Diarrhoea Mashiko Setshedi 01 Feb Practical Diagnostic Approach to Chronic
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1 Diarrhoea Mashiko Setshedi 01 Feb 2019 Practical Diagnostic Approach to Chronic
2
3 Overview Chronic diarrhoea is common (3-5% of population) Considerable diagnostic challenge Several hundred possible differential diagnoses Gastroenterology. 1999; 116(6): Am J Epidemiol 1992;136:
4 Am Fam Physician 2011; 84(10):
5 What is chronic diarrhoea?? Stool form, frequency, consistency Objective >200g of stool per day (unreliable) Accepted definition > 3 BMs per day Bristol 5 Chronic > 4 weeks N.B: Exclude pseudo-diarrhoea (increased frequency, but normal consistency
6 Subtypes Sub-types of diarrhoea OLD NEW Osmotic Secretory Inflammatory Fatty Dysmotility Watery (osmotic, secretory, dysmotility) Inflammatory Fatty
7 Am Fam Physician 2011; 84(10):
8 Am Fam Physician 2011; 84(10):
9 Am Fam Physician 2011; 84(10):
10 Am Fam Physician 2011; 84(10):
11 Approach Primary Sclerosing - history Cholangi2s (PSC) Describe diarrhoea Onset? PaCern - confnuous - intermicent - nocturnal symptoms Associated features (pain, fever, gas etc) Alarm features (new-onset diarrhoea, persistent blood in stool, unintenfonal LOW)
12 Approach Primary Sclerosing - history Cholangi2s (PSC) Describe diarrhoea Onset? PaCern - confnuous - intermicent - nocturnal symptoms Associated features (pain, fever, gas etc) Alarm features (new-onset diarrhoea, persistent blood in stool, unintenfonal LOW)
13 Approach Primary Sclerosing - history Cholangi2s (PSC) Describe diarrhoea Onset? PaCern - confnuous - intermicent - nocturnal symptoms Associated features (pain, fever, gas etc) Alarm features (new-onset diarrhoea, persistent blood in stool, unintenfonal LOW) Associa2ons - travel, food (dairy, sweeteners, FODMAPS, gluten, alcohol, caffeine, liquorice) Past medical history Family hx (IBD, coeliac disease) Other medical condifons - thyroid, DM, collagen vascular disease, pancreafc disease Previous surgery (e.g. SB resecfon, cholecystectomy) Previous radiotherapy Medica2ons (over 700 implicated)
14 Am Fam Physician 2011; 84(10):
15 Approach physical examination Vital signs General appearance anorexia/bulimia Oedema, lymph nodes Thyroid mass Skin rashes (DH), flushing Abdomen scars, tenderness, masses, organomegaly Rectal exam - sphincter tone and squeeze, fistulae
16 Diagnostic objective Make a positive diagnosis with minimal investigations Exclude cancer or inflammation Detect common but underdiagnosed disorders such as bile acid diarrhoea, microscopic colitis, lactose malabsorption or post-radiation diarrhoea
17 Initial approach Hb, Fe if anaemic, CRP, albumin, TSH, coeliac serology AND Stool MCS, ova, cysts, parasites, faecal calprotecfn (>50g/g), consider FIT If negafve, and < 40, and no alarm features and meets Rome IV Confirm IBS. If needs be, flexible sigmoidoscopy If troublesome symptoms despite treatment for IBS Consider Coeliac disease (g-scope + duodenal biopsies) Microscopic colifs (colonoscopy + biopsies) Bile salt diarrhoea (empiric bile acid sequestrants) 17
18 Who should be investigated further? Abnormal initial tests Normal first-line investigations with severe symptoms severe enough to impair QOL No response to initial treatment/ongoing symptoms Suspected organic disease Watery Inflammatory Fatty Other
19 Watery Osm > 125 mmol/kg OSMOTIC Normal Osm DYSMOTILITY Osm < 50 mmol/kg SECRETORY History osmofc laxafves Worse with dairy products hydrogen breath test Consider coeliac disease Osm > 400 mmol/kg CONTAMINATION/SPURIOUS Apply Rome IV IBS or funcfonal diarrhoea Exclude coeliac disease Stool analysis Colonoscopy (microscopic colifs 8 biopsies) MRI/CT TSH/ACTH Tests for hormonesecrefng tumours LaxaFve screen
20 Inflammatory Stool analysis posifve for RBCs, WBCs Colonoscopy + biopsies ± FCP Confirm IBD or infecfous e.g. pseudomembranous, amoebic, CMV colifs YES NO Treat appropriately Inves2gate other causes
21 Fatty Hb, Alb, Fe, Vit B12, folate Malabsorp2on Maldiges2on Gastroscopy + duodenal biopsies MRE VCE DBE SBBO trial anfbiofcs Faecal elastase MRI pancreas (CT if MRI unavailable)
22 If all else fails, think constipation! N.B: with overflow diarrhoea Exclude faecal inconfnence - KUB - anal manometry - endoanal US
23 7-step approach 1. Is it diarrhoea? Establish that it is. 2. Is it funcfonal or organic? 3. Is it colonic, small bowel or pancreafc disease? 4. Is it inflammatory, watery, facy? 5. Determine specific cause. 6. Could it be consfpafon/pelvic pathology? 7. Could it be facffous (4-20%)?
24 Learning Points It begins with a focused, comprehensive history Minimal/non-invasive step-wise invesfgafons to arrive at a diagnosis Test early for coeliac disease Most chronic diarrhoea is due to colonic abnormalifes and generally not infecfous Some condifons are more common than we think
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