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DIARRHOEA AND CONSTIPATION

DIARRHOEA AND CONSTIPATION

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DIARRHOEA AND CONSTIPATION. Diarrhoea. Definition: Abnormal passage of loose or liquid stools more than 3 times daily and/or a volume of stool greater than 200g/day (British Society of Gastroenterology) Acute diarrhoea : < 4 weeks, usually self-limiting Chronic diarrhoea : > 4 weeks . - PowerPoint PPT Presentation

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Page 1: DIARRHOEA AND CONSTIPATION

DIARRHOEAAND

CONSTIPATION

Page 2: DIARRHOEA AND CONSTIPATION

DiarrhoeaDefinition: Abnormal passage of loose or liquid

stools more than 3 times daily and/or a volume of stool greater than 200g/day (British Society of Gastroenterology)

Acute diarrhoea: < 4 weeks, usually self-limiting

Chronic diarrhoea: > 4 weeks

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Pathophysiology1) Increased osmotic load in the gut lumen

(osmotic diarrhoea)

2) Increase in secretion (secretory diarrhoea)

3) Inflammation of the intestinal lining ie IBD

4) Increased intestinal motilityCan involve more than 1 mechanism!

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Causes of diarrhoeaAcute ChronicBacterial and viral infection ie Salmonella, E.coli, Cl. Difficile

Infection: (less likely to be chronic)

Drugs ie allopurinol, Ang II receptor blocker, antibiotics, digoxin, NSAIDs, PPI, SSRI, statins

Functional: Irritable bowel syndrome

Anxiety Diet: Lactose intolerance

Food Allergy Inflammation: IBD – UC, Chron’s

Acute appendicitis Surgery: intestinal/gastric bypass/resection

Acute radiation enteritis Malabsorption syndrome: Coeliac disease, pancreatic insufficiency

Intestinal ischemia – assess CVS risk Tumors: colorectal carcinoma, lymphoma, endocrine tumor: VIPoma, gastrinoma, carcinoid

Endocrine: Hyperthyroidism

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Infective Gastroenteritis

According to Health Protection Agency and Health Protection Scotland: Most common cause:

Causal agent Description

Campylobacter (46%) -transmit through raw, undercooked meat esp poultry, incubation period 2-5 days, bloody diarrhea, abdominal pain, vomiting (uncommon), possible toxic megacolon

Rotavirus (19%) -most common cause of childhood diarrhoea, watery diarrhoea

Norovirus (14%) -outbreaks are difficult to contain, transmit by aerosol & faecal oral,, watery diarrhoea, identify the virus doesn’t alter the management

Salmonella (12%) -transmit from red and white meats, raw or undercooked eggs, milk, dairy products, or person to person. Watery diarrhoea, vomiting, fever

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E.Coli (2%) -Shiga toxin producing E.coli (STEC), transmit from undercooked ground beef, water, cross contamination of cooked products,has potentially serious complication esp HUS, range from mild diarrhoea to haemorrhagic colitis, severe abdominal painEnterotoxigenic E.coli, transmit by feacally contaminated food or water, causes watery diarrhoea

Shigella (1%) -can cause bloody diarrhoea

Acute dysentry = frequent, small bowel movements, accompanied by blood and mucous with tenesmus or pain on defeacation

WHY?Invasive bacteria (most likely Campylobacter, Shigella, STEC) causes inflammatory invasion of colonic mucosa. Feacal leukocytes are present.

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What about watery diarrhoea?- usually typical of small intestinal infection, non-inflammatory process ,

confirmed by absence of feacal leukocytes- mediated by bacterial endotoxins that alter fluid and electrolyte

transport ie:

• Vibrio cholerae: transmit through contaminated water/seafood, rice water stool

• Cl. Difficile: usually due to antibiotics ~4-9 days (ie ampicillin, amoxicillin), varies from mild watery diarrhoea to severe bloody diarrhoea. Complications include hypovolemic shock, toxic megacolon, perforation, haemorrhage, sepsis, eradicate using metronidazole, and withdraw other antibiotics!

• Enterotoxigenic E.coli, Salmonella, Cryptosporidium, Cl.perfringen, Bacillus cereus, Giardia lamblia, rotavirus, norovirus

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Red flag signs for Diarrhoea!!!1) Unintentional and unexplained weight loss2) Rectal bleeding3) Diarrhoea persisting for more than 6

weeks, in a person over 60 years of age4) Family history of bowel or ovarian cancer5) Abdominal mass6) Rectal mass7) Anaemia8) Raised inflammatory markers (may indicate

inflammatory bowel disease).

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Investigation1) Full blood count — to detect anaemia or raised platelet count suggesting inflammation2) Blood culture if its infective cause3) Liver function tests, including albumin level.4) Tests for malabsorption:

Calcium.Vitamin B12 and red blood cell folate.Iron status (ferritin).

5) Thyroid function tests.6) ESR & CRP — elevated levels may indicate IBD7) Antibody testing for coeliac disease — immunoglobulin (Ig)A tissue transglutaminase antibody (tTGA), or IgA endomysial antibody (EMA).

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InvestigationConsider sending stool for culture and sensitivity and examination for ova, cysts and parasites, if an infectious cause is suspected or there is a history of travel to high-risk areas.

Send three specimens (5 mL each) 2–3 days apart, as ova, cysts, and parasites are shed intermittently.

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Management

Treat the cause!

1) Oral rehydration (better than IV), if impossible give 0.9% saline + 20 mmol K+/L IVI

2) Codeine phosphate 30mg/6 hrs3) Loperamide 2mg PO 4) Avoid antibiotics except in infective diarrhoea

causing systemic illness

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CONSTIPATION

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Definition of constipation:

= difficult or infrequent passage of stool ( <3x a week) , hardness of stool, or a feeling of incomplete evacuation.

Absolute constipation:Failure to pass any stools.

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Types of constipation:

1) Functional/primary/idiopathic constipation =chronic constipation without a known cause

2) Secondary/organic constipation - caused by medical conditions or drugs ie opioids, TCA, antispasmodic, calcium supplement, aluminium antacids

3) Faecal loading/impaction

4) Overflow incontinence/ bypass soiling/encopresis leakage of loose stool around impacted faeces.

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Pathophysiology1) Colonic inertia (reduced bowel movement)

2) Outlet delay constipation (or obstructed defecation) which can be caused by pelvic floor dyssynergia (the pelvic floor muscles contract or fail to relax during attempted defecation), and by anismus (the external anal sphincter contracts instead of relaxing during attempted defecation

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Causes of ConstipationAcute constipationBowel obstruction

Volvulus, hernia, adhesions, fecal impaction

Adynamic ileus Peritonitis, major acute illness (eg, sepsis), head or spinal trauma

Drugs Anticholinergics (eg, antihistamines, antipsychotics, antiparkinsonian drugs, antispasmodics), cations (iron, aluminum, Ca, barium, bismuth), opioids, Ca channel blockers, general anesthesia

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Chronic constipation Colonic tumor Adenoca of sigmoid colonMetabolic disorders

DM, hypothyroidism, hypocalcemia or hypercalcemia, pregnancy, uremia, porphyria

CNS disorders Parkinson's disease, MS , stroke, spinal cord lesions

Peripheral nervous system disorders

Hirschsprung's disease, neurofibromatosis, autonomic neuropathy

Systemic disordersSystemic sclerosis, amyloidosis, dermatomyositis, myotonic dystrophy

Functional Slow-transit constipation, irritable bowel syndrome, pelvic floor dysfunction (functional defecatory disorders)

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Predisposing factors

1) Social factors: Low fibre diet2) Lifestyle: Difficult access to toilet, or changes

in routine/lifestyle, Lack of exercise; reduced mobility.

3) Psychological: Anxiety, Depression, Somatization, Eating disorders

4) Physical: Mild pyrexia, dehydration, immobility.

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RED FLAGS FOR CONSTIPATION!1) Persistent unexplained change in bowel habits?2) Palpable mass 3) Persistent rectal bleeding without anal symptoms4) Distended, tympanitic abdomen5) Vomiting6) Family history of colon cancer, IBD7) Unexplained weight loss, iron deficiency anaemia,

fever, or nocturnal symptoms8) Severe, persistent constipation that is unresponsive

to treatment

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How to interpret clinical findings:

1)Abdominal pain2)Vomiting3)Abdominal distention4)Progress of condition5)Sigmoid volvolus6)Ischemia/perforation7)Pseudo obstruction

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How to interpret clinical findings:

How to differentiate Intestinal Obstruction & paralytic Ileus ?IO – partial active, tinkling bowel sounds complete absent bowel sounds & absent flatus, usually severe vomiting

PI – absent bowel sounds & flatus is present

SO?Radiology!

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Small bowel obstructionGallstone ileus-multiple dilated small bowel ThroughoutSMALL ALL->3cm is abnormal-valvulae conniventes -paucity of gas in bowel beyond site of obstruction

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Paralytic ileus

• White arrow – multiple dilated small bowel loops

• Black arrow- surgical staples

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To differentiate small bowel obstruction and paralytic ileus

• CT scan to exclude any obstruction, if there’s no obstruction, check medical history:ie previous surgery or electrolyte imbalance such as hypo/hyperkalemia, hypocalcemia, hypomagnesemia indicates paralytic ileus

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Large Bowel Obstruction

Colon Ca-dilated bowel loops proximal to obstruction-dilated large

bowel loop >6cm

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InvestigationsDepends on clinical findings:1) Constipation with a clear etiology (drugs, trauma) may be treated

symptomatically without further study. 2) Blood tests: FBC, U&E, Ca2+, TFT If suspected malignancy, proceed with:4) Abdominal X-ray5) Sigmoidoscopy and biopsy of abnormal mucosa6) Colonoscopy7) Water soluble contrast enema8) CT Scan or barium X-ray

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Management1) Adjust any constipating medication, if possible.2) Increasing dietary fibre, drinking an adequate fluid intake,

and exercise3) Offer oral laxatives if dietary measures are ineffective, or

while waiting for them to take effect.1) Bulk-forming laxative ie ispaghula husk, methylcellulose,

sterculia, frangula2) Osmotic laxative ie lactulose, macrogols (polyethylene

glycols)3) Stimulant laxative ie bisacodyl, senna, sodium

picosulfate• Laxatives can be stopped once the stools become soft and easily passed

again

Page 28: DIARRHOEA AND CONSTIPATION

Questions1) A 20 year old girl presents with abdominal pain and recently up to 15 bouts of

diarrhoea containing blood and mucus. Her stool culture is negative IBD2) A 23 year old medical student is on elective in Thailand, when he develops

cramping abdominal pain and a watery diarrhoea after drinking the local water. It is self limiting and resolves after few days Entero E.coli

3) A 36 year old woman presents with weight loss, general abdominal discomfort and steatorrhoea. On examination she appears pale and malnourished. Gastric ca

4) A 36 year old woman presents with abdominal pain and an acute watery diarrhoea containing blood. She has no significant PMH apart from a recent pneumonia which was treated with amoxicillin Cl.difficile

A: chronic gastritisB: Cl. Difficile infectionC: IBDD: gastric ca E: Enterotoxigenic E.coliF: ischaemic colitisG: Colorectal CaH: Cholera