Ow: case 3 Flashcards
Diarrhoea, where to start? what to know?
Infection (observe and sytomatic treatment) < 2 weeks duration
- Frequency
- consistency
- Blood (in or coating the stool)
- relationship with meals (osmotic improves with starvation, secretory doesn’t)
- Associated symptoms, travel, medications, fever, weight loss, job
- Nocturnal symptoms? (Functional illness like IBS doesn’t normally)
- What is normal bowel habit
presentation of bleeding?
PR bleeding or BLOODY DIARRHOEA
- Colour? (bright, maroon/plum, black-(also happens with Fe tablets)
- Where? (on the paper, coating the stool, dripped into water-(haemorrhoids)
- Amount? A rough guide but not overly helpful
- When? - everytime, sometimes
Differential for diarrhoea?
I C II C
Infection
Coeliac Disease
Irritable bowel syndrome
Inflammatory bowel disease
Cancer
25 y/o usually fit and well
- 3 months hx of watery diarrhoea 6x a day and 3x at night
- Blood as well with lower abd cramps
- 5kg weight loss
- Light smoker (3c/day)
- No medication other than COC
Infection - unlikely due to timeframe
Coealiac - DOESN’T give blood (no mucosal inflamm or ulceration)
Irritable bowel syndrome - typically swinging habits with gradual onset and no bleeding, weight loss or nocturnal symptoms
Inflammatory bowel disease - Bleeding and diarrhoea common presentation
cancer - unlikely in young people unless FHx of polyp syndrome
25y/o gets blood tests and they come back, discuss?
Normocytic anaemia -
- Iron deficiency? (normally microcytic though)
- From Bleeding? (Chronic bleeding can drop Hb and MCV also drops due to iron def. Acute bleeding drops Hb with stable MCV)
- Response to inflammation (reduced bone marrow activity)
Platelets, WBC and Neutrophils all high - suggest inflammation
CRP - is an actue C-reactive protein marker for inflammation
Low albumin and high ferritin also suggest inflammation
IBD is made up of?
Crohn’s Disease
- Any part of GI tract (most common is iliocolic junction)
- Discontinuous inflammation
- Can cause deep ulcers and transmural inflammation
- Made worse by smoking
- Can be inflammatory, fistulising, stricturing, perianal
Ulcerative Colitis
- Colon only
- Continuous inflammation starting at rectum
- Shallow ulcers with mucosal inflammation
- Smoking is protective
- Only inflammatory behavior
Clinical presentation of Crohn’s?
- Inflammatory - MOST COMMON
- Stricturing
- Fistulising
- Perianal
Inflammatory presentation of Crohn’s
- Collitis - diarrhoea and bleeding
- Ileitis - Abdominal pain typically at least an hour post prandial
- gastritis/duodenitis - dyspepsia
Stricturing presentation of Crohn’s disease?
Starts out as inflamation that becomes irreversible fibrotic rings
- Abdominal pain and distension
- Vomiting
- Bowels not opening
Fistulising presentation of Crohn’s disease?
Fistulising disease making abnormal connections between the gut and other organs or itself (can often be unaware)
Perianal presentation of Crohn’s?
These all have other more common causes but if they are severe or recurrent you must consider Crohn’s
- Perianal abcess
- Perianal fistula to the skin
- Anal fissure
Pathology of UC? Clinical symptoms?
Disease limited to the colon and it continuous microscopic inflammation
Begins in the rectum and spreads proximally
No macroscopic ulceration except in very sevfere disease
- Diarrhoea and bleeding
- Frequent bowel motions and urgency
- Abdominal discomfort
- Fever, malaise, weight loss
- Blood tests: Raised ESR/CRP, platelets
Toxic megacolon?
Very severe complication of UC in hospitilised patients mostly, colon becomes paralytic and begins to distend as inflammation extends into smooth muscle layer. Inflammatory mediators are released and the condition progresses.
Extra-intestinal manifestations of IBD?
These often don’t relate to GUI symptoms and may be present before or after GI symptoms
- Joints - pain or arthritis
- Eye - Uveitis or iritis
- Mouth - ulcers (not often complained about)
- Skin - Eythema nodosum (tender rash on lower limbs), Pyoderma gangrenosum (necrotic leswion on the skin)
- PSC - Primary sclerosing cholangitis - More common in UC (with higher risk of bowel cancer in those with UC and PSC)
Treatrment of IBD?
- 5-aminosalicylates (5-ASA) = mild anti-inflammatory for UC
- Steroids = used to achieve remission of inflammation
- Immunosuppressants = maintenance of suppressed inflammation
- Biologics (Anti-TNF factor) = suppress TNF action
Surgery - curative in UC but isn’t used immediately unless there is a stricture or fistula that needs to repair
