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.
What is diverticulitis?
Refers to inflammation or infection of the diverticula.
Symptomatic
Requires tx
Causes for diverticular disease?
Cause unknown
Risk factors for diverticular disease?
Age (>50 years)
FHx
Low-fibre diet (lowers stool bulk, increases transit time, increased peristaltic activity, hence increased intraluminal pressure)
Diet rick in red meat
Obesity
Smoking
Immunosuppression
Lack of exercise
Medications (NSAIDs, opiates, corticosteroids)
Presentation of diverticular disease?
Left lower quadrant abdominal pain/tenderness
Intermittent abdominal pain
May be triggered by eating and relieved by passage of flatus or opening bowels.
Constipation, diarrhoea, mucus in stool
Possible rectal bleeding
Presentation of diverticulitis?
Presents acutely
Constant and severe left lower quadrant abdominal pain/tenderness/guarding
Fever
Change in bowel habit
Significant rectal bleeding
Dysuria (region where ureter crosses the bowel)
n+v
hx of diverticular disease or diverticulosis
Diffuse abdominal tenderness suggestive of perforation or generalised peritonitis.
Investigations for diverticular disease?
CT scan, USS, endoscopy, colonoscopy
FBC
Faecal occult blood test
U&Es
Renal function tests
Urinalysis
CRP
Management of diverticular disease?
Admit to hospital:
- confirmed diverticular disease and has significant rectal bleeding (urgent blood transfusion may be required)
Lifestyle:
- increase dietary fibre intake
- regular fluid intake
Medical:
- oral abx (e.g. co-amoxiclav)
- analgesia (paracetamol)
- bulk-forming laxative (reduce pressure in the bowel)
Management of diverticulitis?
Admit to hospital:
- age >65 years
- has significant comorbidity or immunosuppression, frailty
- dehydrated or risk of dehydration
- unable to tolerate oral abx
- uncontrollable abdominal pain and features of complicated acute diverticulitis
Medical:
MILD, UNCOMPLICATED DIVERTICULITIS:
- 5 days of co-amoxiclav OR combination of cefalexin and metronidazole OR trimethoprim and metronidazole
- analgesia (paracetamol)
- clear fluids only, introduce food again after 2-3 days if symptoms are improving
- blood test monitoring
- review after 48 hours and admit to hospital if persistent or deteriorating symptoms
May require surgery if presenting with:
- abscess
- perforation
- stricture
- obstruction
Complications of diverticular disease?
Short term:
- abscess formation
- perforation (surgical emergency)
Long term:
- fistula formation
- fibrosis (can result in strictures and large bowel obstruction)
Management of diverticulosis?
No tx required.
Recommend healthy diet containing wholegrains, fruits, and veg. Aim to eat 30g of fibre per day.
Regular fluid intake.
Wt loss if obese.
Exercise
Smoking cessation.
What is inflammatory bowel disease (IBD)?
Refers to chronic, relapsing, non-infectious inflammatory conditions.
These are long term conditions.
It is a broad term for Crohn’s disease and Ulcerative colitis.
Common in developed countries.
What is Crohn’s disease?
Refers to a condition characterised by transmural granulomatous inflammation (full-thickness intestinal wall inflammation) which can affect any part of the gastrointestinal tract (‘from mouth to anus’, commonly the terminal ileum).
Causes of Crohn’s disease?
Thought to be immune-mediated condition caused by environmental triggers in genetically susceptible people.
Risk factors of Crohn’s disease?
Family history
Smoking (x3 increased risk)
Infectious gastroenteritis
Appendicectomy
Drugs (NSAIDs, oral contraceptives)
Presentation of Crohn’s disease?
Unexplained chronic persistent diarrhoea (4-6weeks)
Blood or mucus in stool
Nocturnal diarrhoea (suggests immune related)
Faecal urgency
Tenesmus (incomplete emptying)
Abdominal pain (may be due to adhesions, fistulas, intestinal obstruction, mucosal inflammation)
- fatigue, malaise, anorexia, fever
- right side abdominal tenderness/mass
- wt loss
- clubbing
- aphthous ulcers
- cachectic and pale (anaemia)
- perianal abnormality or tenderness
Skin:
- Erythema nodosum (painful erythematous nodules/plaques on the shins)
- Pyoderma gangrenosum (a well-defined ulcer with a purple overhanging edge)
MSK:
- Enteropathic arthropathy (symmetrical, non-deforming)
- Axial spondyloarthropathy (sacro-iliitis)
- arthritis
Eyes:
- Anterior uveitis (painful red eye with blurred vision and photophobia)
- Episcleritis (painless red eye)
- gallstones
- AA amyloidosis
- renal stones (common in Crohn’s than in ulcerative colitis)
Investigations for Crohn’s disease?
FBC (raised WCC; thrombocytosis; anaemia)
CRP (raised)
ESR (raised)
U&Es
Low albumin
LFT
ferritin
folate, B12, vitamin D
Coeliac serology
Stool MC&S
Faecal calprotectin (antigen produced by neutrophils
Endoscopy
MRI (small bowel disease)
Upper GI (string sign of Kantour -Crohn’s disease)
Colonoscopy with biopsy:
- skip lesions
- rose-thorn ulcers (due to transmural inflammation)
- non-caseating granulomas
- Cobblestone mucosa (due to ulceration and mural oedema)
Management of Crohn’s disease?
Admit to hospital:
- systemically unwell (bloody diarrhoea, fever, tachycardia, or hypotension)
Urgent referral to gastroenterologist:
- if systemically well
Smoking cessation
Assess osteoporosis risk.
Assess for anxiety/depression.
Influenza and pneumococcal vaccine (if taking an immunosuppressive or biologic agent, should not receive live vaccines)
Colorectal cancer monitoring.
Inducing remission:
- offer corticosteroids (oral prednisolone, or IV hydrocortisone if first presentation is severe flare)
- biologic therapy
Maintaining remission:
- add azathioprine or mercaptopurine (if 2 or more exacerbations in a 12 month period; before prescribing, monitor thiopurine methyltransferase (TPMT) activity -underactivity increases risk of bone marrow suppression)
- if above contraindicated/not responsive, offer methotrexate
- biological agents (e.g. infliximab or adalimumab; given if above meds fail; must do CXR due to risk of reactivation of latent TB)
Surgery may be necessary.
Management of Crohn’s disease flare up?
Admit to hospital:
- systemically unwell (bloody diarrhoea 6-8 stools, fever, tachycardia, or hypotension)
- suspect intestinal obstruction or intra-abdominal or perianal abscess
- cachexia (BMI < 18.5 kg/m2) or unintended wt loss
If systemically well:
- urgent referral to gastroenterologist
- consider alternative diagnosis
- consider prescribing drug tx whilst waiting specialist tx
- refer to dietician (malnutrition or wt loss)
Complications of Crohn’s disease?
Fistulas
Strictures
Abscesses
Malabsorption
Perforation
Nutritional deficiencies
Increased risk of colon cancer
Osteoporosis (due to chronic inflammation and corticosteroid use)
Intestinal obstruction and toxic megacolon
What is fistula? What does it commonly involve?
Refers to formation of abnormal connections between different parts of the digestive tract or between the digestive tract and other organs.
Commonly involves the small intestine and other structures like the bladder or skin.
What is stricture? What can it lead to?
Refers to narrowing or tightening of the intestinal walls.
Can lead to bowel obstruction and difficulties with the passage of stool.
What is abscesses? What does it present with?
Refers to collection of pus within the abdomen, often near areas of inflammation.
Presents with localized pain, swelling, and may require drainage.
What is malabsorption? What can it lead to?
Refers to impaired absorption of nutrients due to inflammation and damage to the intestinal lining.
Can lead to nutritional deficiencies and weight loss.
What is perforation? What it can lead to?
Refers to formation of a hole or tear in the intestinal wall.
Can result in peritonitis, a serious and potentially life-threatening condition.
Differences between Crohn’s disease and ulcerative colitis?
Crohn’s disease:
- affects any part of the GI tract from mouth to anus
- patchy skip lesions
- depth: full thickness (transmural)
- Abdominal pain, non-bloody diarrhoea, weight loss
- endoscopy: Cobblestone appearance, deep ulcers
- DIAGNOSIS: MRI (transmural inflammation)
- smoking is a RF
Ulcerative colitis:
- affects the colon and rectum
- inflammation is continuous and involves the entire colon
- depth: limited to the inner lining (mucosa)
- Bloody diarrhoea, abdominal cramps
- endoscopy: Continuous colonic inflammation, ulcers
- DIAGNOSIS: colonoscopy
- smoking is not a RF
What is ulcerative colitis?
Refers to a chronic relapsing-remitting inflammatory disease that primarily affects the large bowel.
Causes of ulcerative colitis?
Unknown
Combination of genetics, environmental factors, dysregulation of immune system.
Risk factors of ulcerative colitis?
FHx
No appendicetomy
Drugs (NSAIDs)
Not smoking
Presentation of ulcerative colitis?
Diarrhea +/- blood and/or mucus
Tenesmus
Pain in the left iliac fossa
Weight loss
Fever
Nocturnal defecation (suggests IBD)
Malaise
Anorexia
Growth concern in children
Pallor (anaemia)
Clubbing
Abdominal distension/tenderness/mass
Arthritis
Erythema nodosum, pyoderma gangrenosum
Mouth ulceration
Eye pathology -anterior uveitis, episcleritis, conjunctivitis
Investigations for ulcerative colitis?
FBC
ESR
CRP
LFTs (low albumin)
U&Es
Ferritin
Folate, B12, vitamin D
Coeliac serology
Stool microscopy culture and sensitivity (exclude C.difficle)
Faecal calprotectin (RAISED IN IBD)
- distinguishes between IBS and IBD
Colonoscopy and biopsy are used to confirm the diagnosis.
- continuous inflammation with an erythematous mucosa, loss of haustral markings, and pseudopolyps
Biopsy:
- loss of goblet cells, crypt abscess, and inflammatory cells
Barium enema:
- lead-piping inflammation
- thumb-printing (bowel inflammation)
- pseudopolyps
Management of ulcerative colitis?
Admit to hospital:
- systemically unwell (bloody diarrhoea, fever, tachycardia, or hypotension)
Urgent referral to gastroenterologist:
- if systemically well
Assess osteoporosis risk.
Assess for anxiety/depression.
Ensure children and young people have growth and pubertal development.
Influenza and pneumococcal vaccine (if taking an immunosuppressive or biologic agent, should not receive live vaccines)
Colorectal cancer monitoring.
Mild-moderate disease
PROCTITIS & PROCTOSIGMOIDITIS:
- 1st line: topical/oral aminosalicylate (ASA)
- 2nd line: Add prednisolone to ASA
- 3rd line: oral tacrolimus
LEFT SIDED or EXTENSIVE DISEASE:
- 1st line: high oral aminosalicylate (ASA)
- 2nd line: Add prednisolone to ASA
- 3rd line: oral tacrolimus
Severe disease
- 1st line: IV corticosteroids (if contraindicated, IV ciclosporin)
- 2nd line: add IV ciclosporin or consider surgery
- 3rd line: Etrasimod
Surgery may be necessary of:
- no/little improvement after 48-72hrs
- Acute fulminant ulcerative colitis
- symptoms worsening despite IV steroids
Complications for ulcerative colitis?
Short term:
- toxic megacolon
- massive lower GI haemorrhage
Long term:
- colorectal cancer
- Cholangiocarcinoma
- Colonic strictures
What is Truelove and Witt’s severity index?
Assesses severity of acute exacerbation of ulcerative colitis.
Bowel movements
Blood in stool
Pyrexia
Pulse >90bpm
Anaemia
ESR
