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Diarrhoea
Lent term year 2
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The Case: Mr JK aged 25• Loose, frequent motions for 2 years• Now presents with more severe diarrhoea
with bleeding and pain in the RIF• On examination: T374C, ill-defined tender
mass in RIF• PR: painful, with anal fissure• PMH: arthritis affecting various joints
which resolved, episode of uveitis 1 year ago
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Differential diagnosis?
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Wide differential diagnosis
• Infective
• Malabsorption
• Malignancy
• Inflammatory
• Iatrogenic
• Motility disorder/functional
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Infections: viruses
• Rotavirus (most common cause in children in UK)
• Norwalk virus (of genus norovirus) occurs in outbreaks- the “Winter vomiting bug”
• Ebola virus- mortality 50-100%
• Enteric adenovirus- usually respiratory infection
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Infections: bacteria• e.coli: 057:H7 one to avoid (enterotoxin)• Salmonella (raw chicken and eggs)• Schigella (bacillary dysentery) Infectivity dose
(ID) very low- 10-100• Vibrio Cholerae (nb John Snow 1854)• Clostridium perfringens (pig-bel) and difficile • Typhoid/paratyphoid (salmonelli typhi/paratyphi)• Bacillus cereus (beware pre-cooked rice)• Campylobacter (beware undercooked chicken)• Listeria- (avoid eating unpasteurised cheese in
pregnancy)
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Infections: parasites• Amoebic dysentery: (Tropical) entamoeba
histolytica. Infective in cyst form
• Giardia lamblia (Giardiasis) Infective in cyst form Low ID. Can be caught in swimming pools
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Stool microscopy:giardia
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And yet more…
• Whipple’s disease Tropheryma whippelii.
Tropical. Causes malabsorption
• Tropical sprue. Another cause of malabsorption ??infective organism
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Don’t forget worms
• roundworm (Ascaris lumbricoides) Can cause intestinal obstruction
• whipworm (Trichuris trichiura) and
• hookworm (Ancylostoma duodenale and Necator americanus).
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Roundworms resected
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Malabsorption
• Coeliac disease
• Cystic fibrosis (lack pancreatic enzymes)
• Lactose intolerance
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Malignancy• Carcinoma of large bowel
• Carcinoid tumour: neuroendocrine tumour usually found in appendix of small bowel
• May produce serotonin and cause carcinoid syndrome: diarrhoea
flushing of the skin, wheezing (similar to asthma), loss of appetite, weight loss.
• Benign villous adenoma
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Inflammatory bowel disease
• Crohn’s disease. Can affect multiple sites from lips to anus. Can affect full thickness of bowel with fistula formation. Can get “skip lesions”. Often affects terminal ileum
• Ulcerative colitis Colon and rectum only- rectum in 95% cases
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Crohn’s disease
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iatrogenic
• Short bowel syndrome
• Laxatives
• Radiotherapy
• Chemotherapy: antibiotics, cytotoxic drugs
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Motility disorder/function
• Diabetic neuropathy
• Ischaemic bowel
• Hyperthyroidism
• IBS
• Overflow (associated with constipation)
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How would you investigate this patient?
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Possible investigations:
• Stool culture (negative)
• Blood tests:
Hb 10.0g/dl
ESR 60 mm/hr
Albumin: 28g/dl
WCC- 14,000
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CT scan:
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Barium follow-through
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Barium enema
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Nuclear scanning: white cell scanning
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So the diagnosis was………!