Piss, Shit & Heartburn Flashcards
What is the difference (in time) between acute and chronic diarrhoea?
4 weeks
Red flags for diarrhoea
Blood in the stool.
Recent hospital treatment or antibiotic treatment.
Weight loss.
Evidence of dehydration.
Nocturnal symptoms — organic cause more likely.
What do you need to know about the character of the diarrhoea?
Frequency
watery, fatty, containing blood or mucus
What factors are suggestive of an infective cause of diarrhoea?
Fever.
Vomiting.
Recent contact with a person with diarrhoea.
Exposure to possible sources of enteric infection (for example, having eaten meals out, or recent farm or petting zoo visits).
Travel abroad
Ask about potential exposures such as raw milk or untreated water.
Food handlers, nursing home residents, and recently hospitalized people
4 mechanisms of diarrhoea
Osmotic - intolerance/malabsorption
Secretion - infection
Inflammation - IBD/Shigella
Motility - diabetes/hyperthyroidism
Most common cause of infectious diarrhoea?
Virus - Noro
Prognosis for diarrhoea in relation to pathogen?
Viral - 2-3 days
Bacterial - 3-7 days
Parasite - potentially for ever
Other than infection, possible causes of diarrhoea
Anxiety Radiotherapy of pelvis New Medication Alcohol IBD
Aside from red flags what do you need to assess in someone with acute diarrhoea?
Dehydration
Examinations for diarrhoea
Abdominal
DRE
Investigations diarrhoes
Consider stool sample
Blood tests if you suspect start of chronic cause
When to admit for acute diarrhoea?
Cannot keep down fluids because of vomiting
Features of dehydration or shock
Older age (people 60 years of age or older are more at risk of complications).
Home circumstances and level of support.
Fever.
Bloody diarrhoea.
Abdominal pain and tenderness.
Increased risk of poor outcome, for example
When to refer for suspected cancer (2 week for dairrhoea)?
They are aged 40 and over with unexplained weight loss and abdominal pain, or
They are aged 50 and over with unexplained rectal bleeding, or
They are aged 60 and over with iron deficiency anaemia or changes in their bowel habit
10 red flags of chronic diarrhoea
Unexplained weight loss.
Unexplained rectal bleeding.
Persistent blood in the stool.
Abdominal mass.
Rectal mass.
Severe abdominal pain.
Iron deficiency anaemia.
Raised inflammatory markers (may indicate inflammatory bowel disease).
Nocturnal or continuous diarrhoea or both (suggestive of an organic rather than functional disorder).
Fever, tachycardia, hypotension, dehydration.
What is chronic fatty diarrhoea suggestive of?
pancreatic insufficiency
malabsorption (coeliac disease)
With diarrhoea what is recent antibiotic or PPI use associated with?
C. diff
Possible underlying causes of chronic diarrhoea and what to enquire about?
Travel - parasite, Giardia Drugs - laxatives Surgery Coeliac Diabetes Fam history IBD Constipation Immunocompromised Hyperthyroidism
In chronic diarrhoea what could abdominal pain indicate?
coeliac disease,
Crohn’s disease,
or malignancy
What would chronic diarrhoea with Weight loss, anxiety, palpitations, tremor suggest
Hyperthyroidism
In chronic diarrhoea what could pyoderma gangrenosum or erythema nodosum suggest?
IBD
Investigations for chronic diarrhoea
Full blood count — to detect anaemia. Urea and electrolytes. Liver function tests, including albumin level. Calcium. Vitamin B12 and red blood cell folate. Iron status (ferritin). Thyroid function tests. ESR and CRP (C-reactive protein). Testing for coeliac disease — immunoglobulin A (IgA), and IgA tissue transglutaminase (tTG)
In chronic diarrhoea what would you test for if they’d been abroad or it seemed infective?
Routine microbiology investigation and examination for ova, cysts and parasites
When would you perform faecal calprotectin testing?
to help differentiate between irritable bowel syndrome and inflammatory bowel disease in people under the age of 40 years
When would you not do faecal calprotectin testing?
With new onset rectal bleeding or bloody diarrhoea.
In whom there is a need to rule out cancer.
Other than suspected cancer when would you refer a person with chronic diarrhoea?
Suspected coeliac disease
suspected IBD
Malabsorption
A person less than 40 years of age does not have typical symptoms of functional bowel disorder and/or has severe symptoms and documented diarrhoea
Safety netting for acute diarrhoea
you or your child (over 5 years) still have signs of dehydration after using oral rehydration sachets
you or your child keep being sick and cannot keep fluid down
you or your child have bloody diarrhoea or bleeding from the bottom
you or your child have diarrhoea for more than 7 days or vomiting for more than 2 days
Other than malignancy what would you consider if someone had the following symptoms for at least 6 months?
Abdominal pain, or
Bloating, or
Change in bowel habit
In addition to abdominal pain, what is a key feature for making a diagnosis of IBS
Related to defecation, and/or
Associated with altered stool frequency (increased or decreased), and/or
Associated with altered stool form or appearance (hard, lumpy, loose, or watery)
In order to make a diagnosis of IBS what other symptoms need to be present with Associated with altered stool form or appearance (hard, lumpy, loose, or watery)?
Altered stool passage (straining, urgency, or incomplete evacuation).
Abdominal bloating (more common in women than men), distension, or hardness.
Symptoms worsened by eating.
Passage of rectal mucus, and
Alternative conditions with similar symptoms have been excluded.
In addition to bowel symptoms, what else might someone with IBS present with?
Lethargy, nausea, back pain, headache. Bladder symptoms (such as nocturia, urgency, and incomplete emptying), dyspareunia, or faecal incontinence.
IBS is a diagnosis of exclusion so what tests would you routinely preform?
FBC
ESR/CRP
Faecal calprotectin
Coeliac serology
Most common symptoms associated with bowel cancer?
diarrhoea, constipation, rectal bleeding, loss of weight, and abdominal pain
If someone had rectal bleeding what additional symptoms would make you consider bowel cancer?
Abdominal pain.
Change in bowel habit.
Weight loss.
Iron-deficiency anaemia.
In a pt with unexplained chronic diarrhoea you find the following upon examination: Pallor, clubbing, aphthous mouth ulcers.
Abdominal tenderness or mass, for example in the right lower quadrant.
Perianal pain or tenderness, anal or perianal skin tag, fissure, fistula, or abscess
What do you suspect?
Crohns
What investigations would you preform in suspected Crohns?
FBC - anaemia CRP/ESR - active inflammation U&E - dehydration Ferratin, B12 & folate - malnutrition Coeliac serology - to rule out Stool microscopy - rule out C.diff Faecal calprotectin - negative in IBS
In a pt with chronic bloody diarrhoea where malignancy is not suspected you gain the following upon examination
Pallor, clubbing, or aphthous mouth ulcers.
Abdominal distension, tenderness or mass, for example in the left lower quadrant.
Signs of malnutrition or malabsorption
What do you suspect?
IBD - Ulcerative Colitis
In addition to malignancy what would you suspect with the following symptoms?
Faecal urgency and/or incontinence.
Nocturnal defecation.
Tenesmus (persistent, painful urge to pass stool even when the rectum is empty).
Abdominal pain, particularly in the left lower quadrant.
Pre-defecation pain, which is relieved on passage of stool.
Non-specific symptoms such as fatigue, malaise, anorexia, or fever (may suggest severe disease).
Weight loss
What do you not prescribe to someone with bloody diarrhoea where diagnosis is uncertain and why?
anti-diarrhoeal drugs
Risk of toxic mega-colon
Bright red, painless rectal bleeding with streaks on the toilet paper is the most common symptom of what?
haemorrhoids
Can people get tenesmus with haemorrhoids?
Yes - with large ones
When do people get pain with haemorrhoids?
Internal - prolapse and becomes strangulated, resulting in intense pain
External - thrombosed
What differentiates haemorrhoids from anal fissure in terms of pain an bleeding?
Fissure - always intense sharp pain on defecation, sometimes bleed
Haemorrhoids - often bleeding, may be painless.
Do you perform a DRE on a suspected anal fissure?
No, will be too painful
What are the mgmt options for haemorrhoids?
Admit - if extremely painful and thrombosed, sepsis
Refer - haemorrhoids too beg or cancer suspected
Advise - fibre intake & hydration, hygiene
Analgesia - NSAIDS, topical cream
Safety netting for haemorrhoids
Temperature becomes high, pus leaking out
Come back if bleeding pain become worse.
If conservative measures dont work
In suspected UTI, who would you not urine dipstick and why?
Over 65
Catheter
Unreliable
6 symptoms that would make you suspect lower UTI in women?
Dysuria Frequency Urgency Changes in urine appearance or consistency: Nocturia
What symptoms would make you suspect pyelonephritis over UTI?
fever,
loin pain
or rigors.
6 Red Flags in suspected UTI
haematuria loin pain rigors nausea vomiting altered mental state
Relevant family history in suspected UTI?
polycystic kidney disease
What must you suspect in all women of childbearing age until proven otherwise, especially with UTI symptoms?
Pregnancy
What is relevant in the PMH with regard to UTI?
neurological conditions, diabetes mellitus, immunosuppression, urolithiasis bladder catheterisation
Relevant medication in suspected UTI?
antibiotics
What would you look for in examination in someone with suspect UTI?
Vital signs - sepsis
Flank and abdominal pain
What does in mean if urine dipstick is positive for nitrite OR leukocyte AND red blood cells?
UTI likely
What does it mean if urine dipstick is negative for nitrite and positive for leukocyte?
UTI is equally likely to other diagnosis.
What does it mean if urine dipstick is negative for everything?
UTI likely
When would you send urine for culture?
If UTI likely from dipstick and previous antibiotic treatment has failed
UTI is equally likely as other diagnosis
When would you send for a urine culture in ALL women with suspected UTI?
Over 65
Pregnant
Have symptoms that are persistent or do not resolve with antibiotic treatment.
Have recurrent UTI (2 episodes in 6 months or 3 in 12 months).
Have a urinary catheter in situ or have recently been catheterised
Have atypical symptoms.
Have visible or non-visible (on urine dipstick) haematuria
If there are urinary symptoms but no evidence of UTI then what are the potential differentials?
Other urological or genitourinary conditions Dermatological Malignancy STI Trauma Drug Reaction
Management of UTI without haematuria in a woman who is not pregnant or catheterized?
Refer is septic
Self care
Antibiotic - immediate/delayed
What is the self care advice for UTI (no haematuria not pregnant)
NSAIDS
Fluids - not cranberry or alkalising agent
What are the risk factors for complication of a UTI?
structural or neurological abnormalities of the urinary tract,
urinary catheters,
virulent or atypical infecting organisms
co-morbidities such as poorly controlled diabetes mellitus or immunosuppression
When would you prescribe antibiotics for UTI?
Risk factors for complication
Recurrent
When would you use a delayed prescription for UTI and what is the time delay?
Mild symptoms - no risk factors
48hrs
Safety net for lower UTI in women
Symptoms worsen rapidly or significantly at any time or fail to improve within 48 hours of starting antibiotics
Antibiotic of choice for lower UTI in women?
Nitrofurantoin
How do you manage asymptomatic bacteriuria in pregnancy?
Prophylactic antibiotics
Relevant FH in dyspepsia?
Oesophageal cancer
What lifestyle factors are relvant to dyspepsia?
Obesity Smoker Alcohol Trigger foods Stress/anxiety
What are you looking for on examination in a pt with dyspepsia?
Weight loss by checking serial weight and body mass index (BMI) measurements.
Signs of anaemia.
Abdominal masses and tenderness
Differential for dydpepsia?
Upper GI maignancy Gallstones Pancreatitis Gastroenteritis Crohns IBS AAA
Lifestyle advice for dyspepsia
Weight loss
Avoid trigger foods
Cut out booze & tabs
Smaller meals and not right before bed
Management of dyspepsia
Lifestyle change Antacids - short term Medication change/stoppage - if relevant PPI H.pylori test
Red flags with dyspepsia?
Sudden onset - associations with angina/MI
Cancer B symptoms
Haematemesis
What are the 2 types of urinary incontinence?
Stress incontinence and Urge incontinence (overactive bladder)
8 red flags relating to incontinence?
Haematuria ▪ Persistent UTI ▪ Constitutional symptoms ▪ Poor renal function ▪ Abnormal neurology ▪ Saddle anaesthesia ▪ Recent back trauma ▪ Recent pelvic surgery
What is stress incontinence?
Urine leaks when the bladder is under pressure
If someone is incontinent when they laugh or cough, what sort of incontinence is this?
Stress
3 risk factors for stress incontinence?
Menopause
Age
Multiparity
In females what condition may occur alongside stress incontinence?
Prolapse
What questions would you ask about to assess if there might be prolapse?
Dragging sensation
lumps
pressure
Conservative management option of stress incontinence?
– increase physical activity,
reduce weight,
physiotherapy & pelvic floor strengthening
Medical management of stress incontinence?
Duloxetine (SSRI)
Is there a surgical option for stress incontinence?
Tape and colposuspension if less invasive
methods fail
What type of incontinence relates to an overactive bladder?
Urge
What type of incontinance relates to these symptoms?
o Sudden, intense urge to pass urine
o Usually frequent passage of small volumes
o Nocturia may also be a problem
Urge
2 risk factors for urge incontinence?
Detrusor overactivity,
high caffeine intake
What 2 investigations would you perform for urge incontinence?
Urine dipstick (infection), Incontinence diary
5 aspects of conservative management for urge incontinence?
Increase physical activity & reduce weight • Reduce fluid intake • Avoid caffeine • Bladder training exercises and drills • Review medications
5 types of medication that can cause urge incontinence
Angiotensin-converting enzyme (ACE) inhibitors o Diuretics o Some antidepressants o Hormone replacement therapy (HRT) o Sedatives
2 medical management options for urge incontinence
Antimuscarinics
• Botox injections into Detrusor muscle
Can you get mixed incontinence?
Yes
