BOWEL MOVEMENT

Presented by:Abdullah Al-RuwaitaAbdullah Al-ManeaYousif Al-Ansari

Supervised by:Prof. Riaz Qureshi, FRCGP

Bowel movement

Normal Abnormal

Constipation Diarrhea

acute

Chronic

CONSTIPATION Dif: hard, dry, lumpy stools that are difficult or

painful to pass

Causes:

- Congenital or Primary.

- Secondary which includes:-Insufficient dietary fiber intake.-Inadequate fluid intake. -Decreased physical activity.-Side effects of medications.-Hypothyroidism.-Obstruction by colorectal cancer.

ACUTE DIARRHEA Dif: three or more loose or watery stools per

day, without abdominal bloating, pressure, and cramps commonly referred to as gas.

Causes:• Infections:

-Viral -Bacterial

- -Parasites• Intestinal disorders• Reaction to certain medications

CHRONIC DIARRHEA Dif: as loose stools that last for at least

four weeks, usually means three or more loose stools per day.

Causes:- Irritable bowel syndrome- Inflammatory bowel disease - Malabsorption syndromes- Chronic infections. 

Chronic diarrhea

Irritable bowel

syndrome

Inflammatory Bowel

Disease

Ulcerative colitis

Crohn's disease

Celiac Disease

Lactose intolerance

1 -IRRITABLE BOWEL SYNDROME Dif: is a gastrointestinal syndrome

characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. It is the most commonly diagnosed gastrointestinal condition.

EPIDEMIOLOGY prevalence of IBS in North America

estimated from population-based studies is approximately 10 to 15 percent

in Europe found an overall prevalence of 11.5 percent

2:1 female:male

CLINICAL MANIFESTATIONS 

Chronic abdominal pain (as a crampy sensation and abdominal pain)

Altered bowel habits (ranging from diarrhea, constipation)

- Diarrhea (frequent loose stools of small, fecal incontinence and feeling of incomplete evacuation)

- Constipation (Stools are often hard, may last from days to months)Other gastrointestinal symptoms 

Other gastrointestinal symptoms (Upper GI symptoms)

DIAGNOSTIC CRITERIA  Rome III diagnostic criteria: Recurrent abdominal pain or discomfort. at least 3 days per month in the last 3 months

associated with 2 or more of the following:

(1) Improvement with defecation(2) Onset associated with a change in frequency of stool(3) Onset associated with a change in form (appearance) of stool

DIAGNOSTIC APPROACH  many disorders present with similar

symptoms (r/o), Routine laboratory studies (complete

blood count, chemistries) are normal in IBS.

"Alarm" or atypical symptoms which are not compatible with IBS include (red flags) :

• Rectal bleeding• Nocturnal or progressive abdominal pain• Weight loss• Laboratory abnormalities such as anemia,

elevated inflammatory markers, or electrolyte disturbances

Patients with one of these alarm symptoms require further imaging studies and/or colonoscopy

CAUSES It is not clear why patients develop IBS. Sometimes it

occurs after an infection of the intestines. This is called post-infectious IBS. There may also be other triggers;

Brain-gut signal problems (thalamic activity). GI motor problems (unpleasant stimuli). Hypersensitivity (stimulation of various receptors in

the gut wall). Mental health problems (Such as anxiety,

depression). Bacterial gastroenteritis. Small intestinal bacterial overgrowth.  Food sensitivity (food intolerance to certain foods). Child Abuse

DIFFERENTIAL DIAGNOSIS Crohn's disease Ulcerative colitis Diverticulosis Celiac Disease Lactose intolerance Colon malignancy Peptic ulcer disease Biliary liver disease Chronic pancreatitis Medications Lymphoma of the GI

TREATMENT Patient education:Education of the proposed mechanisms of IBS helps to validate the patient's illness experience and sets the basis for therapeutic interventions

Dietary modification: dietary history may reveal patterns of symptoms related to specific foods.

- Lactose (similarity that may occur in symptoms of IBS and lactose intolerance, an empiric trial of a lactose free diet should be considered )

- Exclusion of gas-producing foods - Food allergies - Gluten sensitivity - Carbohydrate malabsorption - Fiber (increase in the intake of fiber is often recommended)

Physical activity 

Psychosocial therapies - Cognitive behavior therapy- Relaxation training- Gut-directed Hypnotherapy

MEDICATIONS:- Antispasmodic agentso Mebeverineo Alverineo Dicyclomine (an anticholinergic)- Antidepressants (TCAs, SSRIs)

TAKE HOME MESSAGE Mind and body often combine to

increase the distress of IBS patients.

Psychological intervention worth considering.

IBS patients can be managed well by family physicians.

Don’t forget “red flags” for referral to GI specialist is a must !

Chronic diarrhea

Irritable bowel

syndrome

Inflammatory Bowel Disease

Ulcerative colitis

Crohn's disease

Celiac Disease

Lactose intolerance

INFLAMMATORY BOWEL DISEASE Inflammatory bowel disease (IBD) is comprised of

two major disorders:

1.Ulcerative colitis (UC).2.Crohn's disease (CD).

•IBD can present at any age: –The peak :15 - 30 years. – A second peak 50

•Etiology is unknown but there are 3 main factors contributing to it : Genetic factors, environmental factors, diet.

1 -ULCERATIVE COLITIS Ulcerative colitis is characterized by

recurring episodes of inflammation limited to the mucosal layer of the colon.

•major symptoms of UC are: -Diarrhea -rectal bleeding     ( usually fresh blood )  -Tenesmus -passage of mucus -crampy abdominal pain

DIAGNOSIS : No single modality is enough for Diagnosis .

Combination of clinical picture, laboratory,  Endoscopy, pathology.

Colonscopy findings: –The vascular markings are lost, petechiae, exudates,

touch friability, and frank hemorrhage may be present.

–In Pathology,  biopsy shows : –Crypt abscesses. –chronic changes including branching of crypts,

atrophy of glands, and loss of mucin in goblet cells

MANAGEMENT: –Rule out infection

–5 ASA (5-amino salicylic acids)-  therapy: •Rectal ( if the UC extend less than 20 cm ) •Oral ( if the UC extend more than 20 cm +) in combination with

rectal 

–Corticosteroids:  •Systemic: Prednisolone •Local acting: enema.

–Immunomodulators : •Azithyoprine •Methotrexate

–Anti TNF therapy

2 -CROHN'S DISEASE  Is a disorder of uncertain etiology that is

characterized by transmural inflammation of the gastrointestinal tract.

SYMPTOMS: –Fatigue. –Diarrhea.  –Abdominal pain. –Weight loss. –Fever. –Bleeding is very rare.

DIAGNOSIS: Colonoscopy: • Endoscopic features include focal ulcerations adjacent to

areas of normal appearing mucosa along with polypoid mucosal changes that give a cobblestone

Wireless capsule endoscopy 

Serologic markers  •Inflamatory marker : ESR, CRP •Antibody tests : •Antineutrophil cytoplasmic antibodies (pANCA) > with UC •Anti-Saccharomyces cerevisiae antibodies (ASCA)  > with

CD Stool markers — fecal calprotectin.

COMPLICATIONS:The intestinal complications of Crohn's disease

include the following :-Intestinal obstruction

-Fistulas -Abscess

-Hemorrhage (bleeding) - Unusual in Crohn's disease -Malabsorption

-Carcinoma, Colonic disease increases risk of colon cancer

The longer you have Crohn's disease, the more likely you are to develop complications that can be fatal.

TREATMENT:The goals of treatment of Crohn's disease are

to reduce the underlying inflammation, which then relieves symptoms, prevents complications, and maintains good nutrition.

Aspirin-like anti-inflammatory drugs (mesalamine) reduce the inflammation.

Corticosteroids reduce inflammation and suppress the immune system.

Antibiotics reduce inflammation indirectly by reducing infection.

Immunosuppressants suppress the immune system.

Surgery. (alternative) .

CELIAC DISEASE Celiac disease is a medical condition in which the

absorptive surface of the small intestine is damaged by a substance called gluten. This results in an inability of the body to absorb nutrients: protein, fat, carbohydrates, vitamins and minerals, which are necessary for good health.

SYMPTOMS: –anemia. –chronic diarrhea. –weight loss. –Fatigue. –cramps and bloating. –irritability.

DIAGNOSIS: Screening

Biopsy: A definitive diagnosis can only be made by a small bowel biopsy.

TREATMENT: Celiac disease as yet has no known

cure, but can usually be effectively treated and controlled. The treatment of celiac disease is strict adherence to a GLUTEN FREE DIET FOR LIFE.

LACTOSE INTOLERANCE Lactose intolerance means the body cannot

easily digest lactose, a type of natural sugar found in milk and dairy products. Lactose intolerance occurs when the small intestine does not make enough of an enzyme called lactase.

Lactose intolerance most commonly runs in families, and symptoms usually develop during the teen or adult years.

It could be temporary 

SYMPTOMS: Symptoms of lactose intolerance can be mild

to severe, depending on how much lactase the body makes. Symptoms usually begin 30 minutes to 2 hours after eating or drinking milk products. symptoms may include:

•Bloating. •Pain or cramps. •Gurgling or rumbling sounds in your belly. •Gas. •Loose stools or diarrhea. •Throwing up.

DIAGNOSIS: medical history.

To confirm a diagnosis: -Hydrogen breath test -Lactose tolerance test

TREATMENT: Fortunately, lactose intolerance is

relatively easy to treat. No known way exists to increase the amount of lactase enzyme the body can make, but symptoms can be controlled through diet.

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