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Hospital Based Practice – Altered bowel habits.

History
• Always check what is normal for the patient.
○ 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.
○ Constipation.
 Congenital.
• Hirschprung’s disease
 Mechanical obstruction.
• Inflammatory stricture.
○ Crohn’s disease
○ Diverticulitis
• Neoplasm
• Extra – luminal mass
○ 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.

○ Diarrhoea.
 Infective.
• Bacterial
○ Campylobacter
○ Salmonella
○ Shigella
• Viral
○ Rotavirus
○ Norwalk
○ CMV
• Protozoa.
○ Giardia lamblia
○ Cryptosporidium
○ Entamoeba histolytica.
 Inflammatory.
• Inflammatory bowel disease
• Malignancy
• Radiation enteritis
 Ischaemia
• Emboli
• Mesenteric atheromatous disease
 Functional.
• Irritable bowel syndrome
 Secretory.
• Infection.
○ Eg. cholera
• Zollinger – Ellison
• Carcinoid
• Villous adenoma
• Factitious diarrhoea.
○ Eg. Laxative abuse.
• Bile salt malabsorption.
○ Disruption of enterohepatic circulation.
 Osmotic.
• Medications.
○ Antacids
○ Laculose
• Disaccharide deficiency
• Factitious diarrhoea
 Malabsorption
 Systemic disease.
• Hyperthyroidism
• Diabetes mellitus
• Addison’s disease
 Overflow
 Drugs.
• Alcohol
• Digoxin
• Metformin
• Neomycin.

• Ask about.
○ Normal bowel habit & diet.
○ Onset.
 Sudden or chronic
 Infectious diarrhoea often causes acute onset.
○ Frequency of defecation
○ 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
○ Volume
○ Floating stools.
 High fat content
 Think malabsorption.
○ Drugs.
 Antacids
 Laxatives
 Cimetidine
 Digoxin
 Antibiotics
 Alcohol.
○ Tenesmus
○ Smell.
 Offensive smell suggests malabsorption
 Melaena has a distinctive smell.
○ Infective contacts.
 Foreign travel
 Contact with diarrhoea sufferers
○ Relationship to food
○ Stress
○ Nocturnal symptoms
 Goes against functional disorder
○ Surgical history.
 Multiple bowel resections due to Crohn’s disease can cause malabsorption.
○ Sexual history.
 Gay bowel syndrome
 Suspect if unusual organisms are cultured.

○ 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.

General
– Temperature
Abdomen
Lymph
Hernial
Joints
Rectal
Hands.
Eyes.
Skin exam
nodes
orifices – Other signs of
Infections(carcinoid
Extraintestinal
Appearance
Clubbing
Anaemia
Flushing
Distension of stool infection
TB
manifestations
Faecal
Features
syndrome)
Masses impaction
of thyrotoxicosis.
of – Nutritional
Lymphoma
IBD.
Perianal
Lid
Rashes
Tenderness
lag disease state
Fistulaesounds
Exopthalmos
Extraintestinal
Bowel (Crohn’s)
Extraintestinal of IBD.
manifestations
manifestations of IBD.

• Investigations.
○ Bloods.
 FBC
• Malabsorption causes anaemia due to low.
○ B12
○ Folate
○ Iron
 U&E
• Severe profound secretory diarrhoea causes hyponatraemia
 Calcium
 Thyroid function test
 Glucose
 LFTs
• Albumin is decreased in.
○ Malabsorption
○ Protein – losing enteropathies
○ Inflammatory disease
• Malabsorption causes low levels of fat – soluble vitamins, which causes.
○ Prolonged prothrombin time (Vitamin K)
○ Hypocalcaemia (Vitamin D)
○ Visual impairment (Vitamin A)
 Rare.
 ESR
 CRP
 Antibodies.
• If Coeliac disease suspected.
○ Anti – endomyseal
○ Anti – reticulin
○ α – gliadin
○ Stool.
 Microscopy
 Culture & sensitivity
 Faecal occult blood.
 Detection of C. Diff. toxin.

○ 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

○ Specialised investigations.
 Fat malabsorption
• Faecal fat estimation
• Carbon – 14 trioleate breath test.
 Pancreas exotrine function.
• Pancrealauryl.
○ Urinary levels of molecule cleaved by pancreatic enzymes.
• Secretin.
○ 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.
○ VIPoma
• Serum gastrin.
○ Zollinger – Ellison syndrome
• Calcitonin.
○ Medullary thyroid CA
• Cortisol.
○ Addison’s disease
• Urinary 5 – hydroxyindoleacetic acid.
○ Carcinoid syndrome.

Ulcerative colitis.
• Relapsing remitting inflammatory disorder of the colonic mucosa.
• May affect only the rectum.
○ Proctitis.
○ 50% of cases.
• May affect only the left side of the colon.
○ 30% of cases.
• May affect the whole rectum.
○ Pancolitis
○ 20% of cases.
• Never affects proximal of the illeocaecal valve.
○ Can cause secondary ileitis due to backwash.
• Causes.
○ Unknown
○ Thought to be some kind of genetic susceptibility.
• Pathology.
○ Hyperaemic/ haemorrhagic granular colonic mucosa.
○ Pseudopolyps due to inflammation
○ Punctate ulcers may extend deep into lamina propria.
○ Inflammation is normally not transmural.
• Histology.
○ Inflammatory infiltrate
○ Goblet cell depletion
○ Glandular distortion
○ Mucosal ulcers
○ Crypt abscesses
• Prevalence & Incidence.
○ 100 – 200/100,000
○ 10 – 20/100,000/year
• Epidemiology.
○ More males affected than females.
○ Most present aged 15 – 30 years.
○ Three times more common in non – smokers.
 Contrast with Crohn’s
 Symptoms may relapse on stopping smoking.
• Symptoms.
○ Gradual onset
 Diarrhoea
 May be PR.
• Blood
• Mucous.
○ Crampy abdominal pain
○ |Increased bowel frequency
○ Systemic symptoms are common during attacks.
 Fever
 Malaise
 Anorexia
 Weight loss
○ With rectal disease there is.
 Urgency
 Tenesmus

• Signs.
○ May be none.
○ In acute, severe UC there may be.
 Fever
 Tachycardia
 Tender, distended abdomen.
○ 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.
○ Bloods.
 FBC
 U&E
 LFTs
 CRP
 ESR
 Cultures.
○ Stool.
 MC&S
 C. Diff toxin
○ AXR.
 No faecal shadowing
 Mucosal thickening/ islands
 Colonic dilatation
○ Erect CXR.
 Look for perforation
○ Sigmoidoscopy.
 Inflamed friable mucosa
○ Rectal biopsy.
 See histology above
○ Barium enema
 Loss of haustra
 Granular mucosa
 Shortened colon
 Never do during acute attack or as a diagnostic test.
○ Colonoscopy.
 Shows disease extent.
 Allows biopsy.
• Severity of UC can be assessed using the Truelove – Witts criteria.
Parameter Mild Moderate Severe

Motions/day <4 4–6 >6

Rectal bleeding Small Moderate Large

Temperature at 0600 Apyrexial 37.1 – 37.8 oC >37.8 oC

Pulse (bpm) <70 70 – 90 > 90

Haemoglobin (g/dL) >11 10.5 – 11 < 10.5

ESR < 30 mm/h > 30 mm/h

• Complications.
○ Main dangers are.
 Perforation
 Bleeding
○ Toxic dilation of colon.
 Mucosal islands
 Colonic diameter > 6 cm
○ Venous thrombosis.
 Consider prophylaxis during hospital admission
○ 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.
○ 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.
○ Moderate.
 Higher doses of steroids.
 If symptoms don’t resolve within 2 weeks, escalate to severe protocol.
○ 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.

○ Topical therapies.
 Proctitis may respond to suppositories.
• Prednisolone
• Mesalazine
 Procto – sigmo
 Left – sided colitis may respond to retention enemas.
○ Surgery.
 20% will require surgery at some stage.
 Most common procedure is proctocolectomy with terminal ileostomy.
• Sometimes possible to retain ileocaecal valve.
○ 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.
○ 2 week course of antibiotic dual therapy.
 Metronidazole
 Ciprofloxacin
○ Immunosuppressants

○ Novel therapies.
 Ciclosporin
• Short course
• May induce faster remission in steroid – sensitive UC.
• Markedly nephrotoxic.
○ Can only be used for short courses.
○ Monitor with regular.
 Blood levels
 U&E
 LFT
 BP
○ 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.
○ Dizziness
○ Nausea.
• Maintaining remission.
○ 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.
○ 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
○ Transmural ranulomatous inflammation.
○ Skip lesions of unaffected bowel.
• Can affect any part of the gut.
○ Favours terminal ileum and proximal colon.
○ Affects this are in 50% of cases.
• Cause.
○ Unknown
○ Gene mutations increase risk.
 NOD2
 CARD15
• Prevalence & incidence.
○ 50 – 100/100,000
○ 5 – 10/100,000/year
• Associations.
○ High sugar, low fibre diet.
○ Anaerobes
○ Mucins
○ Altered cell – mediated immunity
○ Smoking increases risk 3 – 4 times.
○ NSAIDs may exacerbate disease.
• Symptoms.
○ Diarrhoea
○ Abdominal pain
○ Weight loss
 Failure to thrive in children
○ Active disease causes.
 Fever
 Malaise
 Anorexia
• Signs.
○ Aphthous ulceration.
○ Abdominal tenderness
○ Right iliac fossa mass
○ Perianal
 Abscesses
 Fistulae
 Skin tags.
○ Anorectal strictures.
○ Extraintestinal signs.
 As with ulcerative colitis.

• Complications.
○ Small bowel obstruction
○ Toxic dilation.
 Colonic diameter > 6 cm
○ Abscess formation.
 Abdominal
 Pelvic
 Ischiorectal
○ Fistulae.
 Present in 10% of cases.
 Colovesical (bladder)
 Colovaginal
 Perianal
 Enterocutaneous (skin)
○ Rectal haemorrhage
○ Colonic CA.
 Not as common as in ulcerative colitis.
• Investigations.
○ 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
○ Stool.
 MC&S
 C. Diff toxin
○ Sigmoidoscopy + biopsy.
 Even if mucosa looks normal.
 20% have microscopic granulomas.
○ Small bowel enema.
 Illial disease.
• Strictures
• Proximal dilatation
• Inflammatory mass
• Fistulae

○ Capsule endoscopy.
 Increasing role in assessing small bowel disease.
○ Barium enema.
 Cobblestoning
 ‘Rose thorn’ ulcers
 Colon stricture with rectal sparing.
○ Colonoscopy.
 Preferred to barium enema to assess disease extent and take biopsies.
○ MRI.
 Allows assessment of pelvic disease.

• Management.
○ Severity is harder to assess than with UC.
○ Severity is reflected by.
 Pyrexia
 Tachycardia
 Raised ESR
 Raised CRP
 Raised WCC
 Low albumin
○ If these features are present it warrants admission.

○ 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,

○ Severe attacks.
 Admit.
 IV Hydrocortisone
 NBM & IV hydration
 PR hydrocortisone for rectal disease
 IV Metronidazole is helpful.
• Especially in.
○ Perianal disease
○ Superadded infection.
• Side effects.
○ Alcohol intolerance
○ 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.
○ 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.
○ Infliximab
○ Local surgery
○ Seton insertion.

○ 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
○ Neutrophil accumulation
○ 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.
○ Sepsis
○ Raised LFTs
○ Ciclosporin therapy
○ 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.
○ Failure to respond to drugs.
 Most commonly
○ Intestinal obstruction due to strictures
○ Intestinal perforation
○ Local complications
 Fistulae
 Abscesses
• Surgery is never curative.
• Aims are to.
○ Provide rest for diseased distal areas.
 Eg. With an ileostomy.
○ 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.
○ Often no specific cause is found.
• Ask about.
○ Details of food and water taken.
○ Cooking methods
○ Time until onset of symptoms
○ Whether fellow diners are ill
○ 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&V Meat

Pain

Hypotension

Bacillus cereus 1 – 5 hours D&V Rice

Salmonella 12 – 48 hours D&V Meat

Pain Eggs

Fever Poultry

Septicaemia

C. perfringens 8 – 24 hours Diarrhoea Meat

Pain

Afebrile

C. botulinum 12 – 36 hours Vomiting Processed food

Paralysis

C. difficile 1 – 7 days Bloody diarrhoea Antibiotic – associated

Pain Strain BI/NAP is very


virulent.
GI perforation

Toxic megacolon

Vibro parahaemolyticus 12 – 24 hours. Profuse D&V Seafood

Pain

Vibro cholera 2 hours – 5 days Massive ‘rice water’ Water


diarrhoea.

Fever

Vomiting

Rapid dehydration

Campylobacter 2 – 5 days Bloody Diarrhoea Milk

Pain Poultry

Fever Water

Listeria 2 – 5 days Meningoencephalitis Cheese

Miscarriage Paté

‘flu – like symptoms

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


syndrome
Fever

Vomiting

Dehydration

Y. Enterocolitica 24 – 36 hours Diarrhoea Milk

Pain

Fever

Cryptosporidium 4 – 12 days Diarrhoea Cows are the other


reservoir
Pre – existing HIV

Giardia lamblia 1 – 4 weeks Diarrhoea Nappies

Malabsorption Cats

Dogs

Crows

Entamoeba histolytica 1 – 4 weeks Asymptomatic Water

Mild diarrhoea

Amoebic dysentry

Norovirus 36 – 72 hours Fever Inhalation

Diarrhoea

Projectile vomiting

Rotavirus 1 – 7 days D&V Infants aged > 6 weeks


can be vaccinated.
Fever
Malaise

Shigella 2 – 3 days Bloody diarrhoea Any food.

Pain

Fever

Source Incubation period Clinical features Notes/ sources of


infection.

Red beans 1 – 3 hours D&V

Heavy metals 5 minutes – 2 hours Vomiting

Pain

Zinc poisoning.

➢ Delayed fever
➢ Flu symptoms

Scrombotoxin 10 – 60 minutes Diarrhoea Fish

Flushing

Sweating

Erythema

Hot mouth

Mushrooms 15 minutes – 24 hours D&V

Pain

Fits

Coma

Hepatic failure

Renal failure.

• Investigations.
○ Stool.
 Microscopy
 Culture & sensitivity.
○ If high risk, MC&S food.
 Returning traveller
 Institutionalised
 Outbreak suspected.
• Prevention.
○ Hygiene
 Avoid unboiled/ unbottled water, ice cubes and salad if abroad
 Peel own fruit
 Eat only freshly prepared hot food.
• Management.
○ Usually symptomatic.
○ Maintain fluid intake.
○ Give oral rehydration salts.
○ For severe symptoms, up to dysentery.
 Antiemetics.
• Eg. Prochlorperazine
 Antidiarrhoeals
• Codeine
• Loperamide
○ Antibiotics only indicated if.
 Systemically unwell
 Immunocompromised
 Elderly.
○ Choice of antibiotic.
 Resistance is common.
 Cholera.
• Tetracycline
 Salmonella, Shigella or Campylobacter.
• Ciprofloxacin