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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 .

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Presentation Transcript
slide1

DIARRHOEA

AND

CONSTIPATION

diarrhoea
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

slide3

Pathophysiology

  • Increased osmotic load in the gut lumen (osmotic diarrhoea)
  • Increase in secretion (secretorydiarrhoea)

3) Inflammation of the intestinal lining ie IBD

4) Increased intestinal motility

Can involve more than 1 mechanism!

slide5

Infective Gastroenteritis

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

slide6

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.

slide7

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:
  • Vibriocholerae: transmit through contaminated water/seafood, rice water stool
  • Cl. Difficile: usually due to antibiotics ~4-9 days (ieampicillin, 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!
  • EnterotoxigenicE.coli, Salmonella, Cryptosporidium,Cl.perfringen, Bacillus cereus, Giardialamblia, rotavirus, norovirus
red flag signs for diarrhoea
Red flag signs for Diarrhoea !!!
  • Unintentional and unexplained weight loss
  • Rectal bleeding
  • Diarrhoea persisting for more than 6 weeks, in a person over 60 years of age
  • Family history of bowel or ovarian cancer
  • Abdominal mass
  • Rectal mass
  • Anaemia
  • Raised inflammatory markers (may indicate inflammatory bowel disease).
investigation
Investigation
  • 1) Full blood count — to detect anaemia or raised platelet count
  • suggesting inflammation
  • 2) Blood culture if its infective cause
  • 3) 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 IBD

7) Antibody testing for coeliac disease — immunoglobulin (Ig)A

tissue transglutaminase antibody (tTGA), or IgAendomysial

antibody (EMA).

investigation1
Investigation

Consider 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.

management
Management

Treat the cause!

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

Codeine phosphate 30mg/6 hrs

Loperamide 2mg PO

Avoid antibiotics except in infective diarrhoea causing systemic illness

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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 ieopioids, TCA, antispasmodic, calcium supplement, aluminium antacids

3) Faecal loading/impaction

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

pathophysiology
Pathophysiology
  • Colonic inertia (reduced bowel movement)
  • 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
predisposing factors
Predisposing factors
  • Social factors: Low fibre diet
  • Lifestyle: Difficult access to toilet, or changes in routine/lifestyle, Lack of exercise; reduced mobility.
  • Psychological: Anxiety, Depression, Somatization, Eating disorders
  • Physical: Mild pyrexia, dehydration, immobility.
red flags for constipation
RED FLAGS FOR CONSTIPATION!
  • Persistent unexplained change in bowel habits?
  • Palpable mass
  • Persistent rectal bleeding without anal symptoms
  • Distended, tympanitic abdomen
  • Vomiting
  • Family history of colon cancer, IBD
  • Unexplained weight loss, iron deficiency anaemia, fever, or nocturnal symptoms
  • Severe, persistent constipation that is unresponsive to treatment
slide20

Abdominal pain

Vomiting

Abdominal distention

Progress of condition

Sigmoid volvolus

Ischemia/perforation

Pseudo obstruction

How to interpret clinical findings:

how to interpret clinical findings
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!

small bowel obstruction
Small bowel obstruction

Gallstone ileus

-multiple dilated

small bowel

Throughout

SMALL ALL

->3cm is abnormal

-valvulae

conniventes

-paucity of gas in

bowel beyond site

of obstruction

paralytic ileus
Paralytic ileus
  • White arrow – multiple dilated small bowel loops
  • Black arrow- surgical staples
to differentiate small bowel obstruction and paralytic ileus
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
large bowel obstruction
Large Bowel Obstruction

Colon Ca

-dilated bowel

loops proximal

to obstruction

-dilated large bowel loop >6cm

investigations
Investigations

Depends on clinical findings:

  • Constipation with a clear etiology (drugs, trauma) may be treated symptomatically without further study.
  • Blood tests: FBC, U&E, Ca2+, TFT

If suspected malignancy, proceed with:

  • Abdominal X-ray
  • Sigmoidoscopy and biopsy of abnormal mucosa
  • Colonoscopy
  • Water soluble contrast enema
  • CT Scan or barium X-ray
management1
Management
  • Adjust any constipating medication, if possible.
  • Increasing dietary fibre, drinking an adequate fluid intake, and exercise
  • Offer oral laxatives if dietary measures are ineffective, or while waiting for them to take effect.
    • Bulk-forming laxative ieispaghula husk, methylcellulose, sterculia, frangula
    • Osmotic laxative ielactulose, macrogols (polyethylene glycols)

3) Stimulant laxative iebisacodyl, senna, sodium picosulfate

  • Laxatives can be stopped once the stools become soft and easily passed again
questions
Questions
  • 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 IBD
  • 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 EnteroE.coli
  • A 36 year old woman presents with weight loss, general abdominal discomfort and steatorrhoea. On examination she appears pale and malnourished. Gastric ca
  • 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 gastritis

B: Cl. Difficile infection

C: IBD

D: gastric ca

E: EnterotoxigenicE.coli

F: ischaemic colitis

G: Colorectal Ca

H: Cholera