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Case 15 Inflammatory Bowel disease Infectious Diarrhoea Brought to you by: Molly Tavender Contents 0 0 Symptoms and IBD Overview management of 1 4 IBD 0 Intestinal 0 Irritable bowel 2 features of IBD 5 syndrome 0 Extraintestinal 0 Infectious 3 features of IBD diarrhoea 6 Ulcerative Colitis Pathophysiology Clinical Features Histology ● Continuous inflammation ● Bloody diarrhoea ● Crypt Abscesses of the colon, affecting the submucosa and mucosa ● Lymphocyte infiltration ● Mucous in stool ● Decreased goblet cells only ● Continuous inflammation of ● Rectum is the most ● Urgency and mucosa and submucosa tenesmus only common region affected ● Rectum most commonly ● Associated with HLA-B27 ● Abdominal pain affected and pANCA antibodies ● Only large bowel affected ● Complications: toxic megacolon Crohn’s Disease Pathophysiology Clinical Features Histology ● Transmural inflammation of the GI tract ● Non-bloody diarrhoea ● Increased goblet cells ● Affects anywhere from ● Abdominal pain ● Transmural inflammation - mouth to anus – skip lesions muscosa to the serosa ● Weight loss ● Ileo-caecal region is most ● Non-casseating ● Fistulas granulomas commonly affected – which vitamin may be ● Perianal abscesses deficient in CD? ● Associated with HLA-B27 Key Differences Crohn’s Disease Ulcerative colitis ● Transmural inflammation ● Continuous inflammation limited to the mucosa and submucosa ● Increased goblet cells ● Goblet cell depletion ● Affects anywhere from mouth to Vs anus – asymmetric distribution ● Limited to the colon only ● Ileo-caecal region is the most ● Rectum is the most common site common site affected and rectal affected sparing is seen Ulcerative Crohn’s Disease Colitis Episcleritis Uveitis Painless red eye Painful red eye Erythema Extra- Pyoderma Nodosum Intestinal Gangrenosum Painful red lesions features Painful skin on shins ulceration Gallstones Primary Sclerosing Cholangitis Key Differences Crohn’s disease Ulcerative Colitis ● Non-bloody diarrhoea ● Bloody diarrhoea ● Smoking makes symptoms worse ● Smoking improves symptoms ● Abdominal pain more severe ● Perianal disease and fistulas are not Vs seen ● Perianal disease and fistulas seen ● Appendicectomy improves UC ● Appendicectomy has no effect on symptoms Management of UC Flares Maintaining Remission in UC Mild Moderate Severe < 4 stools per 4-6 bloody > 6 bloody day +/- blood stools per day stools per day No systemic with minimal with systemic Rectal aminosalicylate upset systemic upset upset eg fever Or Oral aminosalicylate Mild/moderate Or both flare 1. Rectal aminosalicylate Management 2. Add an oral aminosalicylate 3. Add an oral corticosteroid of UC If there are >= 2 exacerbations in 1 year: Severe Flare Give Azathioprine or mercaptopurine • Admit to to maintain remission gastroenterology • IV corticosteroids Management of Crohn’s Disease Surgery Inducing remission • Ileostomy – right iliac fossa • Glucocorticoids – • Colostomy – left budesonide 1 line iliac fossa Management of CD Management of Maintaining perianal abscesses remission • Azathioprine or • Incision and mercaptopurine drainage • Antibiotics Irritable Bowel Syndrome ConTopic IBS if the patient has had the following for at least 6 months: • Abdominal pain, and/or • Bloating, and/or • Change in bowel habit Presentation: • Altered bowel habit • Bloating • Symptoms worsened by eating • Relieved after defecation Red Flags • Rectal bleeding • Unexplained weight loss • Family history of bowel or ovarian cancer • Onset after the age of 60 years • Require further investigation for CRC, coeliac disease, IBD etc Irritable Bowel Syndrome Investigations: • FBC Topic • CRP/ESR • Coeliac disease – ttG and IgA Management: 1 line - Treat the predominant symptom: • Pain – antispasmodic agents • Constipation – laxatives • Diarrhoea – loperamide Dietary Advice: • Regular meals • Plenty of fluids • Reduce alcohol, fizzy drinks and caffeine • Increase physical activity IBS vs IBD IBS IBD Normal blood results Anaemia, raised platelets, raised ESR and low albumin may be seen Normal faecal calprotectin Raised faecal calprotectin No weight loss or fever Weight loss and fever common No perianal disease Perianal disease seen in CD No bloody in stool or tenesmus Tenesmus and bloody stools common in UC Infectious Diarrhoea Campylobacter Bacteria Shigella Infectious E.coli Diarrhoea Salmonella 3 or more loose Norovirus Viruses Rotavirus bowel movements within 24 hours that lasts less than 14 Protozoa Cryptosporidium days Giardia lamblia Endogenous Clostridium difficile Infection Appendicitis Viral Causes Viral causes of infectious diarrhoea Norovirus Rotavirus •Non-enveloped ssRNA virus •4 genogroups - I and II most common •dsRNA virus •Group A and B in humans •10 virions needed to be infected - 5 billion in •10-100 virions is infective dose 1g of faeces •Causes diarrhoea and sometimes vomiting •Incubation is 24-48 hours •Incubation is 24-72 hours •Big outbreaks in cruise ships and hospitals •Most common cause of diarrhoea in children •Management: •Vaccine now given o Supportive only- fluids o Live attenuated oral vaccine o Isolation for at least 48 hours until o Given at 8 and 12 weeks symptoms have ended •Detected by: ELISA Campylobacter • Gram negative, curved rod • Most common bacterial cause of infectious diarrhoea in the UK is Campylobacter jejuni found in poultry • Toxin mediated • Incubation is 2-5 days • Transmission most commonly by undercooked chicken or pork Symptoms: • Fever • Watery and sometimes bloody diarrhoea • Malaise Management: • Usually self limiting st • Clarithromycin is 1 line antibiotic if immunosuppressed or not improving Complications: • Guillain barre syndrome and reactive arthritis Entero-Pathogenic Entero- • Toxin mediated and cholera like • NOT toxin mediated • Attaches directly to cells • Seen in travellers and infants – • Seen in infants Traveller’s diarrhoea • Can be long lasting • Breast feeding protects against E. Coli Gram negative Rod shaped May be flagellated Verocyto-toxic E Motile or non motile Entero-Invasive Facultative anaerobe coli (VTEC) Common gut pathogen • May cause haemolytic • Toxin mediated uraemic syndrome in young • Shigella like children • Dysentery like • Thrombocytopaenia, renal • Human disease only failure and haemolytic anaemia Shigella •Gram negative rod shaped •Small infective dose 10-100 organisms •Causes dysentery Faecal oral spread • •S sonnei is most common type in the UK •S dysenterae is most severe Management: •Avoid anti-motility agents •Ensure fluid and hydration therapy •Antibiotics if severe •Prevent withCholerae and sanitation •Gram negative curved rod •Toxin mediated disease •Causes rice water stool •Leads to large fluid loss – 1 litre / hour •Supportive treatments- fluids •Detected by stool culture •Prevention by clean food and water •Vaccine for travellers Salmonella • Gram negative, flagellated rod • Incubation is 8-24 hours • Effects the small intestine Salmonella Enteritidis • Type which causes food poisoning • Found in undercooked food eg chicken • Treated with fluoroquinolones, macrolides or cephalosporins Salmonella typhi • Causes typhoid fever • Fatal febrile illness • Step wise fever seen • Cough and constipation are common • Rose spots are seen • Diagnosed by blood, stool or urine • Requires antibiotics – quinolones Protozoa Causes Protozoa causes of infectious diarrhoea Giardia Lamblia Cryptosporidium • Incubation period > 7 days ● Highly contagious intestinal sporozoan • 2 stage life cycle- flagellated in host’s ● Multiplies in the small intestine duodenum, cysts found in stools ● Most common cause of diarrhoea in • Most common GI parasite worldwide patients with HIV • Usually from contaminated water- Symptoms: resistant to chlorine (swimming pools) • Takes 12 days to develop but can last 5-6 Symptoms: weeks • Bulky, pale and offensive diarrhoea • Diarrhoea, abdo pain, weight loss • May cause chronic diarrhoea • Seen in travellers Management: Management: • Metronidazole • If AIDs- Highly active anti-retroviral therapy Clostridium Difficile •Gram positive •Toxin mediated •Seen in elderly and in hospital settings commonly •Part of normal microflora up to 2 years of age •Use hot water and soap to remove spores- not alcohol gel because the spores stick Caused by • Antibiotics- penicillin's, cephalosporins, clindamycin • PPIs can also cause Clinical features: o Increased WCC o Profuse watery diarrhoea o Fever o Colitis – may cause toxic megacolon Management: o Stop offending agent o Nutrition and fluids o Anti C diff Antibiotics: • Oral Vancomycin is 1 line • If returns within 12 weeks, give fidaxomicin • If life threatening C diff: oral vancomycin and IV metronindazole Surgery: • Stool transplant if medical treatment ineffective High Yield Facts Campylobacter is the most common bacteria cause of infectious diarrhoea in the UK Verocyto-toxogenic E coli causes haemolytic uraemic syndrome Clostridium difficile is gram positive, rest of the bacteria are gram negative Breast feeding protects against Entero-toxigenic E coli ETEC Cholera causes rice water stool • Campylobacter is the most common bacteria cause of infectious diarrhoea in the UK • Verocyto toxogenic E coli causes haemolytic uraemic syndrome • Entero-pathogenic E coli is NOT TOXIN mediated • Clostridium difficile is gram positive, rest of the bacteria are gram negative • Rotavirus is detected by ELISA • Breast feeding protects against Entero-toxigenic E coli ETEC • Cholera causes rice water stool • Giardia causes the bulky, pale and offensive stool • Do not give antibiotics for haemolytic uraemic syndrome caused by Verocyto-toxic E coli • C diff is part of normal microflora up to 2 years of age SBA Question 1 A 32 year old female presents to A Ulcerative Colitis the GP with a 6 week history of abdominal pain, fatigue and non- B Crohn’s disease bloody diarrhoea. Recent bloods have shown a microcytic anaemia and raised CRP. C Coeliac disease Colonoscopy shows a patchy distribution of inflammation, D Irritable bowel syndrome worst in the ileo-caecal region. What is the most likely E Campylobacter infection diagnosis? SBA Question 1 A 32 year old female presents to A Ulcerative Colitis the GP with a 6 week history of abdominal pain, fatigue and non- B Crohn’s disease bloody diarrhoea. Recent bloods have shown a microcytic anaemia and raised CRP. C Coeliac disease Colonoscopy shows a patchy distribution of inflammation, D Irritable bowel syndrome worst in the ileo-caecal region. What is the most likely E Campylobacter infection diagnosis? SBA Question 2 An 18 year old woman presents with 7 months of A Oral aminosalicylate abdominal bloating and frequent diarrhoea which is B Rectal aminosalicylate affecting her job. She is worried it could be something C Mebeverine serious. Bloods have come back as normal and she has D Loperamide no unexplained weight loss. Based on the most likely E Oral budesonide diagnosis, what is the most appropriate management for her diarrhoea? SBA Question 2 An 18 year old woman presents with 7 months of A Oral aminosalicylate abdominal bloating and frequent diarrhoea which is B Rectal aminosalicylate affecting her job. She is worried it could be something C Mebeverine serious. Bloods have come back as normal and she has D Loperamide no unexplained weight loss. Based on the most likely E Oral budesonide diagnosis, what is the most appropriate management for her diarrhoea? SBA Question 3 A Discharge home with oral steroids A 25 year old male with known ulcerative colitis has come to B Oral and rectal aminosalicylates the GP with a 2 day history of 7 bloody stools per day. He has a temperature of 38.3 C Rectal aminosalicylate degrees and feels very unwell. D Oral aminosalicylate What is the most appropriate management for this patient? E Admit to gastroenterology for IV steroids SBA Question 3 A Discharge home with oral steroids A 25 year old male with known ulcerative colitis has come to B Oral and rectal aminosalicylates the GP with a 2 day history of 7 bloody stools per day. He has a temperature of 38.3 C Rectal aminosalicylate degrees and feels very unwell. D Oral aminosalicylate What is the most appropriate management for this patient? E Admit to gastroenterology for IV steroids SBA Question 5 19 year old Luke has just A Campylobacter returned from discovering B ETEC himself in Thailand on his gap year. Unfortunately, he has now got watery stools, C Shigella abdominal pain and nausea. Given Luke’s recent travel D VTEC history, what is the most likely pathogen causing his E Clostridium difficile symptoms? SBA Question 5 19 year old Luke has just A Campylobacter returned from discovering B ETEC himself in Thailand on his gap year. Unfortunately, he has now got watery stools, C Shigella abdominal pain and nausea. Given Luke’s recent travel D VTEC history, what is the most likely pathogen causing his E Clostridium difficile symptoms? SBA Question 6 57 year old Sally has come to A Campylobacter the GP with bloody diarrhoea B Salmonella typhi and abdominal pain for the last 2 days. She has also felt nauseas and has a headache. C Shigella 3 days ago she went to a BBQ where she ate burgers and D Cholera chicken. Which pathogen is most likely to be causing her E Giardia lamblia symptoms? SBA Question 6 57 year old Sally has come to A Campylobacter jejuni the GP with bloody diarrhoea B Salmonella typhi and abdominal pain for the last 2 days. 3 days ago she went to a BBQ where she ate C Shigella burgers and chicken. Stool culture has show a gram D Campylobacter coli negative curved rod. Which pathogen is most likely to be E Giardia lamblia causing her symptoms? SBA Question 7 A Metronidazole You’re on a GI ward and an 82 B Clindamycin year old patient has got new onset diarrhoea. He has recently finished a course of C Amoxicillin antibiotics. Stool culture confirms the presence of C D Ceftriaxone diff. What is the first line treatment? E Vancomycin SBA Question 7 A Metronidazole You’re on a GI ward and an 82 B Clindamycin year old patient has got new onset diarrhoea. He has recently finished a course of C Amoxicillin antibiotics. Stool culture confirms the presence of C D Ceftriaxone diff. What is the first line treatment? E Vancomycin Thank you! 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