Diarrhoea Flashcards by Callum Donoher

What are the most common causes of gastroenteritis?

Eschericia coli
Campylobacter
Shigella
Salmonella
Clostridium difficult
Norovirus
Rotavirus
Staphylococcus aureus

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What are the most common causes of bloody diarrhoea from gastroenteritis?

Camplyobacter
Shigella

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What are the causes of non bloody watery diarrhoea due to gastroenteritis?

Escherchia coli
Cholera

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What is the most common cause of bloody diarrhoea?

Campylobacter

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What are some complications of gastroenteritis?

IBS
GBS (Guillian Barre Syndrome) = hyporeflexia/areflexia

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What is GBS?

Guillian Barre syndrome is an autoimmune condition which antibodies attack the myelin sheath (schwann cells) of nerves

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What are some differentials for chronic bloating and diarrhoea?

Crohn’s disease
Ulcerative colitis
IBS
Coeliacs disease

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What are the similarities between IBS and IBD?

Both can cause:
-diarrhoea
-bloating
-crampy pain
-mucosal stool

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What are the key differences between IBD and IBS presentation?

IBS = NO SYMPTOMS AT NIGT
IBD = SYMPTOMS AT ANY TIME

IBS = No weight loss
IBD = Weight loss

IBS = No other systemic affects
IBD = extra intestinal manifestations and general unwell symptoms

IBS = watery diarrhoea
IBD = often contains blood

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What are the main indications in a patients history with diarrhoea that would make you think IBS over IBD?

NO SYMPTOMS AT NIGHT
No weight loss
No blood in stool

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What investigations would you do for a patient with diarrhoea and spasmodic abdominal pain?

State why you’d do each investigation:

FBC (Gastroenteritis)
Faecal calprotectin (indicates IBD if positive)
Coeliac serology
Faecal elastase (chronic pancreatitis)
Stool culture (MCS)

Colonoscopy
Biopsy if required

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How does UC present?

Bloody diarrhoea
Left lower quadrant abdominal pain
Weight loss
Fever
Extra intestinal manifestations
Stool urgency
Stool frequency
Tenesmus
Mucous discharge

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What are some extra intestinal manifestations of ulcerative colitis?

Arthritis
Erythema nodosum
Uveitis
Pyoderma gangrenosum
Primary sclerosing cholangitis

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What are some complications of ulcerative colitis?

TOXIC MEGACOLON
Bowel obstruction
Bowel perforation
Colorectal adenocarcinoma

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What type of inflammation occurs with ulcerative colitis?

Superficial non granulomatous inflammation originating in rectum spreading proximally potentially up to the ileocaecal valve

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How does Crohn’s disease present?

Episodic abdominal pain
Diarrhoea
Bloody stool
Mucos in stool
Systemic fever
PERIANAL DISEASE

Extra-intestinal manifestations

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What is a key difference in the presentation between Crohn’s disease and ulcerative colitis?

Perianal disease occurs with Crohn’s
Mouth ulcers very commonly happens with Crohn’s

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What are some Perianal diseases seen with Crohn’s?

Perianal fistulae
Perianal abscess
Perianal ulcers

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What are some extra intestinal manifestations of Crohn’s disease?

Enteropathic arthritis
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Iritis
Primary Sclerosing cholangitis

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What type of inflammation is seen with Crohn’s disease?

Skip like lesions that have transmural full thickness inflammation that can span the entire GI tract

Fissures, deep ulcers and fistulae

Granulomatous infalmmation

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What are the complications of Crohn’s disease?

Fistulae
Strictures
GI malignancy
Recurrent Perianal fistulae
Malabsorption
Inc risk of gallstones
Inc risk of renal stones

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What is the management of an acute severe flare of uclerative colitis?

IV corticosteroids (hydrocortisone)
Fluid resuscitation
Prophylactic heparin
TED stockings

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What medication is given to treat a mild to moderate ulcerative colitis flare?

Aminosalicylates topical or rectal like mesalazine

Second line Prednisolone

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What medication is given to treat a mild to moderate ulcerative colitis flare?

Aminsalicylates topical or rectal like mesalazine

If doesn’t work give corticosteroids (Prednisolone)

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What is the management strategy once the acute ulcerative colitis flare has resolved? What happens if theres a relapse??

Ween down the steroids but maintain the oral or rectal mesalazine If relapse give Azathioprine (DMARD)

What are the side effects of azathioprine?

Pancreatitis Myelosuppression

What happens if azathioprine fails to achieve remission for ulcerative colitis?

Try biologics

What are some side effects of steroids?

ACNE Weight gain Immunosuppression Osteoporosis Peptic ulcers

What are the general principles for managing uclerative colitis?

Fluids Severe = IV corticosteroids (hydrocortisone) try ween down till nothing and maintain with mesalazine Mild-moderate = mesalazine oral or rectally if relapse give steroids (prednisolone) then ween to azathioprine

What is the management for Crohn’s disease?

Fluid resus Prophylactic hepatic TED stockings IV corticosteroids Mesalazine or methotrexate/azathiprine if corticosteroids fail

What investigations are used to diagnose coeliac disease?

Colonoscopy with biopsy Coeliac serology

What would be seen on biopsy for a patient with coeliac disease?

Villous atrophy Crypt hyperplasia Lymphocyte infiltration

What is tested for in coeliac serology?

Anti-TTG Anti-Endomysial IgA

What is the management for coeliacs disease?

Gluten free diet

What are the differentials for a patient with diarrhoea, tender mass in right iliac fossa and mouth ulcers?

Appendiceal mass due to Crohn’s disease Appendicitis Appendiceal abcesses Intestinal abscess

How do you differentiate between an Appendiceal mass and an abscess?

CT AP IV contrast

How does management differ between an Appendiceal mass and an abscess?

Steroids for Appendiceal mass/crohns Abx and drainage for abscess

Why does coeliacs disease lead to weight loss?

Villous atrophy Crypt hyperplasia Leads to malabsorption in duodenum and jejunum

What causes of gastroenteritis occurs over a long period of time causing prolonged watery diarrhoea?

Giardiasis (Protozoa)

What are the stools like for gastroenteritis caused by giardia?

Long lasting Profuse watery Yellow and smelly

What antibiotic is given to treat gastroenteritis caused by giardia?

Metronidazole

What are some acute causes of gastroenteritis/food poisoning?

Staphylococcus aureus Bacillus cereus Viral

What is the pathophysiology of acute gastroenteritis/food poisoning?

Staphylococcus aureus and bacillus cereus produce toxins leading to diarrhoea and vomiting

What is the managing for food poisoning?

Supportive treatment (fluids)

What is the main differential if a patient is being treated for a chest infection with co-amoxicillin and clarithromycin?

Clostridium difficile (C.diff)

What is the main class of antibiotic that increases the risk of C.difficile infection?

Cephalosporins

What is an example of a cephalosporin that increases the risk of c.diff infection?

Ceftriaxone

What is an example of a macrolide that increases the risk of c.diff infection?

Clarithromycin

How do you diagnose C.diff?

Stool culture (MCS)

How do you treat a c.diff infection?

1st line = oral vancomycin 10days 2nd line = oral fidoxamicin 3rd line = oral vancomycin + IV metronidazole

How does a C.diff infection occur?

Depleted gut flora allows for the overgrowth of C.diff

What management would you do if a patient has a recurring c.diff infection?

If mild do nothing Of serious give prophylactic vancomycin to get germinating spores

What are the main differentials if a patient is experiencing weight loss and bloating?

Coeliacs disease Crohn’s disease Chronic pancreatitis

What considerations might you make for a patient with wheezy breathlessness and a watery diarrhoea?

Carcinoid syndrome

What is carcinoid syndrome?

Neuroendocrine tumour that originates in the GI tract metastases to somewhere like the liver and become symptomatic due to the substances being secreted avoiding first pass metabolism by the liver

What commonly causes enlarged liver?

Polycystic livers Glycogen storage disease Carcinoid syndromes

What genotypes are commonly associated with coeliacs disease?

HLA-DQ2 HLA-DQ8

What is a skin condition caused by coeliacs disease?

Dermatitis herpetiformis

What is a cause of watery diarrhoea and bloating when all investigations come back normal: -normal FBC -negative coeliac serology -negative faecal calprotecin -negative faecal elastase -stool culture negative

Overflow diarrhoea

What imaging is used to diagnose overflow diarrhoea?

Abdominal x-ray

What is the management for overflow diarrhoea?

Rectal examination Laxatives Stool softeners Manual evacuation

What are some laxatives that can be given to treat overflow diarrhoea?

Macrogol (osmotic laxative) Senna (stimulative laxative)

What are some stool softeners that can be given to treat overflow diarrhoea?

Glycerin Phosphate enemas

What are some risk factors for developing overflow diarrhoea?

Low fibre diet Immobile Suppressing feeling to go Dehydration Stress

Why may a patient have normal investigations but have watery diarrhoea and colonoscopy revealing brown black pigmentation in the large bowel?

Patient chronically overuses laxatives

What is it called when a patient has a brown black pigmentation in their large bowel due to chronic use of laxatives?

Melanosis coli

What is the pathophysiology of melanosis coli?

Macrophages engulf the laxative compounds

How can diabetes lead to watery diarrhoea and weight loss?

Diabetic auto neuropathy

What is the pathophysiology of diabetic autoneuropathy leading to diarrhoea ?

Diabetic neuropathy affects the enteric nervous system leading to stagnation of small bowel contents which can lead to small bowel bacterial overgrowth leading to colitis

What Abx would be used to treat an infection due to diabetic auto-neuropathy?

Rifaxamine Ciprofloxacin Metronidazole

What is the primary differential if a patient has a cholecystectomy and is now suffering from watery diarrhoea with out pain?

Bile salt deficiency diarrhoea

What is the pathophysiology of bile salt deficiency causing diarrhoea?

Removed gall bladder Bile acids not reabsorbed in the terminal ileum as efficiently since the gallbladder is not regulating the flow of bile into the bowel Continuous flow overwhelms the bowel leading to the osmotic diarrhoea

How do you investigate bile salt deficiency diarrheoa?

Radioabbeled bile acids to see how much is retained

How do you treat diarrhoea due to bile slat deficiency?

Bile acid sequestrants

What is an example of a bile acid. Sequestrant?

Cholestyramine

What is used to maintain remission for Ulcerative Colitis following a severe flare or more than 2 exacerbations in a year?

Azithioprine (oral)

What is the first line medication used to treat pain caused by IBS?

Antispasmodics - Mebeverine or hyoscine butylbromide also called Buscopan

What is the first line medication for managing a Crohns flare?

IV Prednisolone

What is the first line medication given to maintain remission with Crohn’s disease?

First line : azathioprine or Mercaptopurine

What is the second line medication given to maintain remission if azathioprine or mercaptopurine aren’t well tolerated?

Methotrexate

What tests need to be commenced before initiating azathioprine?

TPMT levels

What is the first line management for constipation?

Bulk forming laxative = isphalga husk

What is the second line management if isphalga husk fails to clear the constipation?

Osmotic laxatives = macrogol 1st = isphalga husk 2nd = macrogol

Diarrhoea Flashcards

(83 cards)