Hospital Based Practice – Altered bowel habits.

History Always check what is normal for the patient.

o Most people vary from 3 times a day to once every 3 days.

Also check what the patient means by “diarrhoea” and “constipation” Differential diagnosis.

o Constipation.

Congenital. Hirschprung’s disease

Mechanical obstruction. Inflammatory stricture.

o Crohn’s disease

o Diverticulitis

Neoplasm Extra – luminal mass

o Eg. Pelvic mass

Rectocele. Lifestyle.

Diet Dehydration Immobility Lack of privacy

Pain. Anal fissure Thrombosed haemorrhoids Post – operative.

Metabolic/ endocrine. Hypothyroidism Hypercalcaemia Diabetic neuropathy

Drugs. Opiates Anticholinergics Diuretics

Neurological. Paraplegia MS

Functional Irritable bowel syndrome

Idiopathic megacolon/ rectum.

o Diarrhoea.

Infective. Bacterial

o Campylobacter

o Salmonella

o Shigella

Viralo Rotavirus

o Norwalk

o CMV

Protozoa.o Giardia lamblia

o Cryptosporidium

o Entamoeba histolytica.

Inflammatory. Inflammatory bowel disease Malignancy Radiation enteritis

Ischaemia Emboli Mesenteric atheromatous disease

Functional. Irritable bowel syndrome

Secretory. Infection.

o Eg. cholera

Zollinger – Ellison Carcinoid Villous adenoma Factitious diarrhoea.

o Eg. Laxative abuse.

Bile salt malabsorption.o Disruption of enterohepatic circulation.

Osmotic. Medications.

o Antacids

o Laculose

Disaccharide deficiency Factitious diarrhoea

Malabsorption Systemic disease.

Hyperthyroidism Diabetes mellitus Addison’s disease

Overflow Drugs.

Alcohol Digoxin Metformin Neomycin.

Ask about.

o Normal bowel habit & diet.

o Onset.

Sudden or chronic Infectious diarrhoea often causes acute onset.

o Frequency of defecation

o Stool appearance.

Formed, loose or watery? Colour.

Red Lower GI bleeds. Black Upper GI bleed Yellow Mucous & slime “Redcurrant jelly” Intussusception Putty – coloured Obstructive jaundice

o Volume

o Floating stools.

High fat content Think malabsorption.

o Drugs.

Antacids Laxatives Cimetidine Digoxin Antibiotics Alcohol.

o Tenesmus

o Smell.

Offensive smell suggests malabsorption Melaena has a distinctive smell.

o Infective contacts.

Foreign travel Contact with diarrhoea sufferers

o Relationship to food

o Stress

o Nocturnal symptoms

Goes against functional disorder o Surgical history.

Multiple bowel resections due to Crohn’s disease can cause malabsorption.o Sexual history.

Gay bowel syndrome Suspect if unusual organisms are cultured.

Lymph nodesInfectionsTBLymphoma

Hernial orifices

JointsExtraintestinal manifestations of IBD.

Rectal examAppearance of stoolFaecal impactionPerianal diseaseFistulae (Crohn’s)

Hands.Clubbing

Eyes.AnaemiaFeatures of thyrotoxicosis.Lid lagExopthalmosExtraintestinal manifestations of IBD.

SkinFlushing (carcinoid syndrome)RashesExtraintestinal manifestations of IBD.

AbdomenDistensionMassesTendernessBowel sounds

o Also ask about any associated features.

Pain Fever Vomiting Weight loss Symptoms of thyrotoxicosis.

Weight loss Heat intolerance Sweating Tremor Irritability Emotional labiality Oligomenorrhoea.

Extra – intestinal manifestations of inflammatory bowel disease. Clubbing Aphthous oral ulcers Erythema nodosum Pyoderma gangrenosum Conjunctivitis Episcleritis Iritis Large joint arthritis Sacro – illiitis Ankylosing spondylitis Fatty liver Primary sclerosing cholangitis Cholangiocarcinoma Renal stones Osteomalacia Nutritional deficits Amyloiditis.

Examination.

Investigations.

General- Temperature- Other signs of

infection- Nutritional

state

o Bloods.

FBC Malabsorption causes anaemia due to low.

o B12

o Folate

o Iron

U&E Severe profound secretory diarrhoea causes hyponatraemia

Calcium Thyroid function test Glucose LFTs

Albumin is decreased in.o Malabsorption

o Protein – losing enteropathies

o Inflammatory disease

Malabsorption causes low levels of fat – soluble vitamins, which causes.o Prolonged prothrombin time (Vitamin K)

o Hypocalcaemia (Vitamin D)

o Visual impairment (Vitamin A)

Rare. ESR CRP Antibodies.

If Coeliac disease suspected.o Anti – endomyseal

o Anti – reticulin

o α – gliadin

o Stool.

Microscopy Culture & sensitivity Faecal occult blood. Detection of C. Diff. toxin.

o Imaging.

AXR. Pancreatic calcification suggests chronic pancreatitis Distended intestinal loops and fluid level suggest obstruction Gross dilatation of the colon suggests Hirschprung’s disease

Rigid sigmoidoscopy. Can be performed without sedation in outpatients. Allows inspection/ biopsy of rectal mucosa.

Examination of the large bowel can be performed with Flexible sigmoidoscopy Colonoscopy Barium enema

Upper GI endoscopy. Can detect malabsorption Can take D2 biopsy.

Abdominal US or CT. Masses Pancreatitis

ERCP/ MRCP Biliary pathology Pancreatic pathology.

Barium meal/ enteroscopy. Small bowel pathology

o Specialised investigations.

Fat malabsorption Faecal fat estimation Carbon – 14 trioleate breath test.

Pancreas exotrine function. Pancrealauryl.

o Urinary levels of molecule cleaved by pancreatic enzymes.

Secretin.o Aspiration of duodenal juice after pancreas stimulation.

Mucosal function. Xylose absorption test

Assessment of enterohepatic circulation. Give radio – labelled bile acids.

Bacterial overgrowth. Lactose hydrogen breath test.

Protein – losing enteropathy. Faecal clearance of alpha – 1 – antitrypsin.

Confirm and quantify constipation. Colonic transit study.

Pelvic flood function. Defaecography. Anal manometry.

Specific blood tests. Serum vasoactive intestinal polypeptide.

o VIPoma

Serum gastrin.o Zollinger – Ellison syndrome

Calcitonin.o Medullary thyroid CA

Cortisol.o Addison’s disease

Urinary 5 – hydroxyindoleacetic acid.o Carcinoid syndrome.

Ulcerative colitis. Relapsing remitting inflammatory disorder of the colonic mucosa. May affect only the rectum.

o Proctitis.

o 50% of cases.

May affect only the left side of the colon.o 30% of cases.

May affect the whole rectum.o Pancolitis

o 20% of cases.

Never affects proximal of the illeocaecal valve.o Can cause secondary ileitis due to backwash.

Causes.o Unknown

o Thought to be some kind of genetic susceptibility.

Pathology.o Hyperaemic/ haemorrhagic granular colonic mucosa.

o Pseudopolyps due to inflammation

o Punctate ulcers may extend deep into lamina propria.

o Inflammation is normally not transmural.

Histology.o Inflammatory infiltrate

o Goblet cell depletion

o Glandular distortion

o Mucosal ulcers

o Crypt abscesses

Prevalence & Incidence.o 100 – 200/100,000

o 10 – 20/100,000/year

Epidemiology.o More males affected than females.

o Most present aged 15 – 30 years.

o Three times more common in non – smokers.

Contrast with Crohn’s Symptoms may relapse on stopping smoking.

Symptoms.o Gradual onset

Diarrhoea May be PR.

Blood Mucous.

o Crampy abdominal pain

o |Increased bowel frequency

o Systemic symptoms are common during attacks.

Fever Malaise Anorexia Weight loss

o With rectal disease there is.

Urgency

Tenesmus

Signs.o May be none.

o In acute, severe UC there may be.

Fever Tachycardia Tender, distended abdomen.

o Extraintestinal signs.

Clubbing Apthous oral ulcers Erythema nodosum Pyoderma gangrenosum Conjunctivitis Episcleritis Iritis Large joint arthritis Sacroiliitis Akylosing spondylitis Fatty liver Biliary disease Renal stones Osteomalacia Amyloiditis.

Investigations.o Bloods.

FBC U&E LFTs CRP ESR Cultures.

o Stool.

MC&S C. Diff toxin

o AXR.

No faecal shadowing Mucosal thickening/ islands Colonic dilatation

o Erect CXR.

Look for perforationo Sigmoidoscopy.

Inflamed friable mucosao Rectal biopsy.

See histology aboveo Barium enema

Loss of haustra Granular mucosa Shortened colon Never do during acute attack or as a diagnostic test.

o Colonoscopy.

Shows disease extent. Allows biopsy.

Severity of UC can be assessed using the Truelove – Witts criteria.Parameter Mild Moderate SevereMotions/day <4 4 – 6 >6Rectal bleeding Small Moderate LargeTemperature at 0600 Apyrexial 37.1 – 37.8 oC >37.8 oCPulse (bpm) <70 70 – 90 > 90Haemoglobin (g/dL) >11 10.5 – 11 < 10.5ESR < 30 mm/h > 30 mm/h

Complications.o Main dangers are.

Perforation Bleeding

o Toxic dilation of colon.

Mucosal islands Colonic diameter > 6 cm

o Venous thrombosis.

Consider prophylaxis during hospital admissiono Colonic cancer.

Rate of about 15% in patients with pancolitis for 20 years. Surveillance colonoscopy may be used.

Every 2 – 4 years. May not actually save lives.

Inducing remission.o Mild disease.

If patient well and < 4 motions/day. Prednisolone Mesalazine Mild distal disease.

PR steroids BD Hydrocortisone Prednisolone.

If symptoms don’t resolve within 2 weeks, escalate to moderate protocol.o Moderate.

Higher doses of steroids. If symptoms don’t resolve within 2 weeks, escalate to severe protocol.

o Severe.

If systemically unwell and passing >6 motions/day. Admit. Nil by mouth and IV hydration. IV hydrocortisone PR hydrocortisone. Monitor.

Temperature Pulse BP Stool frequency & character

Examine twice daily for. Abdominal distension.

Bowel sounds Tenderness

Daily. FBC ESR CRP U&E AXR

Consider need for blood transfusion if Hb < 10 g/dL Parentral nutrition only needed if severely malnourished. If improving by day 5, change management to

Prednisolone Sulfasalazine.

If, on day 3, CRP > 45 or stool frequency > 6, consider need for. Ciclosporin Infliximab Surgery.

o Topical therapies.

Proctitis may respond to suppositories. Prednisolone Mesalazine

Procto – sigmo Left – sided colitis may respond to retention enemas.

o Surgery.

20% will require surgery at some stage. Most common procedure is proctocolectomy with terminal ileostomy.

Sometimes possible to retain ileocaecal valve.o Reduces liquid loss.

An alternative is colectomy, with an ileo – anal pouch. Surgical mortality.

2 – 7% normally 50% if perforation has occurred. Pouchitis can be successfully treated with.

o 2 week course of antibiotic dual therapy.

Metronidazole Ciprofloxacin

o Immunosuppressants

o Novel therapies.

Ciclosporin Short course May induce faster remission in steroid – sensitive UC. Markedly nephrotoxic.

o Can only be used for short courses.

o Monitor with regular.

Blood levels U&E LFT BP

o Stop drug if bloods abnormal.

Oral tacrolimus. May help in steroid – sensitive UC.

Infliximab. May be effective as rescue therapy. Evidence is unclear

Nicotine. Transdermal Can induce remission Side effects.

o Dizziness

o Nausea.

Maintaining remission.o 5 – ASAs

Eg. Sulphasalazine Mesalazine Olsalazine

Sulphasalazine is the 1st line drug of choice. Reduce remission rate to 20% from 80%. Side effects.

Headache Nausea Anorexia Malaise Fever Rash Haemolysis Hepatitis Pancreatitis Oligospermia.

o Azothioprine.

Take after food. Indicated when

Steroids are causing unacceptable side effects. Relapse occurs quickly when steroid course is finished.

Treat for several months. Monitor FBC every 4 – 6 weeks.

Crohn’s disease. Chronic inflammatory GI disease. Characterised by

o Transmural ranulomatous inflammation.

o Skip lesions of unaffected bowel.

Can affect any part of the gut.o Favours terminal ileum and proximal colon.

o Affects this are in 50% of cases.

Cause.o Unknown

o Gene mutations increase risk.

NOD2 CARD15

Prevalence & incidence.o 50 – 100/100,000

o 5 – 10/100,000/year

Associations.o High sugar, low fibre diet.

o Anaerobes

o Mucins

o Altered cell – mediated immunity

o Smoking increases risk 3 – 4 times.

o NSAIDs may exacerbate disease.

Symptoms.o Diarrhoea

o Abdominal pain

o Weight loss

Failure to thrive in childreno Active disease causes.

Fever Malaise Anorexia

Signs.o Aphthous ulceration.

o Abdominal tenderness

o Right iliac fossa mass

o Perianal

Abscesses Fistulae Skin tags.

o Anorectal strictures.

o Extraintestinal signs.

As with ulcerative colitis.

Complications.o Small bowel obstruction

o Toxic dilation.

Colonic diameter > 6 cmo Abscess formation.

Abdominal Pelvic Ischiorectal

o Fistulae.

Present in 10% of cases. Colovesical (bladder) Colovaginal Perianal Enterocutaneous (skin)

o Rectal haemorrhage

o Colonic CA.

Not as common as in ulcerative colitis. Investigations.

o Bloods.

FBC U&E LFT ESR CRP Cultures If anaemia.

Red Cell Folate B12 Serum iron

Active disease will cause. Low Hb Raised ESR Raised CRP Raised WCC Low albumin

o Stool.

MC&S C. Diff toxin

o Sigmoidoscopy + biopsy.

Even if mucosa looks normal. 20% have microscopic granulomas.

o Small bowel enema.

Illial disease. Strictures Proximal dilatation Inflammatory mass Fistulae

o Capsule endoscopy.

Increasing role in assessing small bowel disease.o Barium enema.

Cobblestoning ‘Rose thorn’ ulcers Colon stricture with rectal sparing.

o Colonoscopy.

Preferred to barium enema to assess disease extent and take biopsies.o MRI.

Allows assessment of pelvic disease.

Management.o Severity is harder to assess than with UC.

o Severity is reflected by.

Pyrexia Tachycardia Raised ESR Raised CRP Raised WCC Low albumin

o If these features are present it warrants admission.

o Mild attacks.

Patients are symptomatic, but systemically well. Prednisolone.

High dose for 1 week Lower dose for 1 month.

Review in clinic every 2 – 4 weeks Reduce steroids when symptoms relieve,

o Severe attacks.

Admit. IV Hydrocortisone NBM & IV hydration PR hydrocortisone for rectal disease IV Metronidazole is helpful.

Especially in.o Perianal disease

o Superadded infection.

Side effects.o Alcohol intolerance

o Irreversible neuropathy

Monitor. Temperature Pulse BP Stool frequency and character

Twice daily examination. Daily.

FBC U&E ESR CRP Plain AXR

Consider need for blood transfusion if Hb < 10 g/dL Consider parentral nutrition If improving after 5 days.

Switch to oral prednisolone. If no response or deteriorating in spite of IV therapy.

Seek surgical advice.

o Perianal disease.

Occurs in about 50% of cases. MRI and examination under anaesthetic is an important part of assessment. Treatment includes.

Oral antibiotics. Immunosuppressant therapy Sometimes.

o Infliximab

o Local surgery

o Seton insertion.

o Other therapies.

Azathioprine. Effective therapy Useful as a steroid – sparing therapy. Takes 6 – 10 weeks to work.

Elemental diets. Made by mixing single amino acids. Antigen free Not as good as steroids at inducing remission Do have beneficial effect Low residue diet may help control activity. Diet alone is not effective at inducing remission.

Methotrexate. Weekly low – dose IM injections. Induce remission Allows complete withdrawal from steroid. No substantial side effects.

Infliximab Anti – TNF monoclonal antibody. Reduces Crohn’s activity Counters

o Neutrophil accumulation

o Granuloma formation

Activates complement. Cytotoxic to CD4+ cells. Can induce remission with a single dose Some studies show it can be used for maintenance. Contraindicated in.

o Sepsis

o Raised LFTs

o Ciclosporin therapy

o Tacrolimus therapy

Side effect of rash Sulphasalazine.

No role in Crohn’s

Surgery. 50 – 80% will need surgery at some point. In severe cases, can become cycle of deterioration. Indications.

o Failure to respond to drugs.

Most commonlyo Intestinal obstruction due to strictures

o Intestinal perforation

o Local complications

Fistulae Abscesses

Surgery is never curative. Aims are to.

o Provide rest for diseased distal areas.

Eg. With an ileostomy.o Resect most affected areas.

Can cause complications associated with short bowel. If small bowel is < 1 m long, parentral nutrition will be

required. Bypass or pouching surgery is not helpful in Crohn’s

Gastroenteritis. Ingesting bacteria, viruses or toxins is a common cause of diarrhoea and vomiting. Contaminated food and water are common sources.

o Often no specific cause is found.

Ask about.o Details of food and water taken.

o Cooking methods

o Time until onset of symptoms

o Whether fellow diners are ill

o Contact with water.

Swimming Canoeing

Food poisoning is a notifiable disease in the UK.

Source Incubation period Clinical features Notes/ sources of infection.

Staph Aureus 1 – 6 hours D&VPainHypotension

Meat

Bacillus cereus 1 – 5 hours D&V RiceSalmonella 12 – 48 hours D&V

PainFeverSepticaemia

MeatEggsPoultry

C. perfringens 8 – 24 hours DiarrhoeaPainAfebrile

Meat

C. botulinum 12 – 36 hours VomitingParalysis

Processed food

C. difficile 1 – 7 days Bloody diarrhoeaPainGI perforationToxic megacolon

Antibiotic – associatedStrain BI/NAP is very virulent.

Vibro parahaemolyticus 12 – 24 hours. Profuse D&VPain

Seafood

Vibro cholera 2 hours – 5 days Massive ‘rice water’ diarrhoea.FeverVomitingRapid dehydration

Water

Campylobacter 2 – 5 days Bloody DiarrhoeaPainFever

MilkPoultryWater

Listeria 2 – 5 days MeningoencephalitisMiscarriage‘flu – like symptoms

CheesePaté

E. coli 0157 12 – 72 hours ‘Rice water’ diarrhoea.FeverVomitingDehydration

Haemolytic – uraemic syndrome

Y. Enterocolitica 24 – 36 hours DiarrhoeaPainFever

Milk

Cryptosporidium 4 – 12 days DiarrhoeaPre – existing HIV

Cows are the other reservoir

Giardia lamblia 1 – 4 weeks DiarrhoeaMalabsorption

NappiesCatsDogsCrows

Entamoeba histolytica 1 – 4 weeks AsymptomaticMild diarrhoeaAmoebic dysentry

Water

Norovirus 36 – 72 hours FeverDiarrhoeaProjectile vomiting

Inhalation

Rotavirus 1 – 7 days D&VFeverMalaise

Infants aged > 6 weeks can be vaccinated.

Shigella 2 – 3 days Bloody diarrhoeaPainFever

Any food.

Source Incubation period Clinical features Notes/ sources of infection.

Red beans 1 – 3 hours D&VHeavy metals 5 minutes – 2 hours Vomiting

PainZinc poisoning.

Delayed fever Flu symptoms

Scrombotoxin 10 – 60 minutes DiarrhoeaFlushingSweatingErythemaHot mouth

Fish

Mushrooms 15 minutes – 24 hours D&VPainFitsComaHepatic failureRenal failure.

Investigations.o Stool.

Microscopy Culture & sensitivity.

o If high risk, MC&S food.

Returning traveller Institutionalised Outbreak suspected.

Prevention.o Hygiene

Avoid unboiled/ unbottled water, ice cubes and salad if abroad Peel own fruit Eat only freshly prepared hot food.

Management.o Usually symptomatic.

o Maintain fluid intake.

o Give oral rehydration salts.

o For severe symptoms, up to dysentery.

Antiemetics. Eg. Prochlorperazine

Antidiarrhoeals Codeine Loperamide

o Antibiotics only indicated if.

Systemically unwell Immunocompromised Elderly.

o Choice of antibiotic.

Resistance is common. Cholera.

Tetracycline

Salmonella, Shigella or Campylobacter. Ciprofloxacin