Diarrhoea on the AMU. Dr Chris Roseveare

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1 Diarrhoea on the AMU Dr Chris Roseveare The Society for Acute Medicine, Spring Meeting, Radisson Blu Hotel, Dublin 3-4 May 2012

2 Acute diarrhoea in developed countries adult populations Mainly a primary care / outpatient issue

3 Key Challenges for the AMU Doctor Admit or Discharge? Isolate or Observe? What s the diagnosis? What investigations are going to be helpful? What immediate treatment is required?

4 Why admit? Admission or discharge? Septic / Hypovolaemic Shock Rehydration / electrolyte replacement Risk of perforation / peritonitis Failure of outpatient management Parenteral treatment Urgent investigation Social factors

5 The isolation dilemma. Observation or Isolation?

6 What s the Diagnosis? Patient Groups Flare-up of known IBD Diarrhoea in the immunosuppressed patient Diarrhoea in the returning traveller The patient with unexplained diarrhoea Young? Older?

7 The young patient with unexplained diarrhoea Dear Medical Team Thank you for seeing this 25 year old woman with profuse diarrhoea, up to 10 times per day for the past 3 days; she looks unwell and dehydrated. She was well before this and has not travelled recently.

8 The young patient with unexplained diarrhoea Initial considerations Features of septic shock? Infectivity? Hydration / volume status? Electrolytes / renal function? Is perforation possible / imminent? Tenderness / distension / ileus / tachycardia / lactate

9 The young patient with unexplained diarrhoea Differential Infective First attack of IBD (crohns colitis / UC) Functional bowel disease Something rare!

10 The young patient with unexplained diarrhoea Differential Infective First attack of IBD (crohns colitis / UC) Functional bowel disease Something rare! Consider thyrotoxicosis otherwise forget it for the first 24 hours

11 The young patient with unexplained diarrhoea Diarrhoea predominant irritable bowel Often very profuse (but long-standing) Absence of weight loss, bleeding No systemic upset, fever, tachy, etc Patient looks better than they sound Very rarely wakes patient from sleep usually most prominent in mornings??undisclosed laxative use / abuse

12 What sort of infection? Bacterial? Salmonella Campylobacter Persistence >48 hours,?blood in stool, suggestive food history (eggs or chicken) within 72 hours of onset? E Coli Clostridium difficile

13 What sort of infection? Bacterial? Salmonella Campylobacter E Coli Severely unwell / septic; renal impairment; history of beef consumption within 72 hours; profuse diarrhoea without blood Clostridium difficile

14 What sort of infection? Bacterial? Salmonella Campylobacter E Coli Usually older; history of antibiotic use in past 3 months, hospital / care home stay, profuse watery / bloodstained diarrhoea Clostridium difficile

15 What sort of infection? Viral Norovirus Rotavirus Adenovirus Short history, fever, vomiting, recent contacts, absence of blood in stool?

16 What sort of infection? Protozoal Giardia Watery stool without pus / blood; persistent symptoms without fever / abdo pain Entamoeba Cryptosporidia

17 Could it be IBD? Features favouring infection.. Short history No prior episodes Green stool Disproportionate fever Suggestive food / travel / contact history

18 Could it be IBD? Features favouring IBD.. Prodrome / prior episodes Extraintestinal manifestations Family history

19 What tests are likely to help? Laboratory tests. CRP generally higher with infection Albumin generally lower with IBD Stool culture 30% sensitivity Infection may co-exist with IBD Result takes hours

20 What tests are likely to help? X-rays / other imaging? Establish presence / extent of colitis Identify toxic dilatation Will not help determine cause

21 What about sigmoidoscopy? Will establish presence +/- extent of colitis Deep ulcers, cobblestoning, etc, in UC / crohns Pseudomembrane

22 and the biopsy? Some specific histological features (crypt abscesses, granulomata, etc) Often disappointingly non-specific Features consistent with inflammatory bowel disease Infection should be excluded if clinically suspected

23 Likely Viral Initial treatment hydration / anti-emetic / discharge Likely Bacterial (or protozoal) Ciprofloxacin +/- metronidazole Cef and met Tazocin? Likely IBD Follow guidelines and get specialist help early Not sure IV steroids + antibiotics

24 Antibiotics? Initial Treatment Ciprofloxacin +metronidazole Steroids? Unlikely to do harm even if patient has infection with associated colitis Both? Get specialist help where possible

25 The older patient with unexplained diarrhoea Broader differential Drugs / ischaemia / malignancy / Diverticulitis IBD less likely (but not impossible) Constipation with overflow C Diff more likely Social factors..

26 The older patient with unexplained diarrhoea Dear Medical team Thanks for taking this 75 year old woman with diarrhoea; she is on amiodarone and digoxin for AF. She is normally constipated, but has experienced diarrhoea ever since she came into hospital with a chest infection last month. She has a past history of diverticular disease and colonic polyps. The symptoms have now worsened and her 80 year old husband is struggling to cope..

27 Ischaemic colitis Bloody diarrhoea Disproportionate bleeding Generally older patients Often history of AF / IHD / CVD Often confined to watershed areas

28 Prognosis / Treatment Ischaemic colitis Usually resolves spontaneously over 1-3 months Mortality usually relates to co-morbidities Supportive treatment drugs don t work!

29 Summary Initial resuscitation manage life threatening features Isolation precautions where necessary Consider causes categorise into appropriate patient group Specialist help if fails to settle / IBD considered likely