Small and large bowel disease part 2 Flashcards
What is gastroenteritis?
Refers to inflammation of the mucous membranes of the stomach and intestines.
Causes of gastroenteritis?
Bacteria
- Staphylococcus aureus (cooked meats, cream products)
- Bacillus cereus (reheated rice)
- Clostridium perfringens (reheated meat dishes, cooked meat)
- Clostridium difficile (healthcare environment, caused by abx)
- E.coli
- Salmonella
- Shigella
- Campylobacter
Virus
- Rotavirus (infant gastroenteritis)
- Norovirus (affects all ages)
- Adenovirus
Parasites (less common)
- Cryptosporidium
- Entamoeba histolytica
- Giardia intestinalis
- Schistosoma
Presentation of gastroenteritis?
Abdominal cramps
Diarrhoea
n+v
Fever
How does viral gastroenteritis present?
Watery diarrhoea
Low-grade fever
n+v
Colicky abdominal cramp
Incubation period 1-3 days
How does bacterial gastroenteritis present?
Watery or bloody diarrhoea -symptoms develop rapidly.
Moderate to high-grade fever
Nausea -severe and persistent
Vomiting
Severe and persistent abdominal cramp
Incubation period few hours to days.
How does parasitic gastroenteritis present?
Intermittent or chronic
Fever less common
May have n+v
Mild but longer duration of abdominal cramp
Incubation period days to weeks.
How is gastroenteritis diagnosed?
Clinical diagnosis
Abdominal assessment
Assess signs of dehydration and shock.
What to ask during hx taking for gastroenteritis?
Urine output (nappies change)
Comorbidities/immunosuppression
Occupation (e.g. food handler, health or social care -are they going to put others at risk?)
- recent food intake (cooked meat, expired food?)
- recent abx or PPI use
- some medications may need to be stopped due to risk of AKI (e.g. diuretics, ACEi)
When can stool culture and sensitivity be arranged in relation to gastroenteritis?
Not necessary, won’t change management, so not recommended.
May arrange stool culture and sensitivity testing if:
- pt is systemically unwell
- possible dysentery (acute painful diarrhoea or blood, mucus, and/or pus in the stool)
- prolonged diarrhoea
- recent travel to an at-risk destination
- contact with an affected person or outbreak
Management of gastroenteritis?
Admit to hospital if:
- systemically unwell and/or signs of severe dehydration and/or progression to shock
- high output diarrhoea or intractable vomiting
- suspect serious complication (e.g. sepsis)
Lifestyle:
- wash hands with soap
- don’t share towels
- regular fluid intake
- avoid dairy products, high-fibre foods, spicy or fatty meals
- don’t attend work or social setting until at least 48hours after the last episode
Medical:
- Oral rehydration therapy (ORT; for mild to moderate dehydration, contains electrolytes and glucose)
- IV fluids (for severe dehydration or can’t take oral fluids)
- Antiemetics
- Antidiarrheal agents
- ciprofloxacin (abx for Salmonella and shigella)
- Erythromycin (macrolide abx for Campylobacter)
- Tetracycline (for cholera)
Complications of gastroenteritis?
Dehydration
Sepsis
Haemorrhagic colitis
Reactive arthritis
IBS
IBD
Meningitis
Thrombotic thrombocytopaenic purpura (TTP)
What is irritable bowel syndrome (IBS)?
Refers to a chronic, relapsing, and often debilitating disorder of gut-brain interaction, resulting in abdominal pain or discomfort associated with altered bowel.
No identifiable structural or biochemical abnormalities.
Causes of IBS?
Unknown, but likely to be multifactorial.
Visceral hypersensitivity.
Abnormal GI immune function.
Changes in gut microbiome.
Abnormal autonomic activity.
Abnormal central pain processing of afferent gut signals (altered ‘brain-gut interactions’).
Abnormal GI motility.
Risk factors for IBS?
Genetic
Enteric infection
GI inflammation (e.g. secondary to IBD)
Dietary factors (alcohol, caffeine, spicy and fatty foods)
Drugs (abx)
Psychological (stress, anxiety, depression)
What would you ask during hx taking for suspected IBS?
History of presenting symptoms
Red flags for GI malignancy.
Red flags for urogynaecological malignancy.
Lifestyle and diet
Mental health
Effect of symptoms on daily activities.
Presentation of IBS? What criteria is used?
The Manning criteria:
Abdominal pain related to one or more of the following:
- defecation
- altered stool frequency
- altered stool consistency
+
At least two of the following:
- Altered stool passage (e.g., straining or urgency)
- Abdominal bloating
- Symptoms worsened by eating
- Passage of rectal mucus
Other symptoms:
- lethargy
- backache
- nausea
- bladder symptoms
When is IBS diagnosed?
Diagnosis of exclusion
- other conditions are ruled out
Symptoms must persist for at least 6 months.
What examination would you do in relation to IBS?
Weight
Abdominal exam (tenderness, masses)
Rectal exam (rule out haemorrhoids, strictures)
What investigations are done to rule out other conditions before IBS diagnosis?
Faecal calprotectin (raised in IBD, not IBS)
FBC
ESR (raised in IBD, not IBS)
CRP (raised in IBD, not IBS)
Coeliac serology
Management of IBS?
Lifestyle:
- regular exercise (30mins of moderate intensity exercise on 5 days each wk)
- wt loss
- stress management
- regular fluid intake
- healthy and balanced diet
IBS with diarrhoea:
- reduce alcohol, caffeine, carbonated drinks and gas producing foods,
- reduce insoluble fibre (e.g. bread, cereal, bran, wholegrains)
IBS with constipation:
- increase foods with high soluble fibre (oats, linseed) or try soluble fibre supplements (isphagula)
Medications:
IBS + CONSTIPATION:
- bulk-forming laxative
- not lactulose
IBS + DIARRHOEA
- anti-motility drug (e.g. loperamide)
ABDOMINAL PAIN
- antispasmodics (e.g. mebeverine, alverine citrate, peppermint oil, hydrochloride)
- low-dose tricyclic antidepressants e.g. amitriptyline (2nd line; review after 4 weeks)
Psychotherapy, CBT, mindfulness-based therapy.
Persistent symptoms should be referred to gastroenterologist and/or dietician.
What is diverticula?
Refers to small bulges (or mucosal protrusions) that present commonly in the sigmoid colon.
About 5-10mm in diameter.
Commonly causes pain in the left iliac fossa because that is where the sigmoid colon is located.
What is diverticular disease?
Refers to a condition characterised by the presence of diverticula in the lining of the digestive system, commonly in the sigmoid colon, and symptoms are present.
There is no infection or inflammation present.
What is diverticulosis?
Refers to the simple presence of diverticula but no other associated symptoms.
Asymptomatic
Typically discovered during tests for other conditions.
Recommend healthy diet containing wholegrains, fruits, and veg. Aim to eat 30g of fibre per day.
Regular fluid intake.
Difference between diverticulosis and diverticular disease?
Diverticulosis has diverticula but asymptomatic.
Diverticular disease has diverticula and is symptomatic.
