Grand round presentation Anthony Li

Mrs J D – 54 yrs ♀ PC: HPC: diarrhoea 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 JD – patient of Dr Phillips who she sees in the outpatient clinic Initially referred to Dr Phillips in 1987 – at that time, 54yrs old

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: DH: 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: FH: SH: NKDA ? occupation - home helper smoker - 10/day no EtOH x3 children at home 18yrs, 15yrs, 12yrs

Mrs J D – 54 yrs ♀ O/E: General: RS: CVS: Breasts: thin no jaundice / anaemia / clubbing / lymphadenopathy RS: NAD CVS: Breasts:

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 GHOSH GASTRO SPR

A 54 yr old lady presents with chronic diarrhoea with thickened SI mucosa, stricture and matted loops Any Guess?

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 Inflammatory bowel disease Chronic infections 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 Lymphoma Villous adenoma Gastrinoma VIPoma carcinoid Ischaemic colitis Drugs Neoplastic Motility disorders Radiation enteritis

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

Understanding of patient’s complain of diarrhoea consistency frequency of stools urgency or faecal soiling      Stool characteristics presence of visible blood- IBD or cancer greasy stools that float and are malodorous -fat malabsorption     

Duration of symptoms, nature of onset (sudden or gradual) The volume of the diarrhoea voluminous watery diarrhoea -small bowel 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 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.

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

Further investigation as per BSG protocol

Further investigation as per BSG protocol

Treatment General measures: Therapeutic trials 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 Animal experiments 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 – 513 1950s super voltage therapy 100 patients DeCosse 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

Inflamm infiltrate and oedema Withering of crypts Cystic dilatation of crypt

Diarrhoea/malabsorp’n Late Symptoms SB Diarrhoea/malabsorp’n 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

Chronic Radiation Proctitis Vascular ectasia Thickening of lamina propria with fibrosis

Associated factors Causal Radiotherapy Not associated 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

Dose of rads. & damage Minimal tolerated dose gives 5% radiation enterocolitis within 5 years: SB Trans. colon rectosig. Rads. 4000 5500 5000 Increased Rads. for 6000 7500 7000 high risk tumour Gives 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