1. 1. Becky (couldnt be bothered to turn up), Felicity, Niall, Nasif & Ian 18th June 2009.
2. 2. Objectives Diarrhoea The Basics 10 minute consultation Diagnosis and Management of Irritable Bowel Syndrome Diagnosis and Management of Coeliac Disease Managing Gastroenteritis The Basics of Inflammatory Bowel Disease Diarrhoea, Colorectal Cancer and the 2 week rule
3. 3. Curriculum Headings 8 - Care of Children and Young People 15.2 - Digestive Problems 12 - Care of People with Cancer & Palliative Care
4. 4. Diarrhoea The basics . What is it ? - no universally accepted definition but essentially diarrhoea is an increase in volume (> 250g/day) & frequency of defecation normally with an associated change in consistency - most commonly more liquid. It is very common . - history plays a major role in determining concern, proposed diagnosis & therefore management.
5. 5. Diarrhoea . History . - Onset - Frequency - Stool appearance (colour, malodour, dark / light) - Associated features (eg: pain, blood, mucus, wt/loss, low appetite, vomiting, tenesmus, etc) - Foreign Travel (see after break) - Family / Friends affected ? - Take-aways / restaurants.
6. 6. Diarrhoea Mechanisms: Osmotic: As gut mucosa acts like a semi- permeable membrane fluid leaks out if osmotic potential is greater in lumen than blood. - ingestion of non-absorbable substance (eg: MgSO4) - patient malabsorption eg: glucose-galactose malabsorption. Generally diarrhoea stops on not eating or when mal-absorptive substance is discontinued. Secretory: Active intestinal secretion of fluid & electrolytes in addition to reduced absorption. Causes: - Infective eg: enterotoxins cholera, E.Coli. - Hormonal eg: VIP. - Fatty acids - Bile salts - both common after ileal resection. - Laxative use.
7. 7. Diarrhoea .Mechanisms: Inflammatory Mucosal destruction produces loss of fluid & blood with poor absorption resulting from brush-border damage. Eg: Shigella, Campylobacter, Crohns & Ulcerative Colitis. Abnormal motility Increased frequency secondary to increased gut activity eg: diabetes, post-vagotomy & hyperthyroidism. - Rx of the abnormality will Rx the diarrhoea.
8. 8. Diarrhoea .Classification: Acute - Common, often short-lived (24-48hrs), except Travellers Diarrhoea (2-5 days) - Normally diet related - Assoc with fever, abdo pains, vomiting. - Very young & elderly at risk of dehydration. - Inx if > 1/52 duration stool culture +/- sigmoidoscopy. - Rx: Hypertonic oral solutions or IVI if vomit ++. Chronic - Always needs investigation, greater than 2-4/52 with no improvements. - Normally rectal biopsy +/- sigmoidoscopy.
9. 9. Other classifications . Anti-biotic Associated (Pseudomembranous Colitis) - Occurs after history of Anti- biotic use, lasting up to 6 wks after stopping drug. - Causative agent C.difficile. Bile acid Malabsorption: - Occurs when terminal ileum fails to absorb acids eg: resection in Crohns. - Entry to colon reduces water absorption & at greater concentrations induces secretions & colon motility. Dx: SeHCAT test radio- labelled bile acid with < 19% retention abnormal. Rx: Colestyramine resin binding to bile acids in colon.
10. 10. Other Classifications Factitious Diarrhoea: - Account for 4% of new patients in gastroenterology clinics. Purgative Abuse (eg: senna) - more common in young women, consider if history of eating disorder or extensive investigations / medication with normal results. - Sigmoidoscopy Melanosis Coli pigmented mucosa with rectal biopsy showing pigmented macrophages.
11. 11. 10 Minute Consultation
12. 12. Irritable Bowel Syndrome
13. 13. IBS Quick Facts Always keep in the back of your mind.is this coeliac?? Research has suggested that DIARRHOEA and ANAEMIA may be the best predictors of coeliac disease Prevalence of coeliac thought to be 1 in 100 and left untreated has a 15% risk of malignancy!!!
14. 14. Ok, its IBS, lets move ongeneral notes Get a copy of the guideline, NICE will send you up to 52 guidelines at once, the IBS one is a good one. Feb 2008 Attend the GP update course run by Dr Lucy Jenkins, see Nasifs handout book & find next course on www.gp-update.co.uk Remember its no longer a diagnosis of exclusion, reassure your patients of this
15. 15. IBS specifics.. Please refer to assessor handout Do you know your ABCs?? Features of IBS A: abdominal discomfort B: bloating C: change in bowel habit
16. 16. Positive Diagnostic Criteria, for IBS you need to have Abdo pain/discomfort that is relieved by defaecation OR Associated with altered bowel frequency or altered stool form AND at least 2 of the following Altered stool passage, bloating, symptoms made worse by eating or passage of mucus
17. 17. Do not be put off by other common extra-colonic symptoms.. These may in fact be used to SUPPORT the diagnosis: For example: lethargy, backache, bladder symptoms Time for good use of your lovely open questions!
18. 18. Exclude other diagnoses Nice suggests to carry out: FBC ESR/CRP Coeliac test (EMA/TTG) (Also consider IGA levels and remember 6 wks of wheat containing diet before the test) NICE suggests you do this on any new suspected cases of IBS, what do you think to that use of resources now you know more about coeliac?
19. 19. DO NOT use the following tests to confirm your diagnosis USS Sigmoidoscopy/colonoscopy/barium enema TSH Stool culture Hydrogen breath test for lactose intolerance/bacterial overgrowth (Dont ask me what the last one is!)
20. 20. Never forget your red flags NICE outline 7 can you think of them? 1)Unintentional weight loss 2) Rectal bleeding 3)FHX of bowel/ovarian cancer 4)>60 CIBH >6W (loose/freq stools) 5) Anaemia 6) Mass (abdo/rectal) 7) Raised inflammatory markers
21. 21. Management First line: For bloating, wind & pain: Anti-spasmodic For constipation: laxatives but NOT lactulose! (lactulose causes excess wind/bloating) For diarrhoea: loperamide EDUCATE your pts to adjust their own doses aiming for a soft well formed stool DAILY
22. 22. Second line and alternative.. Tricyclics starting with a low dose at night eg 5-10mg amitryp Consider SSRIs if TCAs ineffective Review after 4wks Psych: CBT, hypnotherapy NICE recommends not to encourage reflexology/acupuncture
23. 23. EVIDENCE BASED Mx: Clinical evidence handbook June 09 Likely to be beneficial: Antidepressants (amitryptilline, cliomipraimine, fluoxetine etc) Anti-spamodics (NNT 5) Soluble fibre supplementation reduces global symptoms. (NNT 6) (1 trial showed peppermint oil NNT 2.5!) And finally......
24. 24. What do I eat doc?..... Increased fibre intake is NOT recommended, indeed bran (insoluble fibre) makes symptoms worse Adv soluble fibre: oats/linseed/fybogel Strict exclusion diets are NOT helpful But if a food clearly triggers symptoms, adv omit for 1 month but only 1 food at a time (GP update may 09) Can also trial probiotics for 4 weeks, monitor effectiveness
25. 25. And general dietary advice.. Drink 8 cups of fluid day, limit caffeine to 3 cups/day Reduce alcohol/fizzy drinks Limit fresh fruit to 3/day If diarrhoea is a problem limit sorbitol (in chewing gum) and artificial sweetener use If you strongly suspect food triggers consider referral to dietician
26. 26. Case Presentation 20 year old presents to his GP complaining of feeling tired all the time, for couple of months. Only other symptom of significance is cramping abdominal pain, which he has had intermittently ever since he can remember.
27. 27. Coeliac Disease - Diagnosis and Management
28. 28. Introduction Autoimmune disorder Pathophysiology Epidemiology Symptoms
29. 29. Symptoms Gastrointestinal Diarrhoea Abdominal pain Abdominal distension Mouth ulcers Risks Malabsorption-related Weight loss Anaemia Osteopenia Abnormal coagulation Bacterial overgrowth
30. 30. Dietary Considerations Before Serological Testing Follow gluten containing diet. Gluten every meal for 6 weeks. Not start a gluten-free diet until diagnosis is confirmed by intestinal biopsy.
31. 31. Management Gluten free diet Dietician input Gluten free food prescriptions Annual review 1. Compliance 2. BMI 3. Bowel function and symptoms 4. Nutritional status 5. Immunisations Osteoporosis Monitoring
32. 32. Refractory Disease Prolonged disease Non-compliance Consuming foods contaminated with gluten Consider steroids or immunosuppressants
33. 33. Gastroenteritis in Children - NICE Guidelines
34. 34. D+V in children Telephone call from worried mother 10 month old child Vomited once, 4 very loose motions What can I do? Do you need to see him? How long will it last What further information do you want? What advice would you give?
35. 35. The right diagnosis? >38 C (< 3 months) or >39 C (>3 months) SOB Features of ICP Features of menigism Features of Septicaemia Blood in stool/vomit Bilious Vomit Acute Abdomen
36. 36. Assessing Dehydration Not Dehydrated Appears well Alert Normal urine Skin colour unchanged Warm extremities Clinical Dehydration Appears to be unwell Irritable or Lethargic Decreased Urine Output Skin colour unchanged Warm Extremities
37. 37. Fluids and Feeds Continue Breastfeeding and milk Encourage Fluids Discourage fruit juice and fizzy drinks
38. 38. Mother phones back 10 motions yesterday Vomited 4 times Still passing urine Looks alright Should I continue with the feeds? Is he drinking enough? Do you need to see him? Can you do a test? What advice would you give? Would you see the child?
39. 39. Risk of Dehydration 3 vomits in 24 hours Unable to tolerate fluids Stopped breastfeeding malnutrition
40. 40. Preventing Dehydration Calculating Maintenance Oral Rehydration Salt (ORS) solution
41. 41. When to send a stool sample Suspect septicaemia Blood/mucus in stool Immunocompromised Foreign travel Not settling after 7 days
42. 42. Mother returns with child 10 motions. Vomiting after milk feeds Only one slightly wet nappy Lethargic Dry mouth What next? When would you refer?
43. 43. Dehydration v Shock Clinical Dehydration Lethargic/irritable Skin colour unchanged Warm peripheries Tachycardia Tachypnoea Normal CRT Normal BP Clinical Shock consciousness Pale/mottled skin Cold peripheries Tachycardia Tachypnoea CRT BP
44. 44. Oral Rehydration 50 ml/kg low ORS over 4 hours Continue maintenance with ORS Calculating rehydration fluids
45. 45. Inflammatory Bowel Disease
46. 46. 25 year old male 4 weeks diarrhoea 4-5 times a day Some abdominal discomfort Grandfather died of bowel cancer Smoker
47. 47. Differential Diagnosis IBS Coeliac disease Infection IBD Colorectal cancer Diverticulitis Ischaemic colitis TB Carcinoid Amyloidosis Behcets Intestinal lymphoma
48. 48. Examination Evidence of weight loss, anaemia Abdominal tenderness, distension, masses Perianal lesions, rectal masses Extraintestinal features mouth ulcers, clubbing, skin lesions
49. 49. What Next? FBC, U&E, LFT, CRP/ESR, Coeliac screen Stool for M,C&S and C diff Hb 11, WCC 16, CRP 50 REFER for flexisigmoidoscopy or colonoscopy
50. 50. Referral Guidelines Urgent referral if: Fever, systemically unwell Abdominal tenderness and distension Severe colitis Prompt referral if: Weight loss, anaemia, raised CRP/ESR Nocturnal diarrhoea
51. 51. Severity Mild: 6 stools per day Severe rectal bleeding Systemic disturbance Signs of malnutrition Weight loss >10%
52. 52. UC vs Crohns 100-200/100000 10-40 years 10-20% have family history Environmental trigger 50-100/100000 15-30 years then 60-80 years 15-20% have family history Smoking causes earlier and more aggressive disease
53. 53. UC vs. Crohns Bloody diarrhoea, abdominal pain, urgency, tenesmus Systemic upset Extraintestinal manifestations Risk of toxic megacolon Diarrhoea, abdominal pain Systemic upset Perianal lesions Mouth ulcers Extraintestinal manifestations
54. 54. Treatment Smoking cessation Acute: 5-ASA or steroids Topical or oral Maintenance: 5-ASA or steroid sparing agents Relapse: If mild can increase maintenance therapy, refer if no improvement in 2 weeks
55. 55. 78 year old female 3 weeks diarrhoea Left lower abdominal ache, nausea, flatulence Usually constipated Cannot afford fruit and vegetables
56. 56. Differential Diagnosis Diverticulitis Colorectal carcinoma IBS Crohns If more acute consider abdominal, gynaecological and urological causes of acute abdomen
57. 57. Examination Mild LIF tenderness PR - NAD
58. 58. What Next? FBC, U&E, LFT, CRP/ESR, Coeliac screen Stool for M,C&S and C diff All normal Colonoscopy, Ba enema, CT colonogram
59. 59. Diverticula 50% of people by 50 years, 70% by 80 years 75% are asymptomatic Definitions: Diverticulosis presence of asymptomatic diverticula Diverticular disease diverticula associated with symptoms Diverticulitis diverticular inflammation with or without local symptoms or signs
60. 60. Diverticulosis Asymptomatic Usually an incidental finding Advise gradual increase in fibre (especially fruit and vegetables) and fluid intake No further follow-up required
61. 61. Diverticular Disease Intermittent lower abdominal pain, change in bowel habit, bloating, rectal bleeding Advise high fibre (particularly fruit and vegetables) and fluid diet. Add bulk forming laxative if diet not adequate or constipation or diarrhoea present
62. 62. Diverticulitis Left lower quadrant pain, change in bowel habit, fever and tachycardia, vomiting, raised inflammatory markers Paracetamol, clear fluids and antibiotics Admit if inadequate pain control or hydration, co- morbidity, complications or symptoms persist >48 hours
63. 63. Complications Haemorrhage abrupt painless fresh bleeding Perforation Fistulas colovesicular or colovaginal Abscess Stricture/obstruction
64. 64. Colorectal cancer and the 2 week rule
65. 65. Colo-rectal Carcinoma. - Second most common cause of cancer deaths in UK - 16,107 deaths in 2003. - Positive correlation between early detection & 5yr survival. - Requires a high index of suspicion as symptoms often mirror less severe illnesses.
66. 66. Risk Factors for Colorectal Cancer .. 1. Age: - single most important risk factor with incidence rising with age after 50yrs. (Peak age of diagnosis is 60-65yrs both men & women) 2. Family History: - only apparent in 5-10% of Ca. - If FHx then diagnosed < 45yrs. (i)Mutations in APC gene for FAP (Familial Adenomatous Polyposis) however represents < 1% of total colo-rectal cancers in UK. (ii) HNPCC (Hereditary Non-Polyposis Colo-rectal Cancer) - Patients tend to develop right- sided tumours at an early age allowing for surveillance. (See Table 1) 3. Gender: - incidence of approx 3:1 ratio of men to women affected.
67. 67. Risk Factors 4. Inflammatory Bowel Disease: - greater risk in patient with IBD for > 10yrs. 5. Lifestyle Factors: - obesity, poor exercise, high alcohol intake, poor diet (high animal fats & low fibre increased colonic transit time. 6. Polyps: - polyp adenoma adeno-carcinoma progression. - majority of polyps are benign, apparent in 25% population aged over 50yrs. 7. Culture: - greater incidence in Western countries compared to Asian & African countries. Majority of bowel cancer is sporadic !!
68. 68. Lifetime Risk of Colorectal cancer in 1st degree relatives of a patient with Colorectal Cancer Table 1. Population Risk 1 in 50 one 1st degree relative affected (any age) 1 in 17 one 1st degree relative & one second degree relative affected 1 in 12 one first degree relative affected (age < 45yrs) 1 in 10 Two first degree relatives affected 1 in 6 Autosomal dominant pedigree 1 in 2
69. 69. Distribution of Sporadic colorectal cancer .. 63% - recto-sigmoid region. 13% - Caecum. 10% - Transverse colon. 8% - Ascending colon. 6% - Splenic flexure / descending colon.
70. 70. Presentation 1. Generally over 50yrs. 2. Altered bowel habit. 3. Blood +/- mucus in stool. 4. Weight loss (not always). 5. Anxiety (improved education). 6. Lethargy. 7. Tenesmus (not always) Examination: - Often abdominal exam unremarkable but must perform PR. - if protracted history then feel for liver edge (may have metastasised !!)
71. 71. Investigations .. Perform but if serious concern dont delay referral to Specialist 1. FBC, U&E, LFTs, Bone profile, ? Coagulation screen. - looking specifically for iron deficiency anaemia, raised Calcium & abnormal biochemistry. 2. Colonoscopy gold standard for macroscopic observation & biopsies for histology +/- staging if required. 3. Double-contrast Barium enema, USS, CT or MRI as required for staging, grading & treatment. 4. FOB ??? no longer recommended. USA showed 15-33% reduced mortality but low sensitivity meant a lot of unnecessary colonoscopies.
72. 72. Treatments . Surgical treatment is main option +/- adjuvant chemotherapy. Success of treatment depends on stage of the primary tumour & extent of any metastases. Only approx 50% patients achieve 5yr survival. TME (Total Mesorectal Excision) where meticulous care is taken to remove all tissue surrounding the cancer may reduce recurrence rates.
73. 73. Primary Care Referral 2 week rule !! Use the following symptoms & signs to identify those requiring urgent referral to Hospital Urgent referral All ages: - definite palpable right sided abdo mass. - definite palpable rectal mass - rectal bleeding WITH change in bowel habit to looser stools &/or increased frequency of defaecation persistent for 6/52. - Fe deficiency anaemia WITHOUT obvious cause (Hb < 11 g/dL in men, < 10 g/dL in women.)
74. 74. Primary Care Referral 2 week rule !! Over 60 years: - Rectal bleeding persistently WITHOUT anal symptoms (eg: soreness, pain, itching, prolapse.) - Change of bowel habit to looser &/or increased frequency of defecation WITHOUT rectal bleeding persisting for 6/52.
75. 75. Low Risk of colorectal cancer symptoms .. 1. Rectal bleeding with anal symptoms (soreness, pain, itch, prolapse, lumps) 2. Change in bowel habit to reduced frequency & harder stools. 3. Abdo pain without clear evidence of intestinal obstruction.
76. 76. Prevention & Screening . Prevention: - low fat & high fibre diet. - endoscopic investigation regularly for patients with HNPCC or FAP, or with family risk. - FOB ?? (see earlier comments) Screening: - CT pneumocolon, endoscopy & refinement of genetic testing occurs in some parts of the USA but ? cost effective.