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Year 4 - GP > GP - Diarrhoea > Flashcards

GP - Diarrhoea Flashcards

1
Q

What does the British Society of Gastroenterology define Diarrhoea as?

A

Abnormal passage of loose or liquid stools > 3 times/day

and / or

a volume of stool > 200 g/day

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2
Q

What is the cut-off for acute vs chronic diarrhoea?

A

< 4-weeks = acute

> 4-weeks = chronic

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3
Q

Name some causes of acute Diarrhoea?

A
  1. Infection e.g. gastroenteritis
    • C.Diff - common cause of infectious diarrhoea in elderly / pts who have taken Abx
    • Infections that can cause bloody diarrhoea; C.diff, CMV, Campylobacter jejuni, Salmonella, E. coli, Shigella, Yersinia, Aeromonas, schistosomiasis, Ebola etc.
  2. Constipation - can cause ‘overflow diarrhoea’
  3. Anxiety
  4. Food allergy
  5. Acute appendicitis
  6. Intestinal ischaemia
  7. Radiation enteritis
  8. Early presentation of chronic cause e.g. IBD
  9. Drugs
    • Abx’s
    • Gout drugs: Colchicine & Allopurinol
    • Metformin
    • NSAIDs
    • PPIs
    • SSRIs
    • Statins
    • Thyroxine
    • Theophylline (asthma)
    • Cytotoxic drugs
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4
Q

Stool specimens are not routeinly required to investigate diarrhoea.

In what situations should a stool specimen be sent for C & S?

A
  1. If pt is systemically unwell (e.g. fever, dehydration)
  2. Immunocompromised
  3. Recent Abx or Recent hospital admission - specifically test for C.diff
  4. Blood or pus in stool
  5. Persistent diarrhoea (i.e. > 1-week)
  6. Recent travel - anywhere other than; western Europe, north America, Austalia or New Zealand
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5
Q

What organisms are often tested for in stool sample C & S?

A
  1. Campylobacter
  2. Cryptosporidium
  3. E. coli
  4. Salmonella
  5. Shigella
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6
Q

What are some important questions to ask in a Diarrhoea history?

A
  • PC / HPC:
    • Vomiting? - if so, any blood?
    • Able to keep fluids down?
    • No. of bowel movements per day?
    • Blood in stool?
    • Abdominal pain?
    • Have you been abroad recently?
    • Exposure - been near anyone with similar symptoms recently?
  • Red Flags:
    • Cancer - weight loss, night sweats, fever?
    • Dehydration - postural hypotention, dizziness, oliguria, ↑ HR, ↓ BP, weakness, confusion, shock
  • DH:
    • Regular medications / new medications?
    • Laxatives, Abx’s, Gout drugs (Colchicine & Allopurinol), Metformin, NSAIDs, PPIs, SSRIs, Statins, Thyroxine
  • FHx:
    • IBD?
    • Colorectal / ovarian cancer?
  • System Review:
    • Heartburn / indigestion?
    • Abdo pain relieved / worsened by eating? (peptic ulcer)
    • Alcohol? (pancreatitis)
    • Tenesmus - feeling of incomplete defecation? (UC)
    • When was last period? (pregnancy)
    • Erectile dysfunction
    • Burning on urination? (UTI)
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7
Q

What home management options can be reccomended for pts with diarrhoea?

A
  1. Wash hands thoroughly and frequently
  2. Avoid preparing food for other people
  3. Increase fluid intake
  4. Drink oral rehydration salts (sachets you can buy in supermarket)
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8
Q

When must you 2WW refere adults suspected of Colorectal cancer?

A
  1. > 40-yrs + unexplained weight loss & abdominal pain
    • OR
  2. > 50-yrs + unexplained rectal bleeding
    • OR
  3. > 60-yrs + iron-deficient anaemia or changes in bowel habit or occult blood in feaces
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9
Q

When should you consider 2WW referral for colorectal cancer?

A
  1. Rectal or abdominal mass
  2. < 50-yrs + rectal bleeding + any of the following:
    • abdominal pain
    • change in bowel habit
    • weight loss
    • iron-deficient anaemia
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10
Q

If you suspect a pt of having GI symptoms due to a parasite, what test do you send a stool sample for?

e.g. foreign travel with diarrhoea

A

O, C & P

(ova, cysts and parasites)

  • O, C & P = microscopic evaluation of stool to identifiy parasites & their eggs (ova, cysts) which are shed in feaces when the parasites infect the GI tract
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11
Q

What instructions should you give to a patient

regarding collecting a stool sample?

A

Collectin Sample:

  1. Healthcare proffesional will provide you with a sterile container (often screw-top tube)
  2. Place something in the toilet e.g. plastic food container or defecate on newspaper
    • Ensure poo doesn’t touch the inside of the toilet, toilet water or urine
  3. Use the spoon / spatula provided to collect a sample of poo then place into screw-top container
  4. Aim to fill ~ 1/3rd of the container
  5. Put everything you used to collect the sample in a plastic bag, tie it up and bin it
  6. Wash hands thoroughly

Storage:

  1. Sample should be handed in ASAP (bacteria can multiply and misrepresent the levels of the bacteria in your gut)
  2. Sometimes you can store it in the fridge (not always and option, depends on stool tests to be done) - if so, store in sealed plastic bag first
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12
Q

What is Campylobacter?

What treatment is needed for Campylobacter food poisoning?

A

Campylobacter are gram-negative, s-shaped, bacteria

  • Commonly collonise poultry –> common cause of food poisoning (undercooked meat)
  • Campylobacter food poisoning often doesn’t require treatment (self-limiting)
  • Pt should stay away from other people for 48 hrs
  • Notifiable disease! - GP’s / hospital doctors must inform Public health England
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13
Q

What Abxs are used to manage C.Diff GI infection?

A
  • 1st episode, mild-moderate infection:
    • Oral Metronidazole (10-14 days)
  • 2nd / subsequent episodes or severe / not-responding to metronidazole:
    • Oral Vancomycin (10-14 days)
    • Oral Fidaxomicin - can replace vancomycin if pt has multiple co-morbidities, severe infection & recieving other Abxs
  • If infection not responding to vancomycin or fidaxomicin, life-threatening or ileus:
    • Oral Vancomycin + IV Metronidazole (10-14 days)
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14
Q

What is C.Diff?

A

A Gram-positive, rod (bacillus) bacteria

  • Produces exotoxin –> causes intestinal dmg & can lead to pseudomembranous colitis
  • Risk factors for C.Diff infection:
    • Broad-spectrum Abx
    • PPIs
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15
Q

What are the features of a C.diff GI infection?

A
  1. Diarrhoea
  2. Abdominal pain
  3. ↑ WCC (characteristic)
  4. Toxic megacolon (if severe)
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16
Q

How is C.Diff infection diagnosed?

A

Stool sample - test for Clostridium Difficle Toxin

  • C.Diff antigen positivity - only shows that pt has been exposed to bacteria rather than a current infection
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17
Q

Common causes of fresh blood in stool?

A
  1. Haemorrhoids
  2. Acute anal fissure (following trauma or severe constipation)
  3. Colorectal neoplasms
  4. Acute proctitis / infective colitis
  5. IBD
  6. Diverticular disease
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18
Q

What is an acute anal fissure?

A

Break/tear in the skin of the anal canal

  • Often directed posteriorly as anal wall is poorly supported posteriorly
  • Can extend down to underlying sphincter muscles
  • Symptoms:
    • severe pain (often when passing stool)
    • fresh blood on toilet paper (rarely enough to cause anaemia)
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19
Q

What investigations are used to confirm/exclude bowel cancer?

A

WITHOUT major comorbidity:

  1. Colonoscopy (if no other major comorbidity)
  2. If suspicious lesion is detected –> biopsy (unless contraindicated e.g. clotting disorder)

WITH major comorbidity:

  1. Flexible sigmoidoscopy then barium enema
  2. If suspicious lesion is detected –> biopsy (unless contraindicated)

Consider CT colonography if radiology department is proficient –> then colonoscopy + biopsy if lesion detected

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20
Q

What staging system is used for Bowel cancer?

A

Duke’s system

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21
Q

What are Duke’s stages for Bowel cancer?

A
  • Dukes’ A = tumour confined to mucosa
    • 5-year survival = 95%
    • mucosa = innermost lining (epithelium) of the colon or rectum or slightly growing into the muscle layer
  • Dukes’ B = tumour invading bowel wall (i.e. growing into / through muscle layer of colon / rectum)
    • 5-year survival = 80%
  • Dukes’ C = lymph node metastases
    • 5-year survival = 65%
    • ​means the cancer has spread to at least one lymph node in the area
  • Dukes’ D = distance metastases
    • 5-year survival = 5% (20% if resectable)
    • means the cancer has spread to somewhere else in the body, such as the liver or lung
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22
Q

What are the TNM stages for bowel cancer?

A

Tumour (T):

  • T1 = cancer has grown no further than the inner layer of the bowel
  • T2 = grown into the muscle layer of the bowel wall (but not through)
  • T3 = grown into the outer lining of the bowel wall
  • T4 = grown through outer lining of the bowel wall (into other parts of the bowel, nearby organ or body structure)

Node (N):

  • N0 = means there are no lymph nodes containing cancer cells
  • N1 = means that 1 to 3 lymph nodes close to the bowel contain cancer cells
  • N2 = means there are cancer cells in 4 or more nearby lymph nodes

Metastasis (M):

  • M0 = cancer not spread to other organs
  • M1 = cancer spread to other parts of body
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23
Q

What is an anterior resection?

A

Resection of colon (often descending, sigmoid or rectum)

via the abdominal wall e.g. laproscopically

  • Commonly used name instead of ‘left hemicolectomy’
24
Q

What is an Abdomino-Perineal (AP) resection?

A

Resection of the Rectum + Anus

  • Pathology is in low anus/rectum
  • Proximal resection margin is pulled through abdominal wall to form permanent end colostomy
26
Q

What are operations that end in “-stomy”?

A

Operations to create artificial openings‘Stoma’ into a hollow organ

e.g. sigmoid colostomy

27
Q

What are the 5-year survival rates for

Duke’s stage A colorectal cancer compared with Duke’s stage D?

A

Duke’s A = 93% 5-year survival

Duke’s D = 7% 5-year survival

28
Q

What are common symptoms / signs of colorectal cancer?

A

In order of coveying the highest to lowest risk of colorectal cancer:

  1. Rectal bleeding + change in bowel habit (35%)
  2. Abdominal/rectal mass (30%)
  3. Iron-deficient anaemia (30%)
  4. Intestinal obstruction (20%)
  5. Change in bowel habit alone (10%)
  6. Rectal bleeding without anal symptoms (6%)
  7. Rectal bleeding with anal symptoms (3%)
  8. Abdo pain (3%)
29
Q

What colorectal cancer screening test has replaced

FOBt (Fecal Occult Blood test)?

A

Faecal Immunochemical Test (FIT) screening

30
Q

What is FAP (familial adenomatous polyposis)?

A

Familial Adenomatous Polyposis (FAP):

Define:

  • Carpet of polyps (colonic adenomas) throughout entire colon
  • Cancer risk = 100% –> often develop colorectal cancer in 20-30’s

Associated Disorders:

  • Gastric fundal polyps (50%)
  • Duodenal polyps (90%) - if severe then 10-year Ca-risk is 30%

Aetiology:

  • Autosomal dominant
  • Mutation of 1 APC allele on chromosome 5q (80% of cases)

Epidemiology:

  • 1 in 7000
31
Q

What is Hereditary Non Polyposis Colorectal Cancer (HNPCC)?

A

Hereditary Non Polyposis Colorectal Cancer (HNPCC):

Define:

  • Also called Lynch syndrome
  • Autosomal dominant
  • ↑ risk of various cancers: 30-70% lifetime colorectal cancer, 30-70% lifetime endometrial cancer, 5-10% gastric cancer

Common cancers:

  • bowel (most common) endometrial (second most common), ovary, stomach, small intestine, upper urinary tract etc.

Aetiology:

  • Autosomal dominant mutation in MMR genes (mis-match repair) –> causes replication error prone DNA - MLH1 + MSH2 account for 90%

Epidemiology:

  • 1 in 500

Phenotype:

  • Proximal colon most common
  • 70-80% penetrance
  • Onset = 30-50s
32
Q

What is the Amsterdam Criteria for HNPCC

(Hereditary non polyposis colorectal cancer)?

A

​

3-2-1 criteria

  1. ≥3 relatives with confirmed colorectal cancer (FAP should be excluded)
  2. 2 succesive generations involved i.e. 1 person is a 1st degree relative of the other 2
  3. 1 or more with age of cancer onset < 50

‘Softer criteria’ were made to include cancers at other HNPCC sites + later onset

33
Q

What are the most common areas for colorectal cancer?

A
  1. Sigmoid Colon
  2. Cecum
  3. Rectum
34
Q

Colorectal cancer adjuvent therapy?

A
  • NO role for radiotherapy
  • Dukes C –> can have 6/12 chemo with 5FU (fluorouracil), results in 5-7 more cured pts per 100 treated
35
Q

In which part of the colon is diverticular disease most common?

A

Sigmoid colon

  • Possibly due to pressure associated with chronic constipation and/or accumulation of faecal matter
36
Q

What is the difference between the following:

  • Diverticulosis
  • Diverticular Disease
  • Diverticulitis
A

Diverticulosis:

  • Herniations/outpouchings of mucosa and submucosa through the muscular layer of the colon
  • Often asymptomatic

Diverticular disease:

  • Is symptomatic diverticulosis
  • e.g. rectal bleeding + altered bowel habits (exclude other pathologies first)

Diverticulitis:

  • Inflammation of diverticulosis
  • Symptoms are more severe + symptoms of inflammation e.g. tenderness
37
Q

What are common risk factors for Diverticular disease?

A
  1. Chronic constipation
  2. Low fibre diet
  3. High intake of meat/red meat
  4. Increasing age
  5. Hereditary factors
38
Q

What are common complications of Diverticular disease?

A
  1. Infection (diverticulitis) - presents similar to acute appendicitis, but with pain often being located on left abdomen or suprapubic
  2. Lower GI Bleeding - occult or overt
  3. Perforation (can cause peritonitis)
  4. Abscesss
  5. Fistula formation
39
Q

What are common causes of an acute abdomen (severe abdo pain often requiring emergency surgery) with generalised pain?

A
  1. Perforated viscus - on background of; peptic ulcer, trauma, appendicitis, GI cancer, diverticulitis, IBD etc.
  2. Acute pancreatitis
  3. DKA
  4. Ischameic Bowel
  5. Bleeding e.g. ruptured AAA, ectopic pregnancy, peptic ulcer
40
Q

Common causes of acute abdomen with right upper quadrant pain?

A
  1. Gallblader disease (e.g. cholecystitis, cholangitis, CBD stone)
  2. Duodenal ulcer
  3. Acute pancreatitis (e.g. in pregnant women due to displacement of pancreas by uterus)
  4. Hepatitis
  5. Hepatic absess
  6. Pyelonephritis
  7. Kidney Stones
  8. Pneumonia (referred pain)
41
Q

Common causes of acute abdomen with left upper quadrant pain?

A
  1. Acute pancreatitis
  2. Splenic infarction
  3. Ruptured splenic artery aneurysm
  4. Spontaneous splenic rupture
  5. Kidney Stones
  6. Pyelonephritis
  7. Pneumonia (referred pain)
42
Q

Common causes of acute abdomen with right iliac fossa pain?

A
  1. Acute appendicitis
  2. Perforated duodenal ulcer
  3. Crohn’s disease (often affects terminal ileum + ceacum) - can mimic appendicitis
  4. Diverticulitis
  5. Constipation
  6. Renal colic / kidney stones
  7. Strangulated hernia
  8. Obs & Gyn - ectopic pregnancy, ruptured ovarian cyst, salpingitis
43
Q

Common causes of acute abdomen with left iliac fossa pain?

A
  1. Diverticulitis
  2. Constipation
  3. Sigmoid volvulus (typically elderly pt)
  4. Crohn’s
  5. Ulcerative Colitis
  6. Kidney stones
  7. Strangulated hernia
  8. Obs & Gyn - ectopic pregnancy, ruptured ovarian cyst, salpingitis
44
Q

Common causes of acute abdomen with epigastric pain?

A
  1. Peptic Ulcer (gastric or duodenal)
  2. Acute pancreatitis
  3. Perforated oesophagus (Boerhaave syndrome - perforated due to vomiting)
  4. Mallory Weiss tear
  5. MI
45
Q

Common causes of acute abdomen with central pain?

A
  1. Early appendicitis
  2. Small intestine obstruction
  3. Mesenteric ischaemia (thrombosis)
  4. Acute pancreatitis
  5. Leaking/ruptured AAA
46
Q

Common causes of acute abdomen with suprapubic pain?

A
  1. Acute urinary retention
  2. UTI
  3. Ectopic pregnancy
47
Q

What investigations would you do for an acute abdomen?

A
  1. FBC - ↑ WCC (infection), ↓ Hb (anaemia / GI bleed due to peptic ulcer)
  2. U+Es - determine kidney function (dictates use of certian medication), ↑ urea if AAA/dissection has compromised renal arteries
  3. LFTs - deranged in intra-hepatic & post-hepatic jaundice, hepatitis
  4. CRP / ESR
  5. Serum glucose - may be elevated in pancreatitis (lack of insulin)
  6. Serum Amylase - ↑ in acute pancreatitis
  7. Serum Lipase - ↑ in acute pancreatitis
  8. ABG + lactate - lactic acidosis can occur is bowel ischaemia due to an embolism e.g. mesenteric artery, metabolic abdominal pain e.g. DKA
  9. Pregnancy test in women (always!)
  10. Urine dipstick - UTI (haematuria, +ve nitrites, +ve leukocyte esterase), pyelonephritis
  11. Erect CXR - GI perf can cause pneumoperitoneum
  12. Supine AXR
48
Q

What is the cut off in cm for a Toxic Megacolon?

A

6cm

49
Q

What are the common patterns of referred pain for

1) Cholecystitis
2) Pancreatitis
3) Appendicitis

A
50
Q

What are the common patterns of referred pain for

1) Perforacted ulcer
2) Pyelonephritis, renal or ureteral colic

A
51
Q

What is Cullen’s Sign and what does it indicate?

A

Cullen’s Sign = superficial bruising around umbilicus

Cullen’s Sign can indicate:

  1. Acute pancreatitis which is bleeding into abdomen
  2. Aortic rupture
  3. Ruptured ectopic pregnancy
52
Q

What is Grey-Turner’s Sign and what does it indicate?

A

Grey-Turner’s Sign = bruising of the flanks

Grey-Turner’s Sign can indicate:

  1. Acute pancreatitis which is bleeding into retropertoneum
  2. Aortic rupture
  3. Ruptured ectopic pregnancy
53
Q

What is a Hartmann’s Procedure?

A

Hartmann’s Procedure:

  • Pathology is in descending, sigmoid or rectum
  • Surgeon closes distal resection margin, leaving rectal stump
  • Proximal resection margin is brought through anterior abdominal wall to form an end colostomy
  • This surgery can be reversed at a later date
54
Q

What are the key points of Faecal Immunochemical Test (FIT) screening?

A

FIT = national screening programme for colorectal cancer

  • Offers screening every 2 years to men/women aged 60-74
  • FIT is sent through post
  • Detects + quantifies amount of human haemoglobin in stool - note: whilst a numerical value is generated, pt / GP will only be informed if result is normal or abnormal
  • If abnormal –> offer colonoscopy:
    • ​5/10 pts have normal exam
    • 4/10 pts have polyps (remove due to pre-malignant potential)
    • 1/10 pts have colorectal cancer
55
Q

When should you consider a 2WW for anal cancer?

A

If pt has unexplained anal mass

OR

unexplained anal ulceration

56
Q

Faecal Occult Blood Testing (FOBT) is no longer part of the screening programme for colorectal cancer - but should still be offered in certain circumstances.

What circumstances are these?

A

FOBT should be offered to:

  • pts > 50-yrs + unexplained abdominal pain OR weight loss
  • pts < 60-yrs + changes in bowel habit OR iron-deficient anaemia
  • pts > 60-yrs + anaemia even in absence of iron-deficiency

Year 4 - GP (18 decks)

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