grand round presentation anthony li

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• floaty• some difficulty flushing• no associated abdominal pain / PR bleeding

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:

– 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:

– NKDA

• FH:– ?

• SH:– occupation - home helper– smoker - 10/day– no EtOH– x3 children at home 18yrs, 15yrs, 12yrs

Mrs J D – 54 yrs ♀• O/E:

– General:• thin• no jaundice / anaemia / clubbing / lymphadenopathy

– RS:• NAD

– CVS:• NAD

– Breasts:• NAD

Mrs J D – 54 yrs ♀

• O/E:– GI:

non-distendedvisible SB segmentation centrallytender RUQ over GB - no guardingno palpable massesBS normal

DRE: tender left lateral pelvic wall but NADpale 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

Any Guess?

A 54 yr old lady presents with chronic diarrhoea with thickened SI mucosa,

stricture and matted loops

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

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


Lymphoma

Villous adenoma

Gastrinoma

VIPoma

carcinoid


Post surgical states- vagotomy/gastrectomy

Endocrine- DM/Hyperthyroidism/carcinoid

Infiltrative SI disease- scleroderma

OCTT-

Ba studies

Radionucleotide scintigraphy


Radiation of more than 50Gy

Ileum and rectum mostly

Mucosal damage and SBBO

Malabsorption

Luminal phase Mucosal phase

1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth

1. Coeliac disease2. Whipple disease3. Lactose intolerence4. Intestinal resection5. Ileal disease

Malabsorption

Luminal phase Mucosal phase

1. Gastric surgery2. Chronic pancreatitis3. Cystic fibrosis4. Bile acid malabsorption5. Bacterial overgrowth

1. Coeliac disease2. Lactose intolerence3. Intestinal resection4. Ileal disease5. Whipple disease

Understanding of patient’s 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

– Duration of symptoms, nature of onset (sudden or gradual)

– The volume of the diarrhoea1. voluminous watery diarrhoea -small bowel2. 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 examinationrarely 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

History or Findings suggestive of MALABSORPTION

Small bowel

Coeliac screenD2 biopsy

BaFT

PancreaticCT Pancreas

Faecal elastase

EnteropathyReview histology

Enteroscopy or capsule endoscopy

Bacterial overgrowthGlucose hydrogen breath testJejunal aspirate and culture

Further structural testsERCP or MRCP


History or Findings suggestive of Colonic or terminal ileal disease

Flexible sigmoidoscopy if <45Complement with Ba enema if >45

Colonoscopy preferred if >45

Terminal ileal disease excluded?Ba FT

99mTc HMPAO75SeHCAT


Difficult diarrhoea

Inpatient assessment24-72 hour stool weights

Stool osmotic gapLaxative screen

Gut hormoneSerum gastrin

VIPUrinary 5 - HIAA

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 )

RADIATION ENTEROCOLITIS

Dr.E.M.Phillips

Historical aspects

Self exposure Deep tissue traumatisation from Roentgen ray exposure

Walsh,D: Br Med J 1897: 272 – 273

Animal experimentsRoentgen ray intoxication. Warren S, Whipple GH:

J Exp Med 1922: 35: 187 – 202

Post radiotherapy pathology 38 patientsWarren 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 patientsDeCosse JJ et al. Natural history & management of radiation induced injury of the gastrointestinal tract Ann Surg 1969; 170: 369 - 384

Symptoms

EarlyDuring therapy and up to six months

LateFive to 31 years after radiotherapyPeak onset 12 – 15 years after

Early

Symptoms

DiarrhoeaColic

Nausea

Mucosal PathologyDecrease: enterocyte turnover &villous heightIncrease:enterocyte death;mucosal oedema &inflammatory infiltratewith mucosal slough

Acute radiation proctitis

Withering of crypts

Cystic dilatation of crypt

Inflamm infiltrate and oedema

LateSymptoms

SBDiarrhoea/malabsorp’nBlind loop syndromeSubacute obstruction

Colon tenesmus & mucus

Both haemorrhage,fistula

perforation

PathologyArteriolar endothelial spasm,

damage & obliterative vasculitis

Submucosa to serosaischaemia, ulceration,

and perforation; increase in bizarre fibroblasts; stricture, webs and fistula

Chronic Radiation Proctitis

Thickening of lamina propria with fibrosis

Vascular ectasia

Associated factorsCausalRadiotherapy• High dose DXT• Total volume gut

irradiated (e.g. para-aortic nodes incl.)

• Low body weight

Surgery• AdhesionsAlso relates to severity

of in-therapy toxicity

Not associatedVascular risk factors:DiabetesHypertensionDyslipidaemias(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 5000IncreasedRads. for 6000 7500 7000high risktumourGives 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. enterocolitisca. 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

grand round presentation anthony li

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