Gut Problems 2 (Clinical) (Ow) Flashcards

1
Q

What sort of questions should you ask around diarrhoea?

A

1) Freq
2) Consistency
3) Blood
4) meals
5) Noctournal
6) Amount
7) Normal BH
8) Associated Symptoms
- Travel
- meds
- Fever/wt loss
- Infections

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2
Q

What sort of questions should you ask around bleeding?

A

1) PR blood?

  • Colour
    • bright red?
    • black: iron/malena,
    • maroon/plum)
      • Black/tarry (melaena): small intestine (upper GI tract) (unlikely)
      • Dark red/maroon: distal small intestine, proximal colon (caecum to transverse colon) (likely)
      • Bright red (mixed with stools) à distal colon/rectum (left colon) (unlikely)
      • Blood fresh on paper: outlet (anal fissure/hemorrhoids) (unlikely) (do not cause iron deficiency)
  • Volume (inaccurate)
    • On the paper?
    • Coating the stool? (haemorrhoides do not coat the stool)
  • How Many Days?
  • Intermittent?
  • Bowl habit? (Constipation?)
  • Weight loss?/Nausea?/Vomit?/Fam history?
  • NSAIDS?/Anti-platelet drugs?

2) Bloody diarrhoea?

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3
Q

What should you ask around weight loss?

A

1) Timespan
2) How much lost / How much they weigh
3) Have the clothes become loose?

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4
Q

25-year-old lady, usually fit and well

3-month history of watery diarrhea

  • 6 times a day, 3 times at night (nocturnal diarrhea usually has to be taken seriously)
  • Blood as well (colour (black, tarry (i.e. melaena), fresh, bright red? maroon?))
  • Lower abdo cramps
  • Lost 5kg in weight

Usual bowel habit once a day (always important to establish what is normal for them!)

Light smoker of 3 cigarettes a day

On oral contraceptive pill, nothing else

What are the differential diagnoses?

A

Infection

  • History too long in an otherwise fit and well person
  • If immunocompromised, it can be longer
  • Exclude C. difficile in someone who has had recent antibiotics (antibiotics can predispose to C. difficile infection)

Coeliac Disease

  • Unlikely because of bleeding (coeliac disease not usually associated with bleeding)

Irritable Bowel Syndrome (IBS)

  • Unlikely because usual bowel habit is regular, symptoms tend to appear gradually (tend to be chronic)
  • Unlikely because of bleeding, nocturnal diarrhea

Inflammatory Bowel Disease (IBD)

  • Possible, bleeding and diarrhea common presentation of IBD

Cancer

  • Not usually in a young person unless family history of polyp syndrome
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5
Q

Analyse these results

Full Blood Count

  • Low Hb: anemia
    • Normocytic (e.g. due to blood loss, chronic inflammation)
  • Normal MCV
  • High platelets: thrombocytosis
  • High WCC: neutrophilia
  • Raised CRP:
  • Low albumin:
  • High ferritin:
  • Stool culture negative
  • 25-year-old lady, usually fit and well*
  • 3-month history of watery diarrhea*
  • 6 times a day, 3 times at night (nocturnal diarrhea usually has to be taken seriously)
  • Blood as well (colour (black, tarry (i.e. melaena), fresh, bright red? maroon?))
  • Lower abdo cramps
  • Lost 5kg in weight
  • Usual bowel habit once a day (always important to establish what is normal for them!)*
  • Light smoker of 3 cigarettes a day*
  • On oral contraceptive pill, nothing else*
A

Analysis

  • Elevated CRP, neutrophils and platelet count suggest inflammation
  • Normocytic anemia
    • Response to inflammation (reduced bone marrow activity)
    • May be due to bleeding as well but less of a factor
      • Acute bleeding can drop Hb without change in MCV but this patient is not behaving like so
      • Chronic bleeding can drop Hb but usually MCV also falls due to iron deficiency
  • Low albumin and high ferritin are both part of an acute phase reaction
  • Everything points to inflammation!
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6
Q

Raised CRP:

Low albumin:

High ferritin:

What do these results indicate?

A

Raised CRP: inflammation

Low albumin: inflammation (acute phase reaction)

High ferritin: inflammation

Stool culture negative

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7
Q

Note that anemia due to acute blood loss tend to be accompanied by….

A

(Note that anemia due to acute blood loss tend to be accompanied by tachycardia, clammy hands)

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8
Q

How do you diagnose IBD?

A

Colonoscopy

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9
Q

Describe the 2 types of Inflammatory Bowel Disease

A

Crohn’s Disease

  • Any part of the GI tract
  • Discontinuous inflammation (skip lesions, may spare rectum)
    • Most common in: ileo-colonic junction
  • Deep ulcers and cobblestone appearance
  • _Transmural inflammation (_common location at terminal ileum/ascending colon (ileo-colonic junction), typical landmarks of normal colon lost)
    • Starts as small ulcers on mucosa (i.e. aphthous ulcers)
    • Progress to deep penetrating ulcers with fissuring
    • Mucosa swollen cobblestone appearance
  • Granulomas may be present (but not required for diagnosis) (seen on biopsy not colonoscopy)
  • Made worse by smoking
  • Different presentations depend on part of GI tract involved and clinical subtype
    • Inflammatory
    • Stricturing
    • Fistulizing
    • Perianal

Ulcerative Colitis

  • Restricted to only colon
  • Continuous inflammation, starting at rectum and spread proximally
  • Shallow ulcers (no macroscopic ulceration expect in severe disease)
  • Mucosal inflammation (does not reach deeper, diffuse and granular)
  • Granulomas not seen on biopsy
  • Smoking is protective
  • Inflammatory is the only type of presentation
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10
Q

Diarrhoea indicates…

A

Inflammation of the COLON (not Small Bowel)

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11
Q

Describe the 4 presentations of Crohn’s Disease

A

Inflammatory Disease

  • Colitis (diarrhea, bleeding)
  • Ileitis (abdominal pain, typically at least an hour or so post-prandial (after eating))
  • Gastritis/duodenitis (dyspepsia)

Stricturing Disease

  • Long-term inflammation (transmural inflammation -> thickened wall -> scar -> stricture)
  • Presents with symptoms similar to bowel obstruction (abdominal pain and distension, vomiting, bowels not opening)

Fistulizing Disease

  • Fistula is an abnormal connection/tract between the gut and another organ/vessel (unique to Crohn’s), which includes:
    • Small intestine and skin,
    • Small intestine and small intestine,
    • Rectum and vagina,
    • Esophagus and trachea

Perianal Disease

  • Perianal abscess
  • Perianal fistula
    • _​_Anal canal to outside
  • Anal fissure (consider Crohn’s with recurring anal fissure, but can occur outside of Crohn’s, e.g. constipation)
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12
Q

What are the presentations of inflammatory ulcerative colitis?

A

Ulcerative Colitis Presentation (Inflammatory)

  • Diarrhea, bleeding
  • Frequent bowel motion and urgency
  • Abdominal discomfort
  • Fever, malaise, weight loss (constitutional symptoms)
  • Raised ESR/CRP and platelets in blood tests
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13
Q

Describe Toxic Megacolon

A

Toxic Megacolon In Ulcerative Colitis

  • Inflammation in mucosa extends into smooth muscle layer
  • Inflammatory mediators released including nitric oxide
    • NO is an inhibitor of smooth muscle tone
    • Arrested colonic movement leads to progressive dilatation
      • _​In_creased risk of perforation
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14
Q

Describe the Extra-intestinal manifestation of IBD

A

Extra-Intestinal Manifestation Of IBD

Some manifestations are more common in Crohn’s than UC and vice versa.

  • Eyes (episcleritis, uveitis)
  • Biliary tract (primary sclerosing cholangitis)
  • Joints (spondylitis)
  • Skin infections (erythema nodosum or pyoderma)
    • Doesn’t always present at the same time with colonic manifestation.
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15
Q

Lady is diagnosed with Crohn’s colitis and terminal ileitis

Has MRI enterography to examine remaining small intestine (no evidence of small intestinal disease apart from terminal ileitis)

What was the cause of her Weight loss?

A

What Is The Cause Of Weight Loss

  • Malabsorption
    • B12 absorption
    • Bile reabsorption (absorb fat)
  • Chronic inflammation -> catabolism and anorexia
  • Pain and reduced intake (reduced appetite)
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16
Q

How do you treat IBD in general?

A

Treatment Of IBD In General

  • 5-aminosalicylates (5-ASA)
    • (mild anti-inflammatory action)
  • Steroids
    • Treat acute flares (diarrhea, bleeding)
    • Stopped as soon as these symptoms are settled
  • Immunosuppression
    • (azathioprine, 6-mercaptopurine)
      • To maintain remission, not to treat flares
  • Biologics (infliximab, adalimumab)
    • Anti-tumour necrosis factor
    • Switch off TNF -> switch off inflammation
    • The most potent medication
17
Q

Describe the role of surgery in IBD

A

I_n UC, colectomy is curative_. In Crohn’s, no cure.

  • F_ailure of medical treatment,_ then resect diseased bowel e.g. colectomy, ileal resection
    • NOT first line treatment
  • Treatment of complications
    • (bowel obstruction, perforation, fistula, abscess)
18
Q

After 4 years of taking azathioprine and mesalazine, she gets increasing abdominal pain

MRI confirms multiple strictures involving distal ileum. She has an operation to remove 100cm of ileum.

What Are Potential Consequences Of Resection Of The Terminal Ileum?

A
  • B12 malabsorption (removal of terminal ileum -> loss of specialized receptors for B12/IF complex)
  • Bile salt malabsorption
    • Reduced re-uptake of bile salts via enterohepatic circulation
    • Bile salts loss through colon/faeces
      • Less bile salts -> fat malabsorption -> fatty diarrhea (i.e. steatorrhea)
      • Bile salt in colon -> irritant to colon -> stimulate water and electrolyte secretion -> s_ecretary diarrhea (not osmotic diarrhea)_
        • _​_Usually one or the other.
19
Q

75 year old man presents with SOB on exertion

Background of heart failure and angina

Intermittent dark rectal bleeding, mixed with stools

No bowel habit disturbance. Longstanding history of constipation and hemorrhoids. Reduced appetite and weight loss of 6kg

Takes aspirin, anti-hypertensives and diuretic

Investigations

Full Blood Count

  • Hb low
  • MCV low
  • Platelets, WCC, neutrophils normal

Other Results

  • CRP normal
  • Albumin low (possibly due to diet)
  • Ferritin low
  • B12 and folate normal

Analyse the findings

A

Analysis

Rectal Bleeding (Colour of Blood)

  • Black/tarry (melaena) -> small intestine (upper GI tract) (unlikely)
  • Dark red/maroon -> distal small intestine, proximal colon (caecum to transverse colon) (likely)
  • Bright red (mixed with stools) -> distal colon/rectum (left colon) (unlikely)
  • Blood fresh on paper -> outlet (anal fissure/hemorrhoids) (unlikely) (do not cause iron deficiency)
  • Unlikely to do be upper GI tract because there’s no melena.
  • Lower GI tract: likely
  • Outlet: unlikely, as usually fresh and on paper, does not cause iron deficiency

Microcytic Aneamia

Low ferritin, microcytic anemia suggests iron deficiency

  • Dietary
    • (ask patient if he is vegetarian)
  • Abnormal absorption possible
    • (indicates coeliac disease)
  • Abnormal losses
    • (no menstrual loss, but GI loss possible)
20
Q

75 year old man presents with SOB on exertion

Background of heart failure and angina

Intermittent dark rectal bleeding, mixed with stools

No bowel habit disturbance. Longstanding history of constipation and hemorrhoids. Reduced appetite and weight loss of 6kg

Takes aspirin, anti-hypertensives and diuretic

Investigations

Full Blood Count

  • Hb low
  • MCV low
  • Platelets, WCC, neutrophils normal

Describe the differential diagnoses

A

Colonic Disease

Possible, includes inflammation, diverticulosis, polyps, cancer. These cause bleeding à iron deficiency

  • Cancer: possible, due to age
  • Diverticulosis (typically occur in left distal colon): possible, due to history of constipation, but less likely because left colon bleed is more likely to present with fresh blood
  • Inflammatory bowel disease: unlikely, no inflammation on blood tests

Coeliac Disease

Possible, can cause iron deficiency, but does not explain for bleeding

Irritable Bowel Syndrome

Not usually in elderly patient.

Does not cause bleeding or iron deficiency.

21
Q

Describe how you investigate iron deficiency

A

Iron Deficiency Anemia

  • Age and gender are important
    • Young women without GI symptoms: likely menstrual loss
    • Young women with GI symptoms often needs investigation
    • Older women (esp. post-menopausal) and in all men: always needs investigation (iron deficiency in older adults may indicate malignancy!)
  • Break it down to
    • _Inadequate dietary i_ntake (vegetarian)
    • Impaired absorption (coeliac disease)
    • Abnormal loss (overt and occult bleeding)
      • E.g. inflammation, ulcers, diverticulosis, polyps, cancer, angiodysplasia (intermittent bleeds due to blood vessels opening into bowel)

If overt bleeding, cannot be coeliac disease

Cancer: always need excluding in an older patient

22
Q

How do you differentiate between Iron deficiency of chronic disease vs iron-deficiency anemia

A

Iron Studies

  • Serum iron
  • Iron binding capacity
  • Iron saturation
  • Ferritin
  • Soluble Transferrin receptor
23
Q

Describe the differential outcomes for different colour of blood ****

A
  • Black/tarry (melaena):
    • small intestine (upper GI tract) (unlikely)
  • Dark red/maroon:
    • distal small intestine, proximal colon (caecum to transverse colon) (likely)
  • Bright red (mixed with stools):
    • distal colon/rectum (left colon) (unlikely)
  • Blood fresh on paper:
    • outlet (anal fissure/hemorrhoids) (unlikely) (do not cause iron deficiency)

Bleeding from small vessels cause occult blood loss

Bleeding from large vessels are likely to cause overt bleeding

24
Q

What can cause bleeding in the Upper GI tract (Malena)

A
  • Oseophagitis
    • Tend to not get melena (bleeding is mucosa)
    • Get haemoptaemosis
  • Varices
    • Heavy and forceful bleeding
    • Massage haemoptaemosis
    • melena(?) in stool
  • Peptic Ulcer
    • Melena
  • Retching
    • Blood in vomit after series of vomitting
  • Cancer of stomach or oesophagus
    • Tend to not have overt bleeding (mucosal and small)
    • Tend to show iron def.
  • Vascular malformations
    • Malformation in capillaries tend to give iron deficiencies
25
Q
A
26
Q

What can give you bleeding in the COLON?

A
  • Inflammation
    • Bloody diarrhoea
  • Diverticulosis (usually on left colon)
    • Usually maroon, or fresh blood loss
    • No changes in bowel habit
  • Cancers
    • If in left colon- tend to show visible bleeding
  • Haemorroids
    • Blood on toilet paper
  • Polyps
27
Q

23 yo man with tiredness

Bloating and loose stools on and off for 3 years

Opens his bowels 2-3 times a day

Sometimes can get constipated instead

Pasta gives him bad abdominal cramps

Investigations

Full Blood Count

  • Hb low (anemia)
  • MCV low (microcytic anemia)
  • Normal platelets, WCC, neutrophils

Other Results

  • CRP normal, albumin normal
  • Low ferritin and B12 (iron deficient)

Anaylse the findings

A

Analysis

  • Normal CRP unlikely inflammation. No acute phase reaction seen
  • Microcytic anemia due to iron deficiency
    • Dietary (ask patient if he’s vegetarian (he is not))
    • Abnormal absorption possible
    • Abnormal losses (no menstrual loss; GI loss: no overt bleeding, but could be occult bleeding)
  • B12 deficiency
    • Dietary (ask patient: he eats good balanced diet)
    • Abnormal absorption (possible)
28
Q

23 yo man with tiredness

Bloating and loose stools on and off for 3 years

Opens his bowels 2-3 times a day

Sometimes can get constipated instead

Pasta gives him bad abdominal cramps

Investigations

Full Blood Count

  • Hb low (anemia)
  • MCV low (microcytic anemia)
  • Normal platelets, WCC, neutrophils

Other Results

  • CRP normal, albumin normal
  • Low ferritin and B12 (iron deficient)
  • Normal folate

Describe the differential diagnoses

A

Infection

  • History too long in an otherwise fit and well person
  • If immunocompromised, it can be longer
  • Exclude C. difficile in someone who has had recent antibiotics (antibiotics can predispose to C. difficile infection)

Coeliac Disease

  • Possible, erratic bowel habit, abdominal discomfort, malabsorption (but gluten causing bowel problems does not always indicate coeliac disease!)

Irritable Bowel Syndrome (IBS)

  • Possible, erratic bowel habit, abdominal discomfort, but does not cause malabsorption (coeliac and IBS have similar clinical presentations, differentiate by blood test for coeliac disease)

Inflammatory Bowel Disease (IBD)

  • Unlikely, as normal blood tests with no evidence of inflammation
  • No bleeding makes it less likely, although in mild cases may not have bleeding
  • Crohn’s can cause malabsorption if affects small intestine

Cancer

  • Occult GI bleed
  • Not usually in a young person unless family history of polyp syndrome

Angiodysplasia

  • Occult GI bleed
  • Possible, but does not explain for erratic bowel habit, abdominal discomfort, and malabsorption
29
Q

23 yo man with tiredness

Bloating and loose stools on and off for 3 years

Opens his bowels 2-3 times a day

Sometimes can get constipated instead

Pasta gives him bad abdominal cramps

Investigations

Full Blood Count

  • Hb low (anemia)
  • MCV low (microcytic anemia)
  • Normal platelets, WCC, neutrophils

Other Results

  • CRP normal, albumin normal
  • Low ferritin and B12 (iron deficient)
  • Normal folate

What next?

A
  • Coeliac serology
    • TTG IgA Ab high
    • DGP IgG high (make sure they are not on low-gluten diet before the test)
    • IgA normal
  • Requires biopsy (histology for a confirmed diagnosis)
  • Gastroscopy and colonoscopy normal (can argue that it wasn’t required)
    • No inflammation
    • No angiodysplasia
    • No polyps
    • Duodenal biopsies taken
30
Q

What is Coeliac Disease?

A
  1. Ingestion of gluten triggers an immune response (IgA predominantly)
  2. damage + flattening of villi
  3. malabsorption
31
Q

Describe the Coeliac Serology

A

Coeliac serology is the first test to look for coeliac disease. It predominantly looks at IgA (most ubiquitous antibody in GI tract)

  • Needs to be done while consuming gluten (if patient restricts gluten before test, can be falsely negative)
  • Prefer measurement of IgA tissue transglutaminase (TTG) antibodies
    • As these are IgA antibodies, result can be falsely negative in people with IgA deficiency (also more common in people with coeliac disease)
  • Other antibodies can be measured, e.g. DGP antibodies (IgG), EMA
    • If IgA deficiency patient, then test for DPG IgG Ab to exclude false negative
32
Q

What would you observe in duodeal biopsies for Coeliac Disease?

A
  • Intra-epithelial lymphocytosis (excessive amounts of lymphocytes in the villi)
  • Crypt hyperplasia (red arrows)
  • Villous blunting (atrophy)
33
Q

What is the gold standard for diagnosis of Coeliac Disease?

A

Endoscopy And Duodenal Biopsy

  • Histological diagnosis is still considered the gold standard for coeliac disease
  • Varying severity of histological changes
  • Biopsies taken from proximal duodenum
  • Sometimes abnormalities can be seen endoscopically as well but often looks normal to the naked eye at endoscopy
34
Q

Is there a “gene” test for Coeliac disease?

A

>99% patients with coeliac disease carry either HLA-DQ2 or HLA-DQ8 (family history at risk). However, >50% general population also have these 2 genes.

  • Positive does not diagnose (because it is also present in many other healthy individuals)
  • Negative helps eliminate possibility (if you don’t have these 2 genes, you’re extremely unlikely to have coeliac disease)
35
Q

What are some associations with Coeliac Disease?

A

Associations With Coeliac Disease

  • Dermatitis herpetiformis (skin condition)
    • (if you see this skin rash, it’s association is almost 100% with coeliac)
  • First degree relative with coeliac disease
    • (have a blood test even if you don’t have symptoms)
  • Type I diabetes

  • Auto-immune thyroid disease
  • Osteoporosis
  • Infertility/recurrent miscarriage
  • Unexplained neurological disease (particularly peripheral neuropathy, ataxia and epilepsy)
  • Unexplained liver disease
  • Addison’s disease
  • Sjogren’s syndrome
  • Down and Turner syndromes
  • Primary biliary cirrhosis
36
Q

Describe the Treatment of Coleiac Disease

A

Treatment Of Coeliac Disease

  • Gluten free diet (main sources of gluten include wheat, barley, rye)
  • Oats
    • A tiny proportion of people with coeliac cannot tolerate oats
    • Beware of cross contamination with wheat