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Grand round presentation Anthony Li

Grand round presentation Anthony Li. Mrs J D – 54 yrs ♀. PC: diarrhoea HPC: bowels ‘not right’ for 10 yrs worse last 1 yr BO normally: x3 - 4 per day firmish floaty some difficulty flushing no associated abdominal pain / PR bleeding. Mrs J D – 54 yrs ♀. HPC:

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Grand round presentation Anthony Li

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  1. Grand round presentation Anthony Li

  2. Mrs J D – 54 yrs ♀ • PC: • diarrhoea • HPC: • bowels ‘not right’ for 10 yrs • worse last 1 yr • BO normally: • x3 - 4 per day • firmish • floaty • some difficulty flushing • no associated abdominal pain / PR bleeding

  3. Mrs J D – 54 yrs ♀ • HPC: • last 6 mths - x6 episodes of severe diarrhoea: • BO x9 in 24 hrs • associated with: • diffuse abdominal pain • vomiting x4 - 5 → unable to keep any PO intake down • no back pain / jaundice / change of colour of urine or stool • symptoms settle next day → feels ‘exhausted’ • no obvious precipitants • admitted to Crawley for 48 hrs with latest attack – no Ix performed • weight loss of approx. 1 st

  4. Mrs J D – 54 yrs ♀ • PMH: • sterilisation • retained placenta • tonsillectomy • Hysterectomy(endometrial ca) • DH: • immodium 2 tabs tds • metoclopramide 1 tab tds • temazepam 40mg nocte • norval 30mg nocte • indomethacin 25mg tds

  5. Mrs J D – 54 yrs ♀ • allergies: • NKDA • FH: • ? • SH: • occupation - home helper • smoker - 10/day • no EtOH • x3 children at home 18yrs, 15yrs, 12yrs

  6. Mrs J D – 54 yrs ♀ • O/E: • General: • thin • no jaundice / anaemia / clubbing / lymphadenopathy • RS: • NAD • CVS: • NAD • Breasts: • NAD

  7. Mrs J D – 54 yrs ♀ • O/E: • GI: non-distended visible SB segmentation centrally tender RUQ over GB - no guarding no palpable masses BS normal DRE: tender left lateral pelvic wall but NAD pale steatorrhoeic stool

  8. Initial investigations • sigmoidoscopy: • 2 - 3 small telangiectases between 12 - 15 cms, otherwise normal to 15cms • bloods: • FBC, U&Es, LFTs, Ca2+, glu – WNL • TFTs, B12, folate – WNL • Inflammotory markers- WNL • Coeliac screen - negative • stool: • 3 day faecal fats – marginally ↑ at 11 g/day ( up to 7.5 g/day ) • swab – no salmonella, shigella or campylobacter • USS abdo: • NAD – no gallstones

  9. Further investigations • Therapeutic trial with colestyramine did not help • Indomethacin withdrawal did not work • Test for SBBO was negative • Faecal elastase was normal • SBFT showed-

  10. Widespread dilated loops matted together

  11. transverse barring from thickened valvulae conniventes- stack of coin appearance

  12. Mucosal irregularities with narrowing of lumen

  13. IT’S ALL ABOUT THIS! DEB GHOSH GASTRO SPR

  14. Any Guess? A 54 yr old lady presents with chronic diarrhoea with thickened SI mucosa, stricture and matted loops

  15. Further history • Endometrial carcinoma treated with post-op radiotherapy 10years back- weighed 6 stone at time of radiotherapy • Severe diarrhoea two weeks post radiotherapy lasting for couple of weeks • Mild symptoms only for next ten years

  16. LATE ONSET RADIATION ENTERITIS

  17. OVERVIEW OF MANAGEMENT OF DIARRHOEA FOR NON -GASTROENTEROLOGIST

  18. What is diarrhoea? • Abnormal passage of 3 or more loose or liquid stools per day for > 4weeks and / or a daily stool weight greater than 200g/day

  19. 1001 causes of Chronic diarrhoea

  20. Major causes • Irritable bowel syndrome • Inflammatory bowel disease • Chronic infections • Malabsorption syndromes Typical symptoms, normal exam and normal screening blood tests- no further investigations needed

  21. Major causes • Irritable bowel syndrome • Inflammatory bowel disease • Chronic infections • Malabsorption syndromes

  22. Major causes Irritable bowel syndrome Inflammatory bowel disease Chronic infections Malabsorption syndromes

  23. Minor causes • Ischaemic colitis • Drugs • Neoplastic • Motility disorders • Radiation enteritis Incidence of ischemic colitis at various locations (%) • Descending colon 37 • Splenic flexure 33 • Sigmoid colon 24 • Transverse colon 9 • Ascending colon 7 • Rectum 3

  24. Minor causes Ischaemic colitis Drugs Neoplastic Motility disorders Radiation enteritis

  25. Minor causes Lymphoma Villous adenoma Gastrinoma VIPoma carcinoid • Ischaemic colitis • Drugs • Neoplastic • Motility disorders • Radiation enteritis

  26. Minor causes • Ischaemic colitis • Drugs • Neoplastic • Motility disorders • Radiation enteritis Post surgical states- vagotomy/gastrectomy Endocrine- DM/Hyperthyroidism/carcinoid Infiltrative SI disease- scleroderma OCTT- Ba studies Radionucleotide scintigraphy

  27. Minor causes • Ischaemic colitis • Drugs • Neoplastic • Motility disorders • Radiation enteritis Radiation of more than 50Gy Ileum and rectum mostly Mucosal damage and SBBO

  28. Understanding of patient’s complain of diarrhoea • consistency • frequency of stools • urgency or faecal soiling • Stool characteristics • presence of visible blood- IBD or cancer • greasy stools that float and are malodorous -fat malabsorption

  29. Duration of symptoms, nature of onset (sudden or gradual) • The volume of the diarrhoea • voluminous watery diarrhoea -small bowel • small-volume frequent diarrhoea -colon • Occurrence of diarrhoea during fasting or at night- secretory or organic diarrhoea

  30. Travel history • Risk factors for HIV infection • Family history of IBD • Weight loss • Systemic symptoms as fevers, joint pains, mouth ulcers, eye redness-IBD • Previous therapeutic interventions- surgery and radiotherapy

  31. A relevant dietary (sugar free products containing sorbitol and use of alcohol) • All medications (including over-the-counter drugs and supplements) • Association of symptoms with specific food ingestion (such as dairy products or potential food allergens) • A sexual history • anal intercourse-infectious proctitis • promiscuous sexual activity -HIV infection

  32. Physical examination rarely provides a specific diagnosis. • Findings suggestive of IBD (eg, mouth ulcers, a skin rash, episcleritis, an anal fissure or fistula, the presence of visible or occult blood on digital examination, • Abdominal masses or abdominal pain, • Evidence of malabsorption (such as wasting, physical signs of anemia, scars indicating prior abdominal surgery), • Lymphadenopathy (possibly suggesting HIV infection), and • Abnormal anal sphincter pressure or reflexes (possibly suggesting fecal incontinence). • Palpation of the thyroid and examination for exopthalmus and lid retraction may provide support for a diagnosis of hyperthyroidism.

  33. Basic laboratory evaluation • FBC • Thyroid function tests • ESR/CRP • U/E • Total protein and albumin, and • Ferritin/ folate/B12/Ca • Stool culture and microscopy

  34. Further investigation as per BSG protocol

  35. Further investigation as per BSG protocol

  36. Further investigation as per BSG protocol

  37. Treatment • General measures: • Hydration and electrolyte balance • Vitamins supplements • Loperamide (also improves bile acid absorption ) • Therapeutic trials • Colestyramine for BAM • Lactose free diet • Antibiotics for SBBO • For bleeding from proctitis in RE • Stool softener • Argon plasma coagulation • Formalin irrigation ( experimental )

  38. RADIATION ENTEROCOLITIS Dr.E.M.Phillips

  39. Historical aspects Self exposure Deep tissue traumatisation from Roentgen ray exposure Walsh,D: Br Med J 1897: 272 – 273 Animal experiments Roentgen ray intoxication. Warren S, Whipple GH: J Exp Med 1922: 35: 187 – 202 Post radiotherapy pathology38 patients Warren S, Friedman NB: Pathology and pathological diagnosis of radiation lesions in the gastrointestinal tract: Am J Path 1942: 499 – 513 1950s super voltage therapy 100 patients DeCosse JJ et al. Natural history & management of radiation induced injury of the gastrointestinal tract Ann Surg 1969; 170: 369 - 384

  40. Symptoms Early During therapy and up to six months Late Five to 31 years after radiotherapy Peak onset 12 – 15 years after

  41. Symptoms Diarrhoea Colic Nausea Mucosal Pathology Decrease: enterocyte turnover & villous height Increase: enterocyte death; mucosal oedema & inflammatory infiltrate with mucosal slough Early

  42. Inflamm infiltrate and oedema Withering of crypts Cystic dilatation of crypt

  43. Symptoms SB Diarrhoea/malabsorp’n Blind loop syndrome Subacute obstruction Colon tenesmus & mucus Bothhaemorrhage, fistula perforation Pathology Arteriolar endothelial spasm, damage & obliterative vasculitis Submucosa to serosa ischaemia, ulceration, and perforation; increase in bizarre fibroblasts; stricture, webs and fistula Late

  44. Chronic Radiation Proctitis Vascular ectasia Thickening of lamina propria with fibrosis

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