Diarrhoea Lent term year 2. The Case: Mr JK aged 25 Loose, frequent motions for 2 years Now presents with more severe diarrhoea with bleeding and pain.

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Presentation transcript:

Diarrhoea Lent term year 2

The Case: Mr JK aged 25 Loose, frequent motions for 2 years Now presents with more severe diarrhoea with bleeding and pain in the RIF On examination: T37 4 C, ill-defined tender mass in RIF PR: painful, with anal fissure PMH: arthritis affecting various joints which resolved, episode of uveitis 1 year ago

Differential diagnosis?

Wide differential diagnosis Infective Malabsorption Malignancy Inflammatory Iatrogenic Motility disorder/functional

Infections: viruses Rotavirus (most common cause in children in UK) Norwalk virus (of genus norovirus) occurs in outbreaks- the “Winter vomiting bug” Ebola virus- mortality % Enteric adenovirus- usually respiratory infection

Infections: bacteria e.coli: 057:H7 one to avoid (enterotoxin) Salmonella (raw chicken and eggs) Schigella (bacillary dysentery) Infectivity dose (ID) very low Vibrio Cholerae (nb John Snow 1854) Clostridium perfringens (pig-bel) and difficile Typhoid/paratyphoid (salmonelli typhi/paratyphi) Bacillus cereus (beware pre-cooked rice) Campylobacter (beware undercooked chicken) Listeria- (avoid eating unpasteurised cheese in pregnancy)

Infections: parasites Amoebic dysentery: (Tropical) entamoeba histolytica. Infective in cyst form Giardia lamblia (Giardiasis) Infective in cyst form Low ID. Can be caught in swimming pools

Stool microscopy:giardia

And yet more… Whipple’s disease Tropheryma whippelii. Tropical. Causes malabsorption Tropical sprue. Another cause of malabsorption ??infective organism

Don’t forget worms roundworm (Ascaris lumbricoides) Can cause intestinal obstruction whipworm (Trichuris trichiura) and hookworm (Ancylostoma duodenale and Necator americanus).

Roundworms resected

Malabsorption Coeliac disease Cystic fibrosis (lack pancreatic enzymes) Lactose intolerance

Malignancy Carcinoma of large bowel Carcinoid tumour: neuroendocrine tumour usually found in appendix of small bowel May produce serotonin and cause carcinoid syndrome: diarrhoeadiarrhoea flushing of the skin, wheezing (similar to asthma), loss of appetite, weight loss. Benign villous adenoma

Inflammatory bowel disease Crohn’s disease. Can affect multiple sites from lips to anus. Can affect full thickness of bowel with fistula formation. Can get “skip lesions”. Often affects terminal ileum Ulcerative colitis Colon and rectum only- rectum in 95% cases

Crohn’s disease

iatrogenic Short bowel syndrome Laxatives Radiotherapy Chemotherapy: antibiotics, cytotoxic drugs

Motility disorder/function Diabetic neuropathy Ischaemic bowel Hyperthyroidism IBS Overflow (associated with constipation)

How would you investigate this patient?

Possible investigations: Stool culture (negative) Blood tests: Hb 10.0g/dl ESR 60 mm/hr Albumin: 28g/dl WCC- 14,000

CT scan:

Barium follow-through

Barium enema

Nuclear scanning: white cell scanning

So the diagnosis was………!