grand round presentation anthony li. mrs j d – 54 yrs pc: –diarrhoea hpc: –bowels not right...
TRANSCRIPT
![Page 1: 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](https://reader035.vdocuments.pub/reader035/viewer/2022070305/5513dbcc5503463a298b5628/html5/thumbnails/1.jpg)
Grand round presentation
Anthony Li
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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
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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
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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
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Mrs J D – 54 yrs ♀
• allergies:– NKDA
• FH:– ?
• SH:– occupation - home helper– smoker - 10/day– no EtOH– x3 children at home 18yrs, 15yrs, 12yrs
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Mrs J D – 54 yrs ♀
• O/E:– General:
• thin• no jaundice / anaemia / clubbing / lymphadenopathy
– RS:• NAD
– CVS:• NAD
– Breasts:• NAD
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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
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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
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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-
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Widespread dilated loops matted together
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transverse barring from thickened valvulae conniventes- stack of coin appearance
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Mucosal irregularities with narrowing of lumen
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IT’S ALL ABOUT THIS!
DEB GHOSHGASTRO SPR
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Any Guess?
A 54 yr old lady presents with chronic diarrhoea with thickened SI mucosa,
stricture and matted loops
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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
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LATE ONSET RADIATION ENTERITIS
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OVERVIEW OF MANAGEMENT OF DIARRHOEA FOR NON -GASTROENTEROLOGIST
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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
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1001 causes of Chronic diarrhoea
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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
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Major causes
• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic infections • Malabsorption
syndromes
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Major causes
• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic infections • Malabsorption
syndromes
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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
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Minor causes
• Ischaemic colitis• Drugs• Neoplastic• Motility disorders• Radiation enteritis
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Minor causes
• Ischaemic colitis• Drugs• Neoplastic• Motility disorders• Radiation enteritis
Lymphoma
Villous adenoma
Gastrinoma
VIPoma
carcinoid
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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
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Minor causes
• Ischaemic colitis• Drugs• Neoplastic• Motility disorders• Radiation enteritis
Radiation of more than 50Gy
Ileum and rectum mostly
Mucosal damage and SBBO
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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
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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
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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
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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
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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
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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
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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
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– 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
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•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
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•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
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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.
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Basic laboratory evaluation
• FBC
• Thyroid function tests
• ESR/CRP
• U/E
• Total protein and albumin, and
• Ferritin/ folate/B12/Ca
• Stool culture and microscopy
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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
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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
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Further investigation as per BSG protocol
Difficult diarrhoea
Inpatient assessment24-72 hour stool weights
Stool osmotic gapLaxative screen
Gut hormoneSerum gastrin
VIPUrinary 5 - HIAA
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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 )
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RADIATION ENTEROCOLITIS
Dr.E.M.Phillips
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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
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Symptoms
Early
During therapy and up to six months
Late
Five to 31 years after radiotherapy
Peak onset 12 – 15 years after
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Early
Symptoms
Diarrhoea
Colic
Nausea
Mucosal Pathology
Decrease:
enterocyte turnover &
villous height
Increase:
enterocyte death;
mucosal oedema &
inflammatory infiltrate
with mucosal slough
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Acute radiation proctitis
Withering of crypts
Cystic dilatation of crypt
Inflamm infiltrate and oedema
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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
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Chronic Radiation Proctitis
Thickening of lamina propria with fibrosis
Vascular ectasia
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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
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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
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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
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Majority of patients with radiation enterocolitis
are tumour free
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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
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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
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THANK YOU