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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.

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Presentation on theme: "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."— Presentation transcript:

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 cms, otherwise normal to 15cms bloods: –FBC, U&Es, LFTs, Ca 2+, 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 ITS 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 colon24 Transverse colon9 Ascending colon7 Rectum3

24 Minor causes Ischaemic colitis Drugs Neoplastic Motility disorders Radiation enteritis

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

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 Malabsorption Luminal phase 1.Gastric surgery 2.Chronic pancreatitis 3.Cystic fibrosis 4.Bile acid malabsorption 5.Bacterial overgrowth Mucosal phase 1.Coeliac disease 2.Whipple disease 3.Lactose intolerence 4.Intestinal resection 5.Ileal disease

29 Malabsorption Luminal phase 1.Gastric surgery 2.Chronic pancreatitis 3.Cystic fibrosis 4.Bile acid malabsorption 5.Bacterial overgrowth Mucosal phase 1.Coeliac disease 2.Whipple disease 3.Lactose intolerence 4.Intestinal resection 5.Ileal disease

30 Malabsorption Luminal phase 1.Gastric surgery 2.Chronic pancreatitis 3.Cystic fibrosis 4.Bile acid malabsorption 5.Bacterial overgrowth Mucosal phase 1.Coeliac disease 2.Whipple disease 3.Lactose intolerence 4.Intestinal resection 5.Ileal disease

31 Malabsorption Luminal phase 1.Gastric surgery 2.Chronic pancreatitis 3.Cystic fibrosis 4.Bile acid malabsorption 5.Bacterial overgrowth Mucosal phase 1.Coeliac disease 2.Whipple disease 3.Lactose intolerence 4.Intestinal resection 5.Ileal disease

32 Malabsorption Luminal phase 1.Gastric surgery 2.Chronic pancreatitis 3.Cystic fibrosis 4.Bile acid malabsorption 5.Bacterial overgrowth Mucosal phase 1.Coeliac disease 2.Whipple disease 3.Lactose intolerence 4.Intestinal resection 5.Ileal disease

33 Malabsorption Luminal phase 1.Gastric surgery 2.Chronic pancreatitis 3.Cystic fibrosis 4.Bile acid malabsorption 5.Bacterial overgrowth Mucosal phase 1.Coeliac disease 2.Lactose intolerence 3.Intestinal resection 4.Ileal disease 5.Whipple disease

34 Understanding of patients 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

35 –Duration of symptoms, nature of onset (sudden or gradual) –The volume of the diarrhoea 1. voluminous watery diarrhoea -small bowel 2. small-volume frequent diarrhoea -colon –Occurrence of diarrhoea during fasting or at night- secretory or organic diarrhoea

36 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

37 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

38 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.

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

40 Further investigation as per BSG protocol History or Findings suggestive of MALABSORPTION Small bowel Coeliac screen D2 biopsy BaFT Enteropathy Review histology Enteroscopy or capsule endoscopy Bacterial overgrowth Glucose hydrogen breath test Jejunal aspirate and culture Pancreatic CT Pancreas Faecal elastase Further structural tests ERCP or MRCP

41 Further investigation as per BSG protocol History or Findings suggestive of Colonic or terminal ileal disease Flexible sigmoidoscopy if <45 Complement with Ba enema if >45 Colonoscopy preferred if >45 Terminal ileal disease excluded? Ba FT 99mTc HMPAO 75SeHCAT

42 Further investigation as per BSG protocol Difficult diarrhoea Inpatient assessment hour stool weights Stool osmotic gap Laxative screen Gut hormone Serum gastrin VIP Urinary 5 - HIAA

43 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 )

44 RADIATION ENTEROCOLITIS Dr.E.M.Phillips

45 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 pathology 38 patients Warren S, Friedman NB: Pathology and pathological diagnosis of radiation lesions in the gastrointestinal tract: Am J Path 1942: 499 – s super voltage therapy 100 patients DeCosse JJ et al. Natural history & management of radiation induced injury of the gastrointestinal tract Ann Surg 1969; 170:

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

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

48 Withering of crypts Cystic dilatation of crypt Inflamm infiltrate and oedema

49 Late Symptoms SB Diarrhoea/malabsorpn Blind loop syndrome Subacute obstruction Colon tenesmus & mucus Both haemorrhage, fistula perforation Pathology Arteriolar endothelial spasm, damage & obliterative vasculitis Submucosa to serosa ischaemia, ulceration, and perforation; increase in bizarre fibroblasts; stricture, webs and fistula

50 Chronic Radiation Proctitis Thickening of lamina propria with fibrosis Vascular ectasia

51 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 associated Vascular risk factors: Diabetes Hypertension Dyslipidaemias (Smoking??) Concomitant chemo. Pelvic sepsis

52 Dose of rads. & damage Minimal tolerated dose gives 5% radiation enterocolitis within 5 years: SB Trans. colon rectosig. Rads Increased Rads. for high risk tumour Gives 50% radiation enterocolitis within 5 years Roswit B et al. Amer. J Roentgenology 1972; 114: 460

53 Surgery & radiation damage Chronic radiation ileitis n=97 SurgeryNil 1 op. 2 op.3 op. Ileitis % Daly NJ et al. Radiother Oncol (4):

54 Majority of patients with radiation enterocolitis are tumour free

55 Prognosis of Rad. enterocolitis ca. 30% may come to surgery: complications:- Anastomotic leak65 – 100% Range Morbidity11 – 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

56 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

57 THANK YOU


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