
as for constipation - last resort is sub-total colectomy
what is the major side effect of a subtotal colectomy?
can lead to chronic diarrhoea
