.

1. Diarrhoea
• What does the patient mean by diarrhoea?
• Normal bowel habit
• Frequency over 24h
• Consistency – colour, steatorrhoea, offensive
smell
• Blood/mucus mixed in
• Associated wt loss or other symptoms:
– N&V
– Abdo pain

2. Diarrhoea - questions
• Systemic symptoms – malaise, lethargy
• Risk factors – foreign travel/recent
contacts
• Infective causes ask about -
– Fever, weight loss, night sweats, malaise,
anorexia, recent travel important

3. Investigation of diarrhoea
• Stool culture
• Exclude causes
– Drugs
– TFTs
– Anti-endomysial antibodies
• Flexi sigmoidoscopy
• Ba. Enema / colonoscopy
• OGD

4. Types of diarrhoea
• secretory diarrhea
• osmotic diarrhea
• motility-related diarrhea
• inflammatory diarrhea

5. Secretory diarrhoea
• increase in the active secretion OR an
inhibition of absorption
• little to no structural damage
• causes
– Cholera toxin

6. Osmotic diarrhoea
• “Too much water”
• Causes
– Malabsorption
• Loss of pancreatic secretions (pancreatitis, CF)
• Bile salt diarrhoea (bile into colon not GB)
• Cealiac disease
• Lactose/fructose intolerance
– Osmotic laxatives
– Short bowel syndrome
– Drugs (antibiotics, antihypertensives, chemotherapy
and antacids containing magnesium)
– Radiation induced fibrosis
– ALCOHOL (hangovers)

7. Motility disorders
• Rapid transit through bowel
– Hyperthyroidism
– Vagotomy
– Diabetic neuropathy

8. Inflammatory causes
• Infective
– Bacterial
• Campylobacter, Salmonella, Shigella, and
Escherichia coli
– Parasitic
• Giardia lamblia, Entamoeba histolytica, and
Cryptosporidium
– Viral
• rotavirus, Norwalk virus, cytomegalovirus, herpes
simplex virus, and viral hepatitis

9. Inflammatory causes
• IBD
• Cancer
– mucin secreting tumours of large bowel
– Hormone secreting tumours, e.g. serotonin
• TB

10. Causes of diarrhoea
Colonic causes Small bowel causes
Inflammatory bowel disease Coeliac disease
Infective colitis – bacterial, viral High –output eg post small
bowel resection
Left sided colon malignancy Terminal ileitis eg TB or
Crohn’s
Ischaemic colitis
Overflow diarrhoea secondary
to constipation

11. causes of persistent diarrhoea
(>4 weeks)
• ulcerative colitis
• Crohn's disease
• irritable bowel syndrome (IBS)
• lactose intolerance
• coeliac disease
• diabetes
• pancreatitis

12. IBS
• Defn: at least 12 weeks of preceding 12
months of abdominal pain or discomfort +
at least two of the following:
• relief by defaecation
• onset with change of frequency of stool
• onset with change in form of stool

13. IBS
• typically 20-30’s
• female 2:1 male
• estimated 10-20% incidence in UK
• causes not defined
– visceral hypersensitivity
– disturbed colonic motility
– post infective bowel dysfunction

14. symptoms
• pain
• bloating
• flatulence
• constipation +/- diarrhoea

15. coeliac
• immune response to gliaden in gluten
• causes villous atrophy in small bowel
• develop intestinal malabsorption
• children – diarrhoea, fatigue and failure to
thrive

16. Coeliac disease in adults
• unexplained iron-deficiency anemia
• fatigue
• bone or joint pain
• arthritis
• osteoporosis
• depression or anxiety
• peripheral parasthesia
• seizures
• missed menstrual periods
• infertility or recurrent miscarriage
• mouth ulcers
• dermatitis herpetiformis

17. Associated genetic conditions
• type 1 diabetes
• autoimmune thyroid disease
• autoimmune liver disease (PBC)
• rheumatoid arthritis
• Addison’s disease
• Sjögren’s syndrome,

18. Ix for coeliac
• Serum
– anti-tissue transglutaminase antibodies
(tTGA)
– anti-endomysium antibodies (EMA).
• HLA typing
– HLA –DQ2, HLA DQ8
• Intestinal biopsy
– OGD (duodenal/jejunal bx)

19. classification
• Marsh classification for coeliac disease
– Marsh stage 0: normal mucosa
– Marsh stage 1: increased number of intra-epithelial
lymphocytes, usually exceeding 20 per 100
enterocytes
– Marsh stage 2: proliferation of the crypts of
Lieberkuhn
– Marsh stage 3: partial or complete villous atrophy
– Marsh stage 4: hypoplasia of the small bowel
architecture

20. Marsh classification for coeliac
disease

21. Constipation - questions
• Normal bowel habit
• Duration of constipation – chronic/acute
• Previous episodes/alternating with diarrhoea?
• Stool – blood/mucus/melaena
• Tenesmus
• Rectal disease – piles, pruritis, fissures
• Weight loss & appetite changes
• Cramps or bloating - ?Ca colon – obstruction
• Cancer – Weight loss, fatigue, anorexia,
haemoptysis, fhx, smoking

22. Haematemesis - questions
• Characterise nature of haematemesis – fresh
blood/coffee grounds
• Number of episodes/previous episodes
• Volume of blood
• Is there melaena or fresh blood PR?
• Other symptoms – epigastric pain, wt loss, ↓
appetite
• Risk factors – alcohol XS, peptic ulcer disease,
oesophageal varices, meds - warfarin

23. Causes of haematemesis
Oesophageal
Oesophagitis, carcinoma,
oesophageal varices,
Mallory-Weiss tear, trauma,
hiatus hernia
Gastric
Gastritis, peptic ulcer, tumours
Duodenal
Duodenitis, duodenal ulcer

24. Rectal bleeding - questions
• Duration of symptoms – yrs, months
• Previous episodes or treatment
• Is the blood:
– mixed in with stool
– separate – found on toilet paper/splashes in
toilet bowl
• Fresh or altered blood - ? Lower vs upper
GI bleed

25. Causes of rectal bleeding
Main differentials :
• Haemorrhoids (piles)
• Colonic carcinoma
• Diverticular disease / bleeding ulcer
• Anal fissure
• Anal carcinoma (rare)