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:– 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
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
Mrs J D – 54 yrs ♀
• allergies:– NKDA
• FH:– ?
• SH:– occupation - home helper– smoker - 10/day– no EtOH– x3 children at home 18yrs, 15yrs, 12yrs
Mrs J D – 54 yrs ♀
• O/E:– General:
• thin• no jaundice / anaemia / clubbing / lymphadenopathy
– RS:• NAD
– CVS:• NAD
– Breasts:• NAD
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
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
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-
Widespread dilated loops matted together
transverse barring from thickened valvulae conniventes- stack of coin appearance
Mucosal irregularities with narrowing of lumen
IT’S ALL ABOUT THIS!
DEB GHOSHGASTRO SPR
Any Guess?
A 54 yr old lady presents with chronic diarrhoea with thickened SI mucosa,
stricture and matted loops
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
LATE ONSET RADIATION ENTERITIS
OVERVIEW OF MANAGEMENT OF DIARRHOEA FOR NON -GASTROENTEROLOGIST
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
1001 causes of Chronic diarrhoea
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
Major causes
• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic infections • Malabsorption
syndromes
Major causes
• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic infections • Malabsorption
syndromes
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
Minor causes
• Ischaemic colitis• Drugs• Neoplastic• Motility disorders• Radiation enteritis
Minor causes
• Ischaemic colitis• Drugs• Neoplastic• Motility disorders• Radiation enteritis
Lymphoma
Villous adenoma
Gastrinoma
VIPoma
carcinoid
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
Minor causes
• Ischaemic colitis• Drugs• Neoplastic• Motility disorders• Radiation enteritis
Radiation of more than 50Gy
Ileum and rectum mostly
Mucosal damage and SBBO
Malabsorption
Luminal phase Mucosal phase
1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth
1. Coeliac disease2. Whipple disease3. Lactose intolerence4. Intestinal resection5. Ileal disease
Malabsorption
Luminal phase Mucosal phase
1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth
1. Coeliac disease2. Whipple disease3. Lactose intolerence4. Intestinal resection5. Ileal disease
Malabsorption
Luminal phase Mucosal phase
1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth
1. Coeliac disease2. Whipple disease3. Lactose intolerence4. Intestinal resection5. Ileal disease
Malabsorption
Luminal phase Mucosal phase
1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth
1. Coeliac disease2. Whipple disease3. Lactose intolerence4. Intestinal resection5. Ileal disease
Malabsorption
Luminal phase Mucosal phase
1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth
1. Coeliac disease2. Whipple disease3. Lactose intolerence4. Intestinal resection5. Ileal disease
Malabsorption
Luminal phase Mucosal phase
1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth
1. Coeliac disease2. Lactose intolerence3. Intestinal resection4. Ileal disease5. Whipple disease
Understanding of patient’s complain of diarrhoea
1. consistency
2. frequency of stools
3. urgency or faecal soiling
Stool characteristics
1. presence of visible blood- IBD or cancer
2. greasy stools that float and are malodorous -fat malabsorption
– Duration of symptoms, nature of onset (sudden or gradual)
– The volume of the diarrhoea1. voluminous watery diarrhoea -small bowel
2. small-volume frequent diarrhoea -colon
– Occurrence of diarrhoea during fasting or at night- secretory or organic diarrhoea
•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
•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
Physical examinationrarely 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.
Basic laboratory evaluation
• FBC
• Thyroid function tests
• ESR/CRP
• U/E
• Total protein and albumin, and
• Ferritin/ folate/B12/Ca
• Stool culture and microscopy
Further investigation as per BSG protocol
History or Findings suggestive of MALABSORPTION
Small bowel
Coeliac screenD2 biopsy
BaFT
PancreaticCT Pancreas
Faecal elastase
EnteropathyReview histology
Enteroscopy or capsule endoscopy
Bacterial overgrowthGlucose hydrogen breath testJejunal aspirate and culture
Further structural testsERCP or MRCP
Further investigation as per BSG protocol
History or Findings suggestive of Colonic or terminal ileal disease
Flexible sigmoidoscopy if <45Complement with Ba enema if >45
Colonoscopy preferred if >45
Terminal ileal disease excluded?Ba FT
99mTc HMPAO75SeHCAT
Further investigation as per BSG protocol
Difficult diarrhoea
Inpatient assessment24-72 hour stool weights
Stool osmotic gapLaxative screen
Gut hormoneSerum gastrin
VIPUrinary 5 - HIAA
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 )
RADIATION ENTEROCOLITIS
Dr.E.M.Phillips
Historical aspects
Self exposure Deep tissue traumatisation from Roentgen ray exposure
Walsh,D: Br Med J 1897: 272 – 273
Animal experimentsRoentgen ray intoxication. Warren S, Whipple GH:
J Exp Med 1922: 35: 187 – 202
Post radiotherapy pathology 38 patientsWarren 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 patientsDeCosse JJ et al. Natural history & management of radiation induced
injury of the gastrointestinal tract Ann Surg 1969; 170: 369 - 384
Symptoms
Early
During therapy and up to six months
Late
Five to 31 years after radiotherapy
Peak onset 12 – 15 years after
Early
Symptoms
Diarrhoea
Colic
Nausea
Mucosal Pathology
Decrease:
enterocyte turnover &
villous height
Increase:
enterocyte death;
mucosal oedema &
inflammatory infiltrate
with mucosal slough
Acute radiation proctitis
Withering of crypts
Cystic dilatation of crypt
Inflamm infiltrate and oedema
Late
Symptoms SBDiarrhoea/malabsorp’nBlind loop syndromeSubacute obstruction
Colon tenesmus & mucus
Both haemorrhage,fistula
perforation
PathologyArteriolar endothelial spasm,
damage & obliterative vasculitis
Submucosa to serosaischaemia, ulceration,
and perforation; increase in bizarre fibroblasts; stricture, webs and fistula
Chronic Radiation Proctitis
Thickening of lamina propria with fibrosis
Vascular ectasia
Associated factors
Causal
Radiotherapy• High dose DXT• Total volume gut
irradiated (e.g. para-aortic nodes incl.)
• Low body weight
Surgery• Adhesions
Also relates to severity of in-therapy toxicity
Not associatedVascular risk factors:DiabetesHypertensionDyslipidaemias(Smoking??)
Concomitant chemo.Pelvic sepsis
Dose of rads. & damage Minimal tolerated dose gives 5% radiation enterocolitis within 5 years:
SB Trans. colon rectosig.Rads. 4000 5500 5000IncreasedRads. for 6000 7500 7000high risktumourGives 50% radiation enterocolitis within 5 years
Roswit B et al. Amer. J Roentgenology 1972; 114: 460
Surgery & radiation damage
Chronic radiation ileitis n=97
Surgery Nil 1 op. 2 op. 3 op.
Ileitis % 2.2 10.1 22.2 50
Daly NJ et al. Radiother Oncol. 1989 14(4): 287 - 95
Majority of patients with radiation enterocolitis
are tumour free
Prognosis of Rad. enterocolitis
ca. 30% may come to surgery: complications:- Anastomotic leak 65 – 100%
Range Morbidity 11 – 65% Range Mortality 0 – 45%
4 review articles: 1979, 1983, 1986, 1991
Outcome improved by attention to detail:• Make anastomosis without clamps• Vessels at cut ends to be pulsatile• Anastomosis tension free with omental wrap• Defunctioning stoma above for at least 1 year
Recent case report in GUT Nov 2005
• Late intestinal toxicity in form of ischaemia and stricture formation is seen in 5% of cases of radiation treatment for intraabdominal malignancy
• 40 year old presented with recurrent bowel obs with normal BaFT was found to have web formation by capsule endoscopy
• Ach induced dilatation in radiated small bowel was reduced because of endothelial dysfunction
THANK YOU