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Year 2 CSI > Diahorrea > Flashcards

Diahorrea Flashcards

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1
Q

How does the patient present?

A 
Terrible diarrhoea
6 weeks but it has gotten much worse
Tummy pain
Could not wait to see GP
3-4 a day for a month
8x recently
Bad overnight
Liquid, brown, sometimes blood from wiping
Sample all clear from GP
Weight loss - 7kg
Tired - no energy
Adopted 
Smokes 5 a day
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2
Q

How does she describe the pain?

A

Comes and goes
Left side
No change after opening bowels

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3
Q

How can diarrhoea be defined?

A

Three or more loose or liquid stools per 24 hours, and/or

Stools that are more frequent than what is normal for the individual lasting <14 days, and/or

Stool weight greater than 200 g/day.

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4
Q

How can diarrhoea be classified?

A

Acute (≤14 days)
Persistent (>14 days), or
Chronic (>4 weeks)

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5
Q

Describe the basic pathophysiology of diarrhoea?

A

10L of fluid enters GI tract daily

Small intestine responsible for reabsorbing (99%)

0.1L excreted in faeces

In diarrhoea there is decreased reabsorption or increased secretion

Or increase in bowel motility

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6
Q

From where is fluid secreted into the GI tract?

A 
Food 
Drink
Salivary glands
Stomach
Pancreas
Bile ducts
Duodenum
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7
Q

What are the two types of diarrhoea?

A

Inflammatory

Non-inflammatory

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8
Q

What can cause inflammatory diarrhoea?

A

Material
Viral
Parasitic

Or early bowel ischaemia, radiation injury or IBD

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9
Q

What are the associated symptoms of inflammatory diarrhoea?

A

Mucoid and bloody stool
Tenesmus
Fever
Severe crampy abdominal pain

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10
Q

What are the main features of the diarrhoea in inflammatory diarrhoea?

A

Small in volume

Frequent bowel movements

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11
Q

What are the most common causes of inflammatory diarrhoea?

A

Campylobacter, Salmonella, Shigella, Escherichia coli, or Clostridium difficile

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12
Q

In who is virus related diarrhoea common in?

A

Children who attend day care centres

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13
Q

What are the most common causes of acute diarrhoea in developing countries?

A

Protozoa and Parasites

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14
Q

What findings might be found in inflammatory diarrhoea?

A

Examination of the stool may show leukocytes, and tests for faecal occult blood may be positive.

The test for faecal leukocytes is plagued by a high rate of false-negative results leading to low sensitivity, but a positive test is very informative.

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15
Q

What are the main features of non-inflammatory diarrhoea?

A

watery, large-volume, frequent stool (>10 to 20 per day).

Volume depletion is possible due to high volume and frequency of bowel movements.

There is no tenesmus, blood in the stool, fever, or faecal leukocytes.

Histologically the GI architecture is preserved.

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16
Q

What can non-inflammatory diarrhoea be further divided into?

A

Secretory

Osmotic

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17
Q

What happens in secretory diarrhoea?

A

Altered transport of ions across the mucosa

which results in increased secretion and decreased absorption of fluids and electrolytes from the GI tract

especially in the small intestine

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18
Q

What causes secretory diarrhoea?

A 
Enterotoxins
Hormonal agents 
Laxative use
Intestinal resection
Bile salts and fatty acids
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19
Q

Where can enterotoxins be from?

A

Vibrio cholerae,

Staphylococcus aureus

enterotoxigenic E coli

and possibly HIV and rotavirus.

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20
Q

What hormonal agents can cause secretory diarrhoea?

A

Vaso-active intestinal peptide
Small-cell cancer of the lung
Neuroblastoma

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21
Q

What conditions can secretory diarrhoea be seen in?

A

Coeliac sprue
Collagenous colitis Hyperthyroidism
Carcinoid tumours

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22
Q

What are the features of osmotic diarrhoea?

A

Smaller stool volume

Improves or stops with fasting

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23
Q

What does osmotic diarrhoea result from?

A

presence of unabsorbed or poorly absorbed solute (magnesium, sorbitol, and mannitol)

in the intestinal tract

that causes an increased secretion of liquids into the gut lumen

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24
Q

What tests are done with osmotic diarrhoea?

A

Measuring stool electrolytes shows an increased osmotic gap (>50), but the test has very limited practical value. Stool (normal or diarrhoea) is always isosmotic (260 to 290 mOsml/L).

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25
What can osmotic diarrhoea be subdivided to?
Maldigestion | Malabsorption
26
What does maldigestion refer to?
Impaired digestion of nutrients within the intestinal lumen or at the brush border membrane of mucosal epithelial cells. It can be seen in pancreatic exocrine insufficiency and lactase deficiency
27
What does malabsorption refer to?
Impaired absorption of nutrients. It can be seen in small bowel bacterial overgrowth, in mesenteric ischaemia, post bowel resection (short bowel syndrome), and in mucosal disease (coeliac disease)
28
How much fluid is secreted into GI tract?
6-7 litres
29
How much fluid is lost in faeces?
0.1L
30
What happens to the fluid that is not excreted?
Gets absorbed via the walls of the small and large intestine
31
Why does fluid enter enterocytes?
There are lots of solutes in enterocytes
32
What happens in inflammatory diarrhoea (enterocytes)?
Destruction of the epithelium due to inflammation Enterocytes cannot absorb fluids Excess fluid in lumen
33
What happens in secretory diarrhoea (enterocytes)?
Ion channels become wrongly activated so solutes moves into the lumen E.g. Cholera - chloride channel on enterocyte membrane becomes activates Fluid follows the chloride
34
What happens in maldigestion diarrhoea (enterocytes)?
Solutes are not able to digest Products remain in lumen - high solute concentration Fluid moves to lumen E.g. lactose intolerance
35
What happens in malabsorption diarrhoea (enterocytes)?
Solutes not absorbed by enterocytes E.g. prunes Sorbitol is not absorbed by enterocytes Water is retained
36
What drug could help inflammatory?
Anti-cytokines e.g. Anti-TNF
37
What drug could help secretory?
Block dysregulated channel
38
What drug could help maldigestion?
Enzyme replacement to facilitate reabsorption
39
What do you acutely want to do for all types of diarrhoea?
Rehydration | e.g. Oral rehydration solution
40
How does ORS work?
SGLT-1 = sodium glucose linked transporter Give 1 glucose and 2 sodium takes both in Pump into enterocytes
41
Why does diarrhoea kill?
Dehydration ORS essential especially in children
42
What is chronic diarrhoea?
Symptoms for more than 6 weeks
43
What is IBS?
Functional cause of diarrhoea No known structural changes Symptoms are unexplained Non-progressive and will not kill patient
44
What are the symptoms of IBS?
``` Tiredness Stomach pain Bloating Diarrhoea Constipation Mucus in stool ```
45
What are the symptoms of IBD?
Abdominal pain Diarrhoea Fatigue Weight loss Fever Blood in stool
46
What are some organic causes of diarrhoea?
IBD Coeliac Bowel Cancer Organic = we can find a cause
47
What are the two types of blood in stool?
Blood on toilet paper Blood mixed in stool
48
What was found on the patients abdo exam?
Soft abdomen Tenderness particulary in LLQ No masses
49
What investigations does the A&E doctor want to conduct?
FBC - anaemia and signs of inflammation U+E's - check renal function and electrolyte status CRP- look for infection/inflammation
50
What further investigation should be conducted?
``` Faecal Occult Blood Stool antigen Faecal calprotectin Colonoscopy LFTs ```
51
What further bloods should be conducted?
LFTs - includes albumin level which if low can indicate acute inflammation or malnutrition Thyroid function tests Ferritin, B12 and Folate Antibody assay for coeliac disease
52
What stool tests should be conducted?
Eggs + Cysts (associated with parasites) shed intermittently in the stool 3 separate stool samples, 2 days apart Faecal calprotectin
53
What stool tests should be conducted?
Eggs + Cysts (associated with parasites) shed intermittently in the stool 3 separate stool samples, 2 days apart Faecal calprotectin - indicated migration of neutrophils into intestinal mucosa Non-specific but looks for evidence of inflammation
54
What are the patients results?
Raised CRP Raised WBC Elevated faecal calprotectin
55
Now, what are the top differentials?
IBD | Colon Cancer
56
What does the A&E doctor do?
Refer to Gastroenterologist
57
What does the specialist do?
Conduct colonoscopy
58
What were the colonoscopic findings?
Non continuous areas of linear ulcers with cobblestone appearance are seen extending from the caecum through to the splenic flexure. When examined under a microscope, changes are seen in the mucosa, submucosa and muscularis propria. Numerous non caseating granulomas and increased goblet cells noted.
59
What is Ms Allen's diagnosis?
Crohn's disease
60
What tells us it is Crohn's disease?
``` Non- continuous Cobbelstone appearance Caecum to splenic flexure Granulomas - collection of neutrophils Changes to mucosa, submucosa, muscularis and serosa (transmural changes) ```
61
What would ulcerative collitis look like on a colonscopy?
``` Continuous areas of inflammation Starts at rectum and continues Does not extend beyond large bowel (illeum potentially in severe disease) Crypt processes Affects only mucosa and submucosa ```
62
What are some complications of Crohn's?
Can get a whole (fistula) forming due to transmural involvement
63
What are some complications of UC?
High predisposition to Colon Cancer
64
What treatments can be used for Crohn's? (conservative)
Stopping smoking - referral to cessation clinic Exercise Dietary advice to prevent malnourishment Psychological support - groups
65
What treatments can be used for Crohn's? (medical)
Corticosteroids to induce remission | Azothiprine or bilogica (Mabs) long term to dampen down immune system
66
What treatments can be used for Crohn's? (surgical)
Bowel resection May need ileostomy for a few months post-op Mainly due to strictures and fistulas Leave as late as possible due to the chance of further surgeries
67
When should you see a GP re crohn's?
blood in your poo diarrhoea for more than 7 days frequent stomach aches or cramps lost weight for no reason, or your child's not growing as fast as you'd expect
68
What causes Crohn's disease?
your genes – you're more likely to get it if a close family member has it a problem with the immune system smoking a previous stomach bug an abnormal balance of gut bacteria
69
What are the other symptoms of Crohn's?
``` a high temperature feeling and being sick joint pains sore, red eyes patches of painful, red and swollen skin – usually on the legs mouth ulcers children grow more slow than usual ```
70
What would your GP ask you about?
your symptoms your diet if you've been abroad recently – you might have an infection any medicines you're taking if you have a family history of Crohn's disease
71
What investigations might your GP do?
feel and examine your tummy take a sample of blood ask you to provide a poo (stool) sample
72
What investigations might a specialist do?
Colonoscopy Biopsy MRI/CT Scan
73
How can steroids help with Crohn's?
can relieve symptoms by reducing inflammation in your digestive system – they usually start to work in a few days or weeks are usually taken as tablets once a day – sometimes they're given as injections may be needed for a couple of months – do not stop taking them without getting medical advice
74
What are the side effects of steroids?
``` weight gain indigestion problems sleeping an increased risk of infections slower growth in children ```
75
What can be helpful in children and young adults?
Liquid diet Drinks containing all the nutrients Avoids the risk of slower growth that happens with steroids
76
What are the side effects of enteral nutrition?
Nausea Diarrhoea Constipation
77
What immunosuppressants might be taken with Crohn's?
azathioprine, mercaptopurine and methotrexate
78
What can immunosuppressants do in Crohn's?
can relieve symptoms if steroids on their own are not working can be used as a long-term treatment to help stop symptoms coming back are usually taken as a tablet once a day, but sometimes they're given as injections may be needed for several months or years
79
What are the side effects of Immunosuppressants?
feeling and being sick, increased risk of infections and liver problems
80
What biological medicines are used in Crohn's?
adalimumab, infliximab, vedolizumab and ustekinumab
81
What can biological medicines do in Crohn's?
can relieve symptoms if other medicines are not working can be used as a long-term treatment to help stop symptoms coming back are given by injection or a drip into a vein every 2 to 8 weeks may be needed for several months or years
82
What are the side effects of biological medications?
increased risk of infections and a reaction to the medicine leading to itching, joint pain and a high temperature
83
When might surgery be recommended?
the benefits outweigh the risks or that medicines are unlikely to work
84
What does a resection involve?
1. Making small cuts in your tummy (keyhole surgery). 2. Removing a small inflamed section of bowel. 3. Stitching the healthy parts of bowel together.
85
What might you need to careful about with Crohn's?
Triggers e.g. certain foods pharmacy medicines
86
What's the deal with Crohn's and vaccinations?
Flub jab yearly | Avoid live vaccines e.g. MMR
87
What might be more difficult during a flare up?
Getting pregnant
88
What might not work as well when you have Crohn's?
Some contraceptives | e.g. the Pill
89
What are possible complications of Crohn's?
Damage to bowel e.g. scarring, narrowing, ulcers, fistulas Difficulty absorbing nutrients - osteoporosis, iron deficiency anaemia Bowel cancer
90
How does the risk of bowel cancer change with Crohn's?
after 10 years the risk is about 1 in 50 after 20 years the risk is about 1 in 10 after 30 years the risk is about 1 in 5
91
What should people with Crohn's do?
Have regular colonoscopies

Year 2 CSI (8 decks)

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