GI diseases II. Tomas Koller, MD. PhD. Assoc. Prof.

Acute diarrhea

Acute diarrhea Definition

>3x/day, >300 g/day

<2 weeks, mostly<1 week

Abrupt onset

Mostly infectious origin

Does not relapse

Acute diarrhea

• Dysenteric syndrome

• Content of pus and blood separated from the stool

• Tenesms (pianful urgency)

• Balloning

• Distal colon

Acute diarrhea Causes

• Toxins from bacteria

• Incubation short (hours)

• Staphylococcus aureus

• Bacillus cereus

• Clostridium perfringens

• Infection

• Incubation <24h

• Viruses

• Salmonella

• Campylobacter

• E.Coli enterohemorhagic

• Yersinia enterocolitica

• Giardia intestinalis

Acute diarrhea Diagnosis

• Diagnosis is clinical

• Evaluate for hypovolemia

• BP<90 mmHg, pulse<120/min

• Oliguria

• Capullary refill tie >3s

• Cold and pale extremities

• Marble skin

• Hypokaliemia

• Abdominal palpation

• Sensibility diffuse due to air

Acute diarrhea Diagnostic workup

• Not indicated unless:

• Blood in the stool, dysenteric syndrome = organic origin

• Signs of sepsis (>39˚C), septic shock, hypothermia

• Severe dehydration

• Cardiac valve disease, elderly, comorbid

• Persisting diarrhea > 3 days

• Full blood count, CRP, stool culture focused on Salmonella, Shigella, Campylobacter, Yersinia, E.Coli 0157

• Dehydration , Na, K , Cl

• Blood in the stool > 4 days, sigmoidoscopy

• Sepsis - hemoculture

Acute diarrhea Therapy

• Symptomatic

• Rehydration

• Correction of electrolytes

• Spontaneous evolution is favorable

• < 5 days

• In patients with sepsis, or risk factors and severe condition

• Bacterial or parasitic agent is identified

• Antibiotics could be prescribed for Campylobacter, Yersinia

• Ciprofloxacin 2x500 mg 3-5 days

• Macrolides (Camppylbacter)

• Antiparasitic drug for Amoeba, Gardia

• Metronidazol

Nosocomial acute diarrhea

• Risk factors

• antibiotics,

• age,

• time in the hospital,

• source of infection in the proximity

• Clostriudium difficile

• Giardia

• Multiresistant microbes

• Klebsiella

• Enterococci

Travellers diarrhea

• During travel or after returning from a trip

• Dysbiosis (loose stools) is frequent, short and benign

• Higher probability of parasitic infection

• Amoeba

• Depending on the country

Acute diarrhea post-antibiotic

• 10% of patients receiving antibiotics have some transit modification

• Usually bening diarrhea after 3-5 days

• No fever, spontaneously terminates

• No therapy

• 10% of post antibiotic diarrhea

• Clostriudiumm difficile (pseudomembranous colitis)

• Klebsiella oxytoca (bloody diarrhea)

• Toxin A or B in the stool

• Glutamate dehydrogenase

• Only the presence of Clostridium diff. does not confirm the diagnosis

• Th: vancomycin orally 4x/day (500 mg -2 g/d)

Clostridium difficile colitis

Chronic diarrhea

Chronic diarrhoe

Definition • >3 stools / day

• > 4 weeks

• Rectal syndrome • Frequent urgency for passing stool

• Non-fecal content (bloody, mucus)

• Sign of organic rectal disease • Cancer

• Inflammation

To be differentiated from

• Fecal incontinence

• False diarrhea of constipation • Exsudation of the mucosa in contact with

hard stool, explosive evaluation, liquid with some small parts of hard stool

Mechanisms and causes of chronic diarrhea

Motoric

Osmotic

Malabsorbtion

Secretory

Exsudative and inflammatory

Mechanisms and causes of chronic diarrhea

Motoric d. • No gut anatomic lesion

• Morning and after meals

• In groups

• Accelerated transit time

• Irritable bowel (IBS-D)

• Autonomic neuropathy • Hyperthyroidism • Endocrine tumors

• VIP, medullary thyroid cancer

Mechanisms and causes of chronic diarrhea

Osmotic d. • No gut anatomic lesion

• Liquid stool • Lactose intolerance

• Magnesium

• Laxative use

• Ingestion of polyols

Malabsorption d.

Mechanisms and causes of chronic diarrhea

• Celiac disease • Crohn’s disease of small bowel • Postradiation enteritis

• Intestinal resection

• Exocrine pancreatic insufficiency

• Short bowel syndrome

• Lymphoma

• Chronic bowel ischemia • Posprandial pain

• Small intestinal bacterial overgrowth

• Whipple disease

Secretory d. • Liquid, hypovolemia, hypokaliemia

• Colitis • Microscopic colitis

• Lymphocytic, colagenous

• Infection in immunocompromised • Giardia intestinalis • Cryptosporidium • Isospora belli

• Neuroendocrine tumors (gastrinoma, VIPoma)

• Mastocytosis

Mechanisms and causes of chronic diarrhea

Exsudative d. • ulcers on the GI mucosa

• exsudation of blood, lymph, proteins

• IBD • Crohn’s disease • Ulcerative colitis

• Lymphoma

• Lymphangiectasia

• Malignant compression of lymph ducts

Mechanisms and causes of chronic diarrhea

Investigations for chronic diarrhea

Clinical and laboratory

• History • Timeline and trendline

• Physical examination • Herpetiform dermatitis • Goiter • Nails and hair abnormalities • Lymphadenoapthy • Hypotension • Flush

Laboratory exams • Blood

• Electrolytes • B12, folate • IgA anti-transglutaminase Ab • ASCA, pANCA antibodies • TSH • Chromogranin • Gastrin

• Stool • ova and parasites • elastase • calprotectin

Investigations for chronic diarrhea

Endoscopy

• Colonoscopy

• Enteroscopy

• Capsule enteroscopy

• EUS

• Upper GI endoscopy

Investigations for chronic diarrhea

Cross sectional imaging

• Ultrasound

• CT and MRI enterography

• CT scan and MRI

Constipation

Constipation

• Definition 1. Less than 3 stools per week 2. Sensation of incomplete evacuation 3. Both 1. and 3.

• A. Habitual • Occasional • Pregnancy and lactation • Travel

• B. Secondary - organic

• C. Idiopathic - functional • Slow transit • Dyschesia

• difficulties in stool evacuation

False diarrhea of constipation

• Fecalome in rectum • False diarrhea

• Frequent passage of liquid stools or mucus

• Risk factors • Chronic constipation

• Elderly

• Use of opiates

• Immobilisation

• Diagnosis • Digital rectal examination

B. Secondary constipation

Causes of secondary constipation • Colonic or anal stenosis

• Colic or extra-colic cancer • Post-colitis stenosis

• IBD, NSAID, Radiation, Diverticulitis, Volvulus

• Pelvic floor abnormalities • Rectocele

• Systemic disease • Neurological (Parkinson, CVA, SM) • Metabolic (DM, low thyroid, SS, low Ca, Mg)

• Drugs • Antidepressants, opiates….

Causes of functional consipation

• Slow transit

• Idiopathic (IBS-C)

• Pelvic floor dysfunction • Static or dynamic

C. Idiopathic “functional” constipation

Constipation

Investigations

• A: Habitual: usually not needed

• B: Secondary: absolutely indicated • Colonoscopy

• CT scan abdomen+pelvis

• Laboratory studies (TSH, A1C, Ca, CRP…)

• C: Idiopathic: functional studies

• Rectal manometry

• Dynamics of evacuation (Xray,MRI)

• Transit of markers

Constipation Management

Osmotic laxatives

• Lactulose

• Macrogol

• Magnesium

Therapy

• A: Habitual • Fiber 15g/day • Physical activity • Hydration

• B: Secondary • Treatment of the cause

• C: Idiopathic • Laxatives (osmotic) • Behavioral therapy • Pelvic floor surgery

Diverticulosis

Diverticulosis

• Diverticuli of the colonic wall • Frequent

• Age related

• Mainly left colon

• Usually asymptomatic • Symptomatic diverticulosis ?

• Complications • Bleeding

• Diverticulitis

• Bowel perforation

Diverticulosis Complications

Acute diverticulitis • Acute inflammation of the bowel wall –

sigmoiditis

• Clinical • Left lower quadrant or epigastric pain • Constipation • Bowel stenosis • Fever

• Investiation • Ultrasound, CT scan, blood tests (Leu, CRP)

• Treatment • Rehydration • +/- antibiotics

Diverticulosis Complications

Acute diverticular bleeding • Severe arterial lower GI bleeding

• Risk factors • Anticoagulants and antiaggregants • Comorbidity

• Chronic renal or cardiac disease

• Clinical • Enterorhagia • Hypotension, tachycardia

• Investigations • Blood count

• Treatment • Correction of volume • Preparation for colonoscopy – macrogol orally

Diverticulosis Complications

Perforation of the colon

• Acute abdominal pain

• Fever

• Signs of peritonitis

• Life threatening

FUNCTIONAL GI DISORDERS

Dyspepsia

DISCOMFORT OR PAIN FOLLOWING A MEAL OR DURING DIGESTION

ABNORMAL SENSATION FROM THE DIGESTIVE TRACT (MAŘATKA)

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Dyspepsia

upper dyspepsia

lower dyspepsia

Upper dyspepsia: causes

Upper dyspepsia Organic dyspepsia Secondary dyspepsia GE reflux Functional dyspepsia

Functional dyspepsia Rome IV criteria

1. Epigastric pain syndrome Ulcer-like dyspepsia

Pain or epigastric burn

2. Postprandial distress syndrome Dysmotility-like dyspepsia

Postprandial fullness

Early satiety

Dyspepsia Investigations

Necessary Alarm symptoms

• Age above 55, new onset dyspepsia

• Family history of upper gi cancer

• Weight loss – unwanted

• GE bleeding

• Dysphagia

• Odynophagia

• Unexplained iron def. anemia

• Vomiting

• Palpable mass

• Lymphadenopathy

• Jaundice

Not necessary

• No alarm symptoms

Management

Epigastric pain syndrome

H.Pylori test (stool) and H.Pylori • eradication if positive

Therapeutic trial • acid supressing therapy • sucralphate – may help • anti-spasmodics – may help

When ineffective • Endoscopy, • USG abdomen

Postprandial distress syndrome

Lifestyle changes

• Weight correction, small meal portions, less fatty meals, no NSA, no gas containing beverages, low coffein,

• Reducing some types of food: garlic, onion, black pepper, spices

• No smoking and alcohol

High placebo effect using any type of therapy Pharmacologic therapy

• Prokinetics – itopride, domperidone, metoclopramide

Dyspepsia lower: causes

Lower dyspepsia Organic cause (IBD, cancer....) Chronic diarrhea (malabs, coeliac.) Secondary causes (gynec, urol, other) Irritable bowel dyndrome (IBS)

Irritable bowel syndrome - IBS

Definition

Abdominal pain

Relief after defecation of loose stool

Provoked in the morning or after a meal

Variants

IBD-D, diarrhea

IBS-C, constipation

IBS-M, mixed type

Irritable bowel syndrome Mechanisms

Associated with microbiome

• Dysbiosis from the “western food”

Associated with gut neurons

• Post infectious IBS • Destruction of some myenteric

plexus neurons by toxins

Lowered pain theshold from the GI tract

Irritable bowel syndrome Investigations

Needed when • Unintentional or unwanted weight-loss

• Rectal syndrome – frequent, false need to pass stool

• Blood in the stool

• Change in stool consistency > 6 weeks in >60 years

• Anemia

• Palpable abdominal mass

• Family history of colorectal cancer

• Typical history and no alarm symtoms

Not needed

Management

Management • Empathy, education, understanding

• Life-style chages • weight loss

• physical exercise • reduction in coffeine, alcohol and fat

• increased consumption of fiber in constipation

• low FODMAP diet in diarrhea

• Drugs • Antispasmodics • Anti-motility agents

• Anti-bloating agents

• Antidepressant