Week 6 - Progressively worsening diarrhoea Flashcards
Mrs. A.F. a 68-year-old female presents to the GP with a history of progressively worsening diarrhoea.
Take a history of this patient.
HPC:
• Since 8 weeks. Blood and mucous since 5 days.
• Sudden, small volume, 2-3 times/day, recently completed course of Augmentin (make you think of pseudomembranous colitis) for URTI.
• Blood mixed* with stool (different types of blood in stool), with colicky abdominal pain (some type of obstruction present/something blocking) 7/10, not related to food (would suggest upper GIT), not relieved by defecation (usually means persisting problem), now tenesmus (pathogenesis?), no bloating.
• 5kg weight loss since 8 weeks, fatigue, feels hot (may be infective).
- Chronic diarrhoea can have weight loss without malignancy but always need to rule it out.
• P/H IBD in her 20s for 5 years, since then in remission (make you think of recurrence of IBD).
• Colonscopy at 35y (polyps, ulcers, tumors, inflammation, infections), GORD for 2y (upper GIT conditions), appendectomy (past surgeries can give rise to intestinal obstructions secondary to scar formation).
• Hypertension on treatment. F/H hypertension, stroke, DM.
• Smoker, sister ovarian cancer* 2y ago (genetic basis of familial cancers).
HPC:
• Onset?
• How many stools per day?
• What do the stools look like?
• Alleviating/exacerbating factors, timing?
• Associated symptoms? i.e abdo pain, tenesmus, bloating.
• Bright red blood, mucus or pus in stool (colonic disease)?
• Pale, greasy, smelly stool, difficult to flush (steatorrhoea)?
• Oil droplets in stool (chronic pancreatitis)?
• Leakage of stool (faecal incontinence)?
• Weight loss (cancer, malabsorption)?
• Treatment with antibiotics recently (C. difficile infection)?
• Recent travel (infection e.g. Giardia)?
• History of IBD or prior GI surgery?
• Family history of coeliac disease, IBD?
• Problems with arthritis (IBD, Whipple’s disease)?
• Fever, rigors or chills (infection, lymphoma)?
PMHx:
• Past history of GI problems, IBD, cancer etc.
PSHx:
• Past surgeries?
Medications:
• Any regular medications?
Allergies:
• Agent, reaction, treatment?
Immunisations:
• E.g. Fluvax, pneumococcal?
FHx:
• Family history of GI problems, IBD, cancer etc.
SHx: • Background? • Occupation? • Education? • Religion? • Living arrangements? • Smoking? • Nutrition? • Alcohol/recreational drugs? • Physical activity?
Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?
Perform a physical examination on this patient.
- Introduction, explanation, consent, wash hands. Patient properly positioned lying flat, chest and abdomen exposed.
- General inspection: distressed/in pain, malaise. Colour (jaundice, pallor), habitus - cachectic.
3. Vital signs: • HR - may be tachycardic. • RR - may be tachypnoeic. • BP - may be hypotensive. • Temp - may be febrile. • O2 sats, BGL, BMI.
- Hands/arms:
• Warm/cool, dry/sweaty.
• Pallor (anaemia due to bleed, malabsorption, chronic disease or autoimmune haemolysis).
• Clubbing, CRT.
• Arthritis of wrists.
• Acanthosis nigricans in axilla (skin marker for GI malignancy). - Face:
• Eyes - conjunctival pallor, scleral jaundice, conjunctivitis, iritis, episcleritis.
• Mouth - hydration, peripheral/central cyanosis, ulcers/mucosal petechiae, angular stomatitis and glossitis (deficiency of iron). Brown black lesions around the mouth and in buccal mucosa in Peutz-Jeghers syndrome. - Neck & chest:
• Shrug shoulders - supraclavicular lymph nodes - enlarged left supraclavicular node (Virchow’s node) secondary to gastric malignancy. - Abdomen:
• Inspection - scars, skin lesions, abdominal distension, prominent veins, visible masses/pulsations, visible peristalsis.
• Palpation - light and deep (tenderness - ?rebound, guarding, rigidity). Hepatomegaly (liver mets), paraortic/inguinal lymph nodes.
• Percussion - ascites.
• Auscultation - bowel sounds.
• Rectal examination. - Legs:
• Erythema nodosum (tender red nodules usually on shins).
• Pyoderma gangrenosum (rare - starts as tender, red raised area that becomes bullous and ulcerates - it may occur anywhere but is often on the anterior aspect of the legs).
• Bruising, muscle wasting.
• Oedema.
• Clubbing, CRT.
• Peripheral pulses.
IBD - episodic or chronic diarrhoea, crampy abdo pain, urgency/tenesmus, weight loss, fever, aphthous ulcerations.
What is your provisional diagnosis and differential diagnoses?
• Provisional diagnosis: IBD (ulcerative colitis) - the patient had IBD in the past. She may have had a relapse as emotional stress, gastroenteritis, recent antibiotics and NSAIDs may cause a recurrence.
• DDx:
- IBS.
- Infective diarrhoea (diarrhoea, infections).
- Pseudomembranous colitis (history of taking antibiotics).
- Colon cancer (polyps and adenocarcinoma) - increased risk of cancer with previous history of ulcerative colitis. Risk is increased after 8 years of active colitis. This patient has a history of 5 years and has been in remission since. No specific mention of family history of bowel cancer in the history - needs to be asked.
What investigations would you carry out on this patient?
- FBC - Hb (anaemia), WCC (infection), platelets.
- U+Es - dehydration.
- ESR/CRP - inflammatory markers - useful to monitor disease severity/activity.
- LFTs.
- Stool microscopy - for ova and parasites.
- Stool culture.
- Flexible sigmoidoscopy.
- Blood culture.
- AXR.
- Erect CXR.
- Colonoscopy.
What treatment does this patient require?
• Steroids - type/route depends on severity.
What symptoms may suggest a diagnosis of bowel cancer in this patient?
- Change in bowel habit - may be a red flag in this patient or may suggest a recurrence of ulcerative colitis.
- Weight loss - may be a red flag in this patient. May be physiological due to dieting or due to other systemic illnesses so important to clarify.
- Blood and mucus in stool - increased risk of colonic cancer with previous history of ulcerative colitis. May also suggest a recurrence of her ulcerative colitis.
What other examinations are essential?
- CVS - pulse of 96 bpm and elevated BP is significant in this patient. Previous history of hypertension.
- Rectal examination - essential.
- Respiratory - should be considered, the patient has had a recent URTI.
- Joint/skin examination - may be relevant in case. However, patient has no joint pains. Erythema nodosum and pyoderma gangrenosum may occur during active disease.
The patient has bloody diarrhoea. What organisms would you consider as a possible cause?
- Clostridium difficle - patient is taking a PPI and has had recent antibiotics. Can occur up to 6 weeks after stopping antibiotics. Other risk factors include use of diclofenac acid, chemotherapy, multiple comorbidities and older age.
- Other infective causes of bloody diarrhoea include campylobacter, shigella, salmonella, amoebic.
This lady is at increased risk of developing bowel cancer because of her previous history of IBD. What specific secondary prevention would you advise this patient to reduce her risk of developing bowel cancer?
- Ensure ingestion of poorly soluble fibres e.g wheat bran.
- Aspirin - taken for several years at doses of at least 75mg daily reduces long-term incidence and mortality due to colorectal cancer. Benefit was greatest for cancers of the proximal colon, which are not otherwise prevented effectively by screening with sigmoidoscopy or colonoscopy.
- Increase calcium - binds bile acids. Cholecystectomy is also associated with a lightly increased risk of bowel cancer.
What bowel screening opportunities does the patient have access to in Australia?
• 2 yearly FOBT - Cancer Council Australia recommends that Australians aged 50 and over complete a faecal occult blood test (FOBT) every 2 years. FOBT is the most effective population screening tool for detecting early signs of bowel cancer.
The Australian Government’s National Bowel Screening Program currently provides a free FOBT kit and pathology to all Australians aged 50, 55, 60 and 65. Cancer Council urges all Australians to participate.
• 5 yearly colonscopy - possibly - because of her increased risk of bowel cancer - previous history of ulcerative colitis. If she had no history of UC and a first degree relative with bowel cancer under the age of 55, this would place her in the moderate risk category.
