Gut Problems 2 (Clinical) (Ow) Flashcards
What sort of questions should you ask around diarrhoea?
1) Freq
2) Consistency
3) Blood
4) meals
5) Noctournal
6) Amount
7) Normal BH
8) Associated Symptoms
- Travel
- meds
- Fever/wt loss
- Infections
What sort of questions should you ask around bleeding?
1) PR blood?
- Colour
- bright red?
- black: iron/malena,
- maroon/plum)
- Black/tarry (melaena): small intestine (upper GI tract) (unlikely)
- Dark red/maroon: distal small intestine, proximal colon (caecum to transverse colon) (likely)
- Bright red (mixed with stools) à distal colon/rectum (left colon) (unlikely)
- Blood fresh on paper: outlet (anal fissure/hemorrhoids) (unlikely) (do not cause iron deficiency)
- Volume (inaccurate)
- On the paper?
- Coating the stool? (haemorrhoides do not coat the stool)
- How Many Days?
- Intermittent?
- Bowl habit? (Constipation?)
- Weight loss?/Nausea?/Vomit?/Fam history?
- NSAIDS?/Anti-platelet drugs?
2) Bloody diarrhoea?
What should you ask around weight loss?
1) Timespan
2) How much lost / How much they weigh
3) Have the clothes become loose?
25-year-old lady, usually fit and well
3-month history of watery diarrhea
- 6 times a day, 3 times at night (nocturnal diarrhea usually has to be taken seriously)
- Blood as well (colour (black, tarry (i.e. melaena), fresh, bright red? maroon?))
- Lower abdo cramps
- Lost 5kg in weight
Usual bowel habit once a day (always important to establish what is normal for them!)
Light smoker of 3 cigarettes a day
On oral contraceptive pill, nothing else
What are the differential diagnoses?
Infection
- History too long in an otherwise fit and well person
- If immunocompromised, it can be longer
- Exclude C. difficile in someone who has had recent antibiotics (antibiotics can predispose to C. difficile infection)
Coeliac Disease
- Unlikely because of bleeding (coeliac disease not usually associated with bleeding)
Irritable Bowel Syndrome (IBS)
- Unlikely because usual bowel habit is regular, symptoms tend to appear gradually (tend to be chronic)
- Unlikely because of bleeding, nocturnal diarrhea
Inflammatory Bowel Disease (IBD)
- Possible, bleeding and diarrhea common presentation of IBD
Cancer
- Not usually in a young person unless family history of polyp syndrome
Analyse these results
Full Blood Count
- Low Hb: anemia
- Normocytic (e.g. due to blood loss, chronic inflammation)
- Normal MCV
- High platelets: thrombocytosis
- High WCC: neutrophilia
- Raised CRP:
- Low albumin:
- High ferritin:
- Stool culture negative
- 25-year-old lady, usually fit and well*
- 3-month history of watery diarrhea*
- 6 times a day, 3 times at night (nocturnal diarrhea usually has to be taken seriously)
- Blood as well (colour (black, tarry (i.e. melaena), fresh, bright red? maroon?))
- Lower abdo cramps
- Lost 5kg in weight
- Usual bowel habit once a day (always important to establish what is normal for them!)*
- Light smoker of 3 cigarettes a day*
- On oral contraceptive pill, nothing else*
Analysis
- Elevated CRP, neutrophils and platelet count suggest inflammation
- Normocytic anemia
- Response to inflammation (reduced bone marrow activity)
- May be due to bleeding as well but less of a factor
- Acute bleeding can drop Hb without change in MCV but this patient is not behaving like so
- Chronic bleeding can drop Hb but usually MCV also falls due to iron deficiency
- Low albumin and high ferritin are both part of an acute phase reaction
- Everything points to inflammation!
Raised CRP:
Low albumin:
High ferritin:
What do these results indicate?
Raised CRP: inflammation
Low albumin: inflammation (acute phase reaction)
High ferritin: inflammation
Stool culture negative
Note that anemia due to acute blood loss tend to be accompanied by….
(Note that anemia due to acute blood loss tend to be accompanied by tachycardia, clammy hands)
How do you diagnose IBD?
Colonoscopy
Describe the 2 types of Inflammatory Bowel Disease
Crohn’s Disease
- Any part of the GI tract
-
Discontinuous inflammation (skip lesions, may spare rectum)
- Most common in: ileo-colonic junction
- Deep ulcers and cobblestone appearance
- _Transmural inflammation (_common location at terminal ileum/ascending colon (ileo-colonic junction), typical landmarks of normal colon lost)
- Starts as small ulcers on mucosa (i.e. aphthous ulcers)
- Progress to deep penetrating ulcers with fissuring
- Mucosa swollen cobblestone appearance
- Granulomas may be present (but not required for diagnosis) (seen on biopsy not colonoscopy)
- Made worse by smoking
- Different presentations depend on part of GI tract involved and clinical subtype
- Inflammatory
- Stricturing
- Fistulizing
- Perianal
Ulcerative Colitis
- Restricted to only colon
- Continuous inflammation, starting at rectum and spread proximally
- Shallow ulcers (no macroscopic ulceration expect in severe disease)
- Mucosal inflammation (does not reach deeper, diffuse and granular)
- Granulomas not seen on biopsy
- Smoking is protective
- Inflammatory is the only type of presentation
Diarrhoea indicates…
Inflammation of the COLON (not Small Bowel)
Describe the 4 presentations of Crohn’s Disease
Inflammatory Disease
- Colitis (diarrhea, bleeding)
- Ileitis (abdominal pain, typically at least an hour or so post-prandial (after eating))
- Gastritis/duodenitis (dyspepsia)
Stricturing Disease
- Long-term inflammation (transmural inflammation -> thickened wall -> scar -> stricture)
- Presents with symptoms similar to bowel obstruction (abdominal pain and distension, vomiting, bowels not opening)
Fistulizing Disease
- Fistula is an abnormal connection/tract between the gut and another organ/vessel (unique to Crohn’s), which includes:
- Small intestine and skin,
- Small intestine and small intestine,
- Rectum and vagina,
- Esophagus and trachea
Perianal Disease
- Perianal abscess
- Perianal fistula
- __Anal canal to outside
- Anal fissure (consider Crohn’s with recurring anal fissure, but can occur outside of Crohn’s, e.g. constipation)
What are the presentations of inflammatory ulcerative colitis?
Ulcerative Colitis Presentation (Inflammatory)
- Diarrhea, bleeding
- Frequent bowel motion and urgency
- Abdominal discomfort
- Fever, malaise, weight loss (constitutional symptoms)
- Raised ESR/CRP and platelets in blood tests
Describe Toxic Megacolon
Toxic Megacolon In Ulcerative Colitis
- Inflammation in mucosa extends into smooth muscle layer
- Inflammatory mediators released including nitric oxide
- NO is an inhibitor of smooth muscle tone
- Arrested colonic movement leads to progressive dilatation
- _In_creased risk of perforation
Describe the Extra-intestinal manifestation of IBD
Extra-Intestinal Manifestation Of IBD
Some manifestations are more common in Crohn’s than UC and vice versa.
- Eyes (episcleritis, uveitis)
- Biliary tract (primary sclerosing cholangitis)
- Joints (spondylitis)
- Skin infections (erythema nodosum or pyoderma)
- Doesn’t always present at the same time with colonic manifestation.
Lady is diagnosed with Crohn’s colitis and terminal ileitis
Has MRI enterography to examine remaining small intestine (no evidence of small intestinal disease apart from terminal ileitis)
What was the cause of her Weight loss?
What Is The Cause Of Weight Loss
- Malabsorption
- B12 absorption
- Bile reabsorption (absorb fat)
- Chronic inflammation -> catabolism and anorexia
- Pain and reduced intake (reduced appetite)
After 4 years of taking azathioprine and mesalazine, she gets increasing abdominal pain
MRI confirms multiple strictures involving distal ileum. She has an operation to remove 100cm of ileum.
What Are Potential Consequences Of Resection Of The Terminal Ileum?
- B12 malabsorption (removal of terminal ileum -> loss of specialized receptors for B12/IF complex)
-
Bile salt malabsorption
- Reduced re-uptake of bile salts via enterohepatic circulation
-
Bile salts loss through colon/faeces
- Less bile salts -> fat malabsorption -> fatty diarrhea (i.e. steatorrhea)
- Bile salt in colon -> irritant to colon -> stimulate water and electrolyte secretion -> s_ecretary diarrhea (not osmotic diarrhea)_
- __Usually one or the other.
How do you differentiate between Iron deficiency of chronic disease vs iron-deficiency anemia
Iron Studies
- Serum iron
- Iron binding capacity
- Iron saturation
- Ferritin
- Soluble Transferrin receptor
Describe the differential outcomes for different colour of blood ****
-
Black/tarry (melaena):
- small intestine (upper GI tract) (unlikely)
-
Dark red/maroon:
- distal small intestine, proximal colon (caecum to transverse colon) (likely)
-
Bright red (mixed with stools):
- distal colon/rectum (left colon) (unlikely)
-
Blood fresh on paper:
- outlet (anal fissure/hemorrhoids) (unlikely) (do not cause iron deficiency)
Bleeding from small vessels cause occult blood loss
Bleeding from large vessels are likely to cause overt bleeding
What can cause bleeding in the Upper GI tract (Malena)
- Oseophagitis
- Tend to not get melena (bleeding is mucosa)
- Get haemoptaemosis
- Varices
- Heavy and forceful bleeding
- Massage haemoptaemosis
- melena(?) in stool
- Peptic Ulcer
- Melena
- Retching
- Blood in vomit after series of vomitting
- Cancer of stomach or oesophagus
- Tend to not have overt bleeding (mucosal and small)
- Tend to show iron def.
- Vascular malformations
- Malformation in capillaries tend to give iron deficiencies
What can give you bleeding in the COLON?
- Inflammation
- Bloody diarrhoea
- Diverticulosis (usually on left colon)
- Usually maroon, or fresh blood loss
- No changes in bowel habit
- Cancers
- If in left colon- tend to show visible bleeding
- Haemorroids
- Blood on toilet paper
- Polyps
What is Coeliac Disease?
- Ingestion of gluten triggers an immune response (IgA predominantly)
- damage + flattening of villi
- malabsorption
What would you observe in duodeal biopsies for Coeliac Disease?
- Intra-epithelial lymphocytosis (excessive amounts of lymphocytes in the villi)
- Crypt hyperplasia (red arrows)
- Villous blunting (atrophy)
