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Flashcards in A Gut feeling Deck (65)
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1
Q

What is health-related quality of life?

A

Broad concept that incorporates the patient’s perceptions, illness experience and functional status as related to a medical condition. It is influenced by social, cultural, psychological and disease-related factors.

2
Q

Why is it useful to assess health-related quality of life?

A

The patient can communicate how the illness has made an impact in his or her life.
The physician can assess the patient’s HRQoL as a tool in describing their level of functioning, and objectively track this function to gauge response to treatment.

3
Q

How is quality of life assessed in IBS?

A

There are a number of different questionnaires that can be used to assess the patient’s quality of life e.g. IBS-QOL
Commonly assessed areas include impact on daily activities, social relationships, sleep and emotional and mental ability to cope.

4
Q

What aspects of IBS have a negative impact on a patient’s quality of life?

A

Their bloating and diarrhoea symptoms were reported to have the greatest impact on quality of life

  • Concerns about having an accident
  • Limits engagement in daily activities like work, travel, and other social/leisure activities
  • Social isolation and mental health problems
  • Body image due to bloating
5
Q

What aspects of IBD have a negative impact on a patient’s quality of life?

A

Frequent recurrence of symptoms, extraintestinal manifestations, the effect of medical and surgical treatments and their side effects, stress of developing cancer, and needing surgery.
Sleep disturbance - fatigue and low mood
Taking time off work
Concerns with being near a toilet

6
Q

What aspects of coeliac disease have a negative impact on a patient’s quality of life?

A

Impact on social life 🡪 Unable to take part in social activities as easily, Difficult to access gluten-free alternatives
Mental health problems 🡪 Lack of public understanding, Constant worry

7
Q

What is diarrhoea?

A

The passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual).

8
Q

How would you categorize diarrhoea by time frame?

A

Acute diarrhoea is defined as lasting for less than 14 days
Persistent diarrhoea is defined as lasting more than 14 days
Chronic diarrhoea is defined as lasting for more than 4 weeks

9
Q

How would you take a history for diarrhoea?

A

Onset – when did it start?/was the onset acute or gradual?
Duration – hours/days/weeks
Severity – e.g. Bristol stool chart
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – is the symptom always present or does it come and go?
Fresh red blood (anal fissure/haemorrhoids/IBD)
Melaena (upper gastrointestinal bleed)
Precipitating factors – are there any obvious triggers for the symptom? E.g. any previous infections, IBS/IBD
Relieving factors – does anything appear to improve the symptoms e.g. increasing dietary intake
Associated features – are there other symptoms that appear associated (e.g. fever/malaise), any recent antibiotics, food poisoning
Previous episodes – has the patient experienced this symptom previously?

10
Q

What are the red flags of diarrhoea?

A

Blood in the stool
Recent hospital treatment or antibiotic treatment
Weight loss
Evidence of dehydration

11
Q

What might be some of the underlying causes of acute diarrhoea?

A
Infection - recent exposure, meals out, travel abroad, high risk group
New drugs - antibiotics/laxatives
Stress or anxiety
IBD, IBS, UC
Radiation to the pelvis
Immunosuppressive treatments
Background medical conditions
Diet and alcohol use
12
Q

What are the signs of dehydration?

A

Increased pulse rate, reduced skin turgor, dryness of mucous membranes, delayed capillary refill time, decreased urine output, hypotension (check for postural changes), and altered mental status.

13
Q

What examinations would you perform in the presentation of diarrhoea?

A

Perform an abdominal examination to assess for pain or tenderness, distension, mass, increased or decreased bowel sounds, or liver enlargement.

Consider a rectal examination to assess for rectal tenderness, stool consistency, and for blood, mucus, and possible malignancy.

14
Q

When would you send a faecal specimen for investigation in someone with acute diarrhoea?

A

Systemically unwell
Blood or pus in the stool
Immunocompromised
Recently received antibiotics or been in hospital
Recently travelled abroad
Amoebae, Giardia, or cryptosporidium are suspected
If infectious or chronic diarrhoea are suspected

15
Q

When would you refer someone for colorectal cancer referral?

A

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, or tests show occult blood in their faeces.
Adults with a rectal or abdominal mass.
Adults aged under 50 with rectal bleeding and any of the following unexplained symptoms
or findings: abdominal pain, change in bowel habit, weight loss, iron-deficiency anaemia.

16
Q

What blood tests would you request for someone with chronic diarrhoea?

A

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
Testing for coeliac disease — immunoglobulin A (IgA), and IgA tissue transglutaminase (tTG), or IgA endomysial antibody (EMA).
Note that antibodies usually will become negative when a person is on a gluten-free diet, so the test should be carried out when they are eating a diet containing gluten.

17
Q

What are the differential diagnoses for diarrhoea?

A
Irritable bowel syndrome
Inflammatory bowel disease
Coeliac disease
Microscopic colitis
Colorectal cancer
Drugs - antibiotics, antihypertensives, NSAIDs, hypoglycemic drugs, PPIs, SSRIs, furosemide
18
Q

What is Crohn’s disease?

A

An idiopathic chronic inflammatory bowel disease characterised by transmural (deep) granulomatous inflammation affecting any part of the GI tract/gut from mouth to anus – especially terminal ileum in 70% and colon.

19
Q

How is Crohn’s disease different to ulcerative colitis?

A

Unlike UC there is areas of unaffected bowel between areas of active disease and inflammation –> skip lesions (patchy).

20
Q

Who gets Crohn’s disease?

A

Typically presents between 20-40 years old. Smoking increases risk x3.

21
Q

What is thought to cause Crohn’s disease?

A

Thought to be caused by an abnormal mucosal immune response to luminal bacteria in genetically susceptible individuals.

22
Q

What are the symptoms of Crohn’s disease?

A

Diarrhoea (80% cases, usually not bloody)
Abdominal pain (crampy right iliac fossa)
Weight loss/failure to thrive
Systemic symptoms may include, fatigue, fever, malaise anorexia

23
Q

What are the signs of Crohn’s disease?

A

Bowel ulceration
Abdominal tenderness
Right iliac fossa mass
Anal and perianal present in 25% of cases often before GI symptoms therefore should always examine anus –> perianal abscess/fistulae, skin tags

24
Q

What investigations would you do with a patient with suspected Crohn’s disease?

A

Bloods - raised ESR, CRP, WBC, platelets are common, anemia is common
Stools test
Small bowel imaging
Capsule endoscopy

25
Q

How would you manage Crohn’s disease?

A

Mild to moderate: Glucocorticosteroids work as immunosuppressants (oral prednisolone)
Dietary approach: based on ‘elemental’ and ‘polymeric’ diets’ effective in children
Severe: IV hydration/electrolyte presentation, IV steroids, consider blood transfusion and nutritional support

26
Q

What’s the prognosis of Crohn’s disease?

A

Good prognosis - older age at diagnosis, limited ulceration at index investigations–> may not require maintenance treatment.
Poor prognosis - young age at diagnosis, deep colonic ulceration, may require long term maintenance immunosuppression.

27
Q

What treatment is on offer for those with Crohn’s disease?

A

Conventional - azathioprine, mercaptopurine, methotrexate
Anti TNF agents - infliximab, adalimumab
Surgery - only performed when there is failure of medical therapy, complications, failure to grow in children when medical treatment, perianal sepsis.

28
Q

What is ulcerative colitis?

A

An idiopathic relapse remitting inflammatory disorder of the colonic mucosa, characterised by inflammation restricted to large bowel mucosa which always involves the rectum and extends proximally in a continuous fashion for variable distance but never spreads proximal to ileocaecal valve.

29
Q

What causes ulcerative colitis?

A

Caused by an inappropriate immune response against (possibly abnormal) colonic flora in genetical susceptible individuals

30
Q

Who gets ulcerative colitis?

A

Typically presents between 20-40 years old, smoking appears to reduce risk, non-smokers x3 likely to have. Been observed that appendectomy has a protective effect on subsequent UC development.

31
Q

What are the symptoms of ulcerative colitis?

A

Episodic or chronic diarrhoea w or w/o blood and mucous, crampy abdominal discomfort.
Bowel frequency relates to severity.
Systemic symptoms in attacks –> fever, malaise, weight loss, anorexia (these features not as severe as in crohns).

32
Q

What are the signs of ulcerative colitis?

A

May be none. In acute severe ulcerative colitis –> fever, tachycardia, tender and distended abdomen. Extraintestinal signs –> clubbing, aphthous ulceration in mouth, conjunctivitis, erytherma nodosum, larger joint arthritis.
Abdomen may be distended and tender. Tachycardia and pyrexia are signs of severe that needs admission. Anus usually normal.

33
Q

What investigations would you perform for ulcerative colitis?

A

Bloods - FBC, ESR, CRP, U&E, LFT, blood culture
Stools to exclude infective causes - campylobacter, C. difficile, Salmonella, Shigella, E. coli, amoebae (recent travel history).
Faecal calprotectin: A simple, non-invasive test for GI inflammation with high sensitivity.
Colonoscopy –> endoscopy w mucosal biopsy is the gold standard investigation for diagnosis. Allows assessment of disease activity and extent.

34
Q

How would you manage ulcerative colitis?

A

Mild to moderate: Aminosalicylate which acts topically in the colonic lumen. Effective in inducing remission in mild active disease and maintaining remission in all forms. 5ASA e.g mesalamine.
Moderate: Induce remission w oral prednisolone then taper and maintain with 5ASA.
Severe: IV hydration/electrolyte replacement, IV steroids, consider blood transfusion/nutritional replacement
Surgery may be needed

35
Q

What is irritable bowel syndrome?

A

A chronic condition, abdominal pain associated with bowel dysfunction, pain relieved by defecation. Sometimes accompanied by abdominal bloating
Different types: IBS with constipation, IBS with diarrhea, IBS with mixed bowel habits, unspecified IBS

36
Q

What might cause irritable bowel syndrome?

A

May be inflammatory or immune basis with IBD but alone has normal mucosal biopsies
Intestinal microbiota may play role in bowel disease
Effects on epithelial barrier integrity and enteroendocrine signalling
Assoc with dysbiosis, less diversity of microbiota
Bacterial overgrowth
Stress and emotional tension

37
Q

What are the risk factors for IBS?

A

Physical and sexual abuse
<50 years age
Female sex
Previous enteric infection

38
Q

What are the differential diagnoses for IBS?

A
Crohn's disease
Ulcerative colitis
Lymphocytic and collagenous colitis
Coeliac disease
Endometriosis
39
Q

How does IBS present?

A

Abdominal discomfort
Alteration of bowel habits assoc with pain
Abdominal bloating or distention

40
Q

What investigations would you perform for IBS?

A
FBCs
Stool studies
Anti-endomysial Antibodies
Anti-tTG Antibodies
Plain abdominal X-ray
Flexible sigmoidoscopy
Colonoscopy
41
Q

How would you manage IBS?

A

Constipation 🡪 adequate water and fibre intake, physical activity, simple laxatives. If 2 of these fail: Prucalopride, Linaclotide or lubiprostone
Diarrhoea 🡪 Avoid sorbitol sweeteners, alcohol, caffeine, reduce dietary fibre, encourage pts to identify own trigger foods, bulking agents +/- loperamide after each loose stool
Colic/bloating 🡪 oral spasmodics, Mebeverine, Hyoscine butylbromide, Combination probiotics in sufficient doses. Help flatulence and bloating, low FODMAP diet
Psychological symptoms 🡪 Emphasise the positive. Consider, CBT, Hypnosis, Tricyclics, Amitriptyline

42
Q

What is Coeliac disease?

A

An autoimmune condition characterised by an abnormal jejunal mucosa that improves when gluten is withdraw from the diet and relapses when gluten is reintroduced.
T-cell responses to gluten (alcohol-soluble proteins in wheat, barley, rye ± oats) in the small bowel causes villous atrophy and malabsorption.

43
Q

Where is gluten found?

A

Gluten is a dietary protein found in 3 types of cereal – Wheat, barley and rye.

44
Q

Who gets coeliac disease?

A

Can develop at any age but two main peaks are during early childhood (Between 8 and 12
months) or later in adulthood (Between 40 and 60 years).
Patient’s more at risk include Type 1 diabetics, patients with autoimmune thyroid disease, Down’s syndrome and Turner syndrome

45
Q

What’s the pathophysiology behind coeliac disease?

A

In gluten, there is a toxic portion known as peptide alpha gliadin. The gliadin is resistant to proteases in the small intestinal lumen so isn’t broken down. This means it passes through the damaged epithelial barrier of the small intestine where it is deaminated by an enzyme in the
tissue known as transglutaminase and this increases its immunogenicity.
The gliadin then interacts with the antigen presenting cells in the lamina propria via HLA DQ2 and DQ8 and this activates gluten sensitive T cells.
This causes an inflammatory cascade and the release of mediators that contribute to villous atrophy and crypt hyperplasia, which are characteristic features of coeliac disease.

46
Q

What are the symptoms of coeliac disease?

A

Caused by eating gluten
Diarrhoea, steatorrhoea, stomach ache, bloating and flatulence, indigestion, constipation, nausea, vomiting.
More generalised: fatigue due to malnutrition, unintentional weight loss, dermatitis herpetiformis, infertility, peripheral neuropathy, ataxia

47
Q

What would you find when investigating coeliac disease?

A

IgA tissue transglutaminase antibodies have a very high sensitivity and specificity for coeliac disease.
Distal duodenal biopsies - increased intraepithelial lymphocytes, crypt hyperplasia with chronic inflammatory cells in the lamina propria and villous atrophy.
Mild anaemia
Small bowel radiology
Bone densitometry - increased risk of osteoporosis

48
Q

How do you manage coeliac disease?

A

Lifelong gluten free diet
Correction of any vitamin deficiencies
Pneumoccoal vaccine

49
Q

What are the complications of coeliac disease?

A

Increased incidence of malignancy, particularly intestinal T cell lymphoma, small bowel and oesophageal cancer.
Other complications include osteoporosis, iron deficiency anaemia and vitamin B12/ folate deficiency anaemia.
Also problems in pregnancy including the baby having a low birth weight.

50
Q

What is diverticulosis?

A

Presence of diverticula
Diverticula: pouches of mucosa extrude through the colonic muscular wall via weakened areas near blood vessels, forming diverticula.

51
Q

What causes diverticular disease?

A

Causes are generally unknown- related to the low-fibre diet eaten in Western populations.
Insufficient dietary fibre leads to increased intracolonic pressure, which causes herniation of the mucosa at sites of weakness

52
Q

What is diverticulitis?

A

Diverticulitis implies inflammation, which occurs when faeces obstruct the neck of the diverticulum.

53
Q

What are the risk factors for diverticular disease?

A

Risk factors include: smoking, obesity, history of constipation, use of NSAIDs, having a close relative with diverticular disease

54
Q

What are the symptoms of diverticular disease?

A

Asymptomatic in 95% of cases
Symptoms are the result of luminal narrowing, bleeding or diverticulitis.
May include diarrhoea/constipation, left iliac fossa pain, fever, nausea, bloating
May lead to perforation which can cause the formation of abscesses or peritonitis, fistula formation into the bladder or vagina, bleeding dark purple blood from the rectum or intestinal obstruction.

55
Q

What investigations would you perform for suspected diverticular disease?

A

Blood tests to rule of coeliac disease and bowel cancer. A high number of white blood cells may suggest diverticulitis infection.
Colonoscopy, where a thin tube with a camera on the end is passed through your rectum into your colon may be used to visualise the diverticula.
May use a CT scan to confirm the diagnosis.

56
Q

What is the treatment for diverticular disease?

A

Analgesia - over-the-counter paracetamol (avoid NSAIDs)
High fibre diet
Bulk-forming laxative to reduce constipation
Blood transfusion in the case of heavy bleeding

Diverticulitis
Antibiotics
Colectomy or stoma surgery in severe cases

57
Q

In men, what could abdominal pain be a sign of?

A
Testicular torsion
Prostatitis
Benign prostatic hyperplasia
Increased risk of hernia
Increased risk of appendicitis
58
Q

In women, what could abdominal pain be a sign of?

A
Menstrual pain
Inter-menstrual pain
Endometriosis
Polycystic ovarian syndrome
Miscarriage
Ectopic pregnancy
Pelvic inflammatory disease
Fibroid
Ovarian cyst
59
Q

What is Dermatitis herpetiformis?

A

Described as itchy, symmetrical eruption of vesicles and crusts over the extensor surfaces of the body, with deposition of granular immunoglobulin (Ig) A at the dermoepidermal junction of the skin including areas not involved with the rash. Patients also have a gluten sensitive enteropathy, which is usually asymptomatic. The skin condition response dapsone but both the gut and the skin will improve on a gluten free diet.

60
Q

What is Tropical sprue?

A

A progressive small intestinal disorder presenting with diarrhoea, steatorrhoea and megaloblastic anaemia. It occurs in residents or visitors of endemic areas in the tropics. Likely to be infective. Diagnosis is based on demonstrating evidence of malabsorption and a small bowel mucosal biopsy showing similar features, but not identical, to that of untreated coeliac disease. Treatment with folic acid and tetracycline for 3 – 6 months and correction of nutritional deficiencies.

61
Q

What is Bacterial overgrowth?

A

The upper small intestine is almost sterile. Bacterial growth occurs when there is stasis of intestinal contents because of abnormal motility (Systemic sclerosis or a structural abnormality ie from previous small bowel surgery or diverticulum). Diagnosis is with therapeutic trial antibiotics.

62
Q

What is intestinal resection?

A

The effects of small intestinal resection depend on the extent and the area involved. Resection of the terminal ileum leads to malabsorption of vitamin B12 and bile salts. Most cases are caused through Crohn’s, mesenteric ischaemia, trauma, volvulus or surgical complications.

63
Q

What is Whipple’s disease?

A

A rare disease caused by the bacterium Tropheryma whipplei. Symptoms include steatorrhoea, abdo pain, fever, lymphadenopathy, arthritis and neurological involvement. Small bowel biopsy shows periodic acid – Schiff (PAS) – positive macrophages which on electron microscopy are seen to contain the causative bacteria. Treatment is with co – trimoxazole for 1 year.

64
Q

What is radiation enteritis?

A

Inflammation of the intestines that occurs after radiation. Causes symptoms include diarrhoea, nausea and vomiting and abdo pain. Mostly occurs in patients that receive radiation that targets the abdomen, pelvis or rectum. Important to consider in patients presenting with symptoms who are undergoing cancer treatments.

65
Q

What is Giardiasis?

A

An infection of the small intestine and is the most common cause of parasitic infections in the GI tract. It has two forms, one active and one inactive. The active form attaches to the lining of the small intestine with a sucker and is responsible for causing the signs and symptoms of the conditions. Symptoms include bloating, nausea, malaise and fatigue.