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NME > Functional and Infective Pathology of the Lower GI Tract > Flashcards

Functional and Infective Pathology of the Lower GI Tract Flashcards

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1
Q

Diarrhoea definition

A

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

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2
Q

acute diarrhoea last for

A

0-14 days

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3
Q

Persistent diarrhoea lasts for

A

14 days-4 weeks

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4
Q

Chronic diarrhoea lasts for

A

4+ weeks

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5
Q

Why worry about diarrhoea?

A
  • significant amount of morbidity (but little mortality)
  • dehydration:
    • increases risk of life threatening disease in
      young/old
    • electrolyte imbalance (NA,K,HCO3)
    • can lead to acidosis
  • chronic diarrhoea can negatively affect: wellbeing,
    mental health, activity, limited diet, social isolation
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6
Q

Diarrhoea

A
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7
Q

how infections cause diarrhoea

A
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8
Q

4 categories of causes of acute diarrhoea:

A
  • infection
  • medication
  • acute presentation of chronic pathology
  • other
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9
Q

Causes of acute diarrhoea: infection:

A
  • viral (norovirus, rotavirus)
  • bacterial (salmonella, clostridum difficile, cholera)
  • parasites (giardia lamblia)
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10
Q

Causes of acute diarrhoea: ,edications:

A
  • laxatives
  • antibiotics (macrolides)
  • allopurinol
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11
Q

Causes of acute diarrhoea: other:

A
  • anxiety
  • food allergy
  • GI inflammation (acute appy, intestinal ischaemia)
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12
Q

Most cases of infectious diarrhoea are ——- and ——-/ 50% of cases last

A
  • viral and self-limiting
  • <1 day
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13
Q

typically viral untreated infectious diarrhoeas last

A

2-3 days

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14
Q

typically bacterial untreated infectious diarrhoea last

A

3-7 days

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15
Q

typically protozeal untreated infectious diarrhoea lasts

A

weeks-months

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16
Q

Assessing acute diarrhoea: history:

A
  • onset, duration, severity
  • character (watery, fatty, blood stained, mucous)
  • triggers (infective contacts, diet, travel)
  • associated features: vomiting, fever, abdo pain, med
    changes, stress, surgery
  • Red flags: blood, recent antibiotics, weight loss,
    dehydrationn, nocturnal symptoms
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17
Q

Assessing acute diarrhoea: examination:

A
  • assess fluid status: tachycardia, reduced skin turgor,
    dryness of mucous membrane, delayed capillary refill,
    decreased urine output, hypotension, confusions
  • abdominal exam: pain, tenderness, distension, mass,
    increased or decreased bowel sounds
  • DRE: tenderness, stool consistency, mass,
    blood/mucous
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18
Q

Investigating acute diarrhoea

A
  • not always needed if the patient is well and the length
    of symptoms are short/quickly resolving
  • stool testing: exclude infections, pt vulnerable
  • blood tests: FBC, ESR. CRP,LFTs, U&Es, iron) to rule out
    other causes
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19
Q

Managing acute diarrhoea:

A
  • usually nothing: hydration, hypertonic saline/glucose
    sol
  • if unwell, hospital:
    • subsequent diagnostics once acute episode settles
    • even with proven infection, antibiotics rarely used
    • dehydration most common concern
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20
Q

5 categories of chronic diarrhoea causes:

A
  • diet
  • bowel disease
  • constipation and impaction
  • drugs
  • others
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21
Q

Chronic Diarrhoea Causes: Diet:

A
  • malabsorption
  • artifical sweeteners
  • excessive sorbitol
  • caffeine
  • alcohol
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22
Q

Chronic Diarrhoea Causes: Bowel Disease:

A
  • IBS
  • IBD
  • microscopic colitis
  • coeliac disease
  • etc
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23
Q

Chronic Diarrhoea Causes: Constipation and Impaction:

A

…

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24
Q

Chronic Diarrhoea Causes: Drugs:

A
  • macrolides
  • ACE inhibitor
  • NSAIDs
  • metformin
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25
Chronic Diarrhoea Causes: other:
- infection - endocrine - CF - lymphoma - hormone secreting tumours
26
Assessing chronic diarrhoea: history:
- onset, duration, frequency, severity of symptoms - character (watery, fatty, blood stained, mucous) - triggers (infective, diet, const, drugs, IBS, IBD) - associated features: vomiting, fever, abdominal pain, changes in medication, stress, past surgery - red flags: blood in stool, Abx, weight loss, dehydration, nocturnal symptoms
27
Assessing chronic diarrhoea: examination:
- assess fluid status: tachycardia, reduced skin turgor, dryness of mucous membranes, delayed capillary refill time - abdo exam: pain, tenderness, distension, mass, increased or decreased bowel sounds,, organomegaly - DRE: rectal tenderness, stool consistency, masses, blood/mucous
28
Investigating chronic diarrhoea:
- stool MC&S: add in parasitology, infection - blood tests: FBC, B12/folate, CA, ferretin, hormones) - qFIT: faecal calprotectin, feacal elastase - imaging: USS, CT/MRI, endoscopy
29
qFIT stands for
Quantitative faecal immunohistochemical test
30
qFIT:
- 1st line investigation for changes in bowel habits (rule out bowel cancer) - contra-indicated for rectal bleeding - if normal (<10 micrograms Hb/g faeces) risk of bowel cancer is 0.4% - if >10 risk of bowel cancer 6% - if >150 risk of bowel cancer 31% - reduces need for invasive investigations
31
Managing chronic diarrhoea:
- treat the underlying cause - supportive care for patient
32
Irritable Bowel Syndrome (IBS) definition
abdo pain which is either releated to defecation and/or associated with altered stool frequency or appearance AND there are at least two of the following: - altered stool passage (straining, urgency, incomplete evacuation) - bloating or distension - worsened by eating - passing rectal mucous AND: - alternative conditions are excluded
33
IBS management:
- rule out alternative causes and REASSURE - dietary manipulation: - diarrhoea: - reduce insoluble fibre intake - reduce food triggers (caffeine, alcohol, carbonated drinks) - constipation: - soluble fibre supplements or food high in soluble fibre - maintain adequate fluid intake - low FODMAP diet, fermentable oligosaccharide, disaccharides, monosaccharides, polyols) - probiotics may help
34
IBS medical therapies:
Diarrhoea: - Loperamide (antimotility) - most common side effect is constipation, cardiac arrhythmias in higher doses - antispasmodic drugs for abdo cramps Constipation: - Laxatives - bulk forming - avoid lactulose Low dose tricyclic antidepressant amytriptyline 4 weeks, >90% will respond to varying levels of success
35
Constipation definition:
- bowel movements less than 3 times a week - excessive straining - associated abdominal pain or bloating - change in intrinsic pattern
36
Constipation can be categorised by either
Time: - acute: 0-3 months - chronic 3+ months Causes: - Primary (functional) - Secondary (organic)
37
Why worry about constipation?
- distressing - concerns over underlying cause - increased morbidity (especially in elderly/frail)
38
Consequences of constipation:
- nausea/appetite loss - confusion - functional decline - overflow diarrhoea - urinary retention - haemorrhoids - anal fissures
39
Assessment on Constipation: History:
- how long? - speed of onset? - getting worse/better? - triggers: lifestyle, stress, meds, surgical changes) - associated symptoms (bleeding, loss of weight, abdo pain) - PMHx of GI disease
40
Assessment of constipation: examination:
- well/unwell - general exam: pyrexia, jaundice, cachexia - abdominal examination: tenderness, distention, masses - rectal exam: masses, empty rectum v impacted stool
41
Investigations for Constipation:
- blood tests: FBC, inflamm markers, iron, liver function, thyroid, HbA1c, Ca, B12 and folate) - stool tests: qFIT, calprotein - imaging: abdo X ray, CT scan - endoscopy - special investigations: bowel transit study, pelvic floor investigations
42
3 categories of acute constipation causes:
- functional: dehydration, diet, stress - medication: opiates, loperamide, iron - acute presentation of chronic pathology: bowel obstruction
43
Opiates and Constipation:
- 5 classes: kappa, delta, mu, zeta, nociception - all G coupled protein receptors - opiod receptors inhibit calcium channels leading to decreased neurotransmitter release - activation of mu and delta receptors, leading to reduced GI motility and increased sphincter tone leading to constipation - GI Tract can develop a tolerance ot opiods - loperamide acts by binding specifically to mu receptors promoting constipation
44
Acute constipation Management:
- remove the insult - support the patient - may need laxatives
45
Chronic Constipation 6 categories of causes:
- functional constipation - medication - colonic - pelvic floor/defecator disorders - endocrine - neurological
46
Chronic Constipation Causes: Functional Constipation:
- dehydration, diet, stress, IBS, pregnancy, withholding
47
Chronic Constipation Causes: Medication:
- opiates, loperamide, iron, calcium channel blockers
48
Chronic Constipation Causes: colonic:
- cancer - IBD - diverticular disease
49
Chronic Constipation Causes: Pelvic Floor/Defecator disorders:
- rectal prolapse - recocele - pelvic floor dyssynergia
50
Chronic Constipation Causes: Endocrin:
- hypothyroidism - hypercalcaemia - diabetes mellitus - porphyria
51
Chronic Constipation Causes: ENurological:
- MS - spinal cord lesions - Parkinson's
52
Management of Chronic Constipation:
- remove the insult where possible - make the environement as facourable for bowel opening as possible: - adequate fibre and fluid intake, removing constipating meds - resolve faecal impaction first if present: enemas/suppositories - laxatives - neuromodulation (sacral nerve stimulation) - surgery: total colectomy, stoma
53
Important causes of constipation:
- diverticulitis - bowel obstruction - bowel cancer
54
Diverticular disease
- protrusion of mucosal pouches through bowel wall musculature - intimately linked with constipation: - cause or effect - poor dietary fibre implicated - >90% have no symptoms
55
Proximal bowel obstruction
bowels may still be functional despite obstruction; history can be misleading
56
Absolute constipation
no passage of stool or passing of flatus: often indicates distal mechanical obstruction of colon
57
Important to establish the cause of bowel obstruction quickly:
- determination if spontaneous resolution possible - adhesional small bowel obstruction; will settle with surgery in >90% cases
58
Causes of Bowel Obstruction: Extrinsic:
- abdominal masses - adhesions.sar tissue - hernias
59
Causes of Bowel Obstruction: Bowel wall problem:
- neoplasia - inflammatory stricture
60
Causes of Bowel Obstruction: Luminal:
- bezoar/foreign body
61
Management of Suspected Bowel Obstruction:
- immediate resuscitation if unwell - early investigation essential: CT highly sensitive and specific for bowel obstruction - decision to make: will this settle or is intervention needed - closed loop lasege bowel obstruction is an emergency: - competent ileocaecal valve (50%) prevents reflux into ileum - beware the obstructed colon with right lower abdominal pain
62
Bowel Cancer:
- can have very vague or no GI symptoms - iron deficiency anaemia and qFIT increases concerns of bowel ca
63
Laxatives
64
Other laxatives:
65
Side effects: Laxatives:

NME (52 decks)

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