Diarrhoea, Constipation and C.Diff

Question 1

What are the characteristics of steatorrhoea?

Answer 1

Steatorrhoea is characterised by increased gas, offensive smell and floating, hard-to-flush stools.

Question 2

What are the 2 typical conditions that can lead to steatorrhoea?

Answer 2

Giardiasis and Coeliac disease

Question 3

What are present in the stools of inflammatory diarrhoea?

Answer 3

Inflammatory diarrhoea has blood and pus in the stools

Question 4

What are the common causes of diarrhoea?

Answer 4

Gastroenteritis, Parasites/Protozoa (Campylobacter, Shigella/Salmonella, amoebiasis, E. Coli), IBS, Colorectal cancer, Crohn’s, UC, coeliac

Question 5

Which conditions will present with mucus in the stools?

Answer 5

IBS, Colorectal cancer and Polyps

Question 6

Which conditions will present with explosive diarrhoea?

Answer 6

Giardiasis, Cholera, Yersinia, Rotavirus

Question 7

Detection of eosinophilia in blood cultures suggest?

Answer 7

Eosinophilia in blood cultures suggest parasites

Question 8

Under what conditions are IV fluids necessary?

Answer 8

If patient is dehydrated and had bloody diarrhoea for more than 2 weeks.

Question 9

What are the 2 medications that can be given to decrease the frequency of loose stools? Provide dosage and frequency, and route.

Answer 9

Codeine phosphate 30MG TDS PO

Loperamide 2MG PRN PO, max 16MG/day

Question 10

What is Dysentery?

Answer 10

Dysentery is an infection of the intestines that causes diarrhoea containing blood or mucus.

Question 11

What are the 2 types of dysentery and which is more common in the UK?

Answer 11

1. Bacillary dysentery/Shigellosis: caused by Shigella bacteria. Most common in the UK
2. Amoebic dysentery/Amoebiasis: caused by an amoeba, Entamoeba Histolytica, mainly found in tropical areas.

Question 12

What are the treatment for Clostridium difficile?

Answer 12

Stop the causative antibiotic if possible. Treatment is usually not needed if asymptomatic, but if symptomatic, give Metronidazole 400MG TDS PO for 10-14/7.
Vancomycin 125MG QDS PO for 10-14/7 is better for severe conditions. (or Fidaxomicin 200MG BD for 10-14/7 if patient has multiple co-morbidities and are receiving concomitant antibiotics.)

Question 13

When is urgent colectomy indicated for Clostridium Difficile patients?

Answer 13

If there is toxic megacolon, LDH increased or if deteriorating.

Question 14

White cells are microscopically absent in?

Answer 14

Amoebiasis, Cholera, E. Coli and viruses.

Question 15

What is the presumptive treatment given to patients who present with fever >38 degree celsius and diarrhoea with visible blood?

Answer 15

Ciprofloxacin 500MG BD PO for 6/7

Question 16

What is the Rome Criteria?

Answer 16

The Rome criteria is a measure which determines if one has constipation.
Constipation is defined as the presence of >2 symptoms during bowel movements (BMs) :
- Straining for >25% of BMs
- Lumpy or hard stools in 25% of BMs
- Sensation of incomplete evacuations for>25% of BMs
- Sensation of anorectal obstruction or blockage for >25% of BMs
- Manual manoeuvers (eg digital evacuation, support of the pelvic floor) to facilitate at least 25% of BMs
- fewer than 3 BMs per week

Question 17

What term is used to describe “feeling of incomplete evacuation”?

Answer 17

Tenesmus

Question 18

What are the indications for investigation for patients presenting with constipation?

Answer 18

> 40 yo
change in bowel habit
associated symptoms such as weight loss, PR mucus or blood, tenesmus)

Question 19

What is the mechanism of action of Senna?

Answer 19

Senna acts directly as an irritant on the colonic wall to induce fluid secretion and colonic motility.

Question 20

What is a common side effect of Senna?

Answer 20

Abdominal cramps

Question 21

What are the 4 types of drugs used to treat constipation?

Answer 21

1. Bulking agents
2. Stimulant laxatives
3. Stool softeners
4. Osmotic laxatives

Question 22

What is the mechanism of action of bulking agents? State some examples of bulking agents

Answer 22

Bulking agents increase the volume of the stool and makes it easier to pass. Examples include Bran and Ispaghula husk

Question 23

What is the mechanism of action of stimulant laxatives? Give examples of stimulant laxatives.

Answer 23

Stimulant laxatives are substances that act on the intestinal mucosa or nerve plexus, altering water and electrolyte secretion.
Examples are Bisacodyl and Senna

Question 24

What is the mechanism of action of osmotic laxatives?

Give examples of osmotic laxatives.

Answer 24

Osmotic laxatives cause the intestines to hold more water within and create an osmotic effect that stimulates a bowel movement.
Examples are Lactulose and Macrogol (Movicol)

Question 25

What is the mechanism of action of stool softeners?

Answer 25

Stool softeners are anionic surfactants that allows additional water and fats to be accumulated in the stools, making them easier to move through the GI tract

Question 26

In which conditions will there be "frank pus"?

Answer 26

IBD, diverticulitis, fistula/abscess

Question 27

What are the signs and symptoms of severe C. Diff infection?

Answer 27

WCC >15x10^9 Acute rising serum creatinine And/or colitis

Question 28

Until how many days of treatment will it be deemed a failure if patients with C. Diff are not improving or worsening?

Answer 28

7 days

Question 29

Which medication should not be prescribed to patients with acute C. Difficile infection?

Answer 29

Anti-motility agents such as Loperamide

Question 30

What is suspected if there is microcytic anaemia (decreased MCV) and iron deficiency? How about macrocytic anaemia?

Answer 30

Decreased MCV and iron deficiency, suspect coeliac disease and colorectal cancer. If there is increased MCV, think of alcohol abuse or vitamin B12 deficiency due to coeliac or Crohn's.

Question 31

What is the sign of severe dehydration in U&E testing?

Answer 31

Decreased potassium

Question 32

What is looked for in Coeliac serology?

Answer 32

Anti-endomysial antibodies (an IgA antibody) | Anti-transglutaminase antibody

Question 33

Which laxative is commonly used for patients before procedures? What type of laxative is it?

Answer 33

Sodium Picosulfate. It is a stimulant laxative.

Question 34

Which types of laxatives should be avoided if there is GI obstruction?

Answer 34

Bulking agents and stimulant laxatives

Question 35

What is Hirschsprung's disease?

Answer 35

Hirschsprung's disease is a condition that prevents movement of the distal colon due to missing nerves cells caused by a birth defect. It is presented as constipation in newborns and toddlers.

Question 36

What are the common causes of diarrhoea?

Answer 36

1. Gastroenteritis 2. Parasites/Protozoa 3. IBS 4. Colorectal cancer 5. Crohn's, Ulcerative Colitis, Coeliac

Question 37

When are bulk-forming agents useful?

Answer 37

Bulk-forming agents are useful for diarrhoea in diverticular disease, and for reducing the fluidity of faeces in patients with ileostomy and colostomy.

Question 38

In infectious diarrhoea, which form of anti-diarrhoeal medications are KI? Why?

Answer 38

Anti-motility drugs such as codeine, Loperamide and diphenoxylate. These drugs reduce pathogen clearance and can precipitate toxic megacolon.