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GI diseases II. Tomas Koller, MD. PhD. Assoc. Prof.
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GI diseases II. - uniba.sk

Feb 05, 2022

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Page 1: GI diseases II. - uniba.sk

GI diseases II. Tomas Koller, MD. PhD. Assoc. Prof.

Page 2: GI diseases II. - uniba.sk

Acute diarrhea

Page 3: GI diseases II. - uniba.sk

Acute diarrhea Definition

>3x/day, >300 g/day

<2 weeks, mostly<1 week

Abrupt onset

Mostly infectious origin

Does not relapse

Page 4: GI diseases II. - uniba.sk

Acute diarrhea

• Dysenteric syndrome

• Content of pus and blood separated from the stool

• Tenesms (pianful urgency)

• Balloning

• Distal colon

Page 5: GI diseases II. - uniba.sk

Acute diarrhea Causes

• Toxins from bacteria

• Incubation short (hours)

• Staphylococcus aureus

• Bacillus cereus

• Clostridium perfringens

• Infection

• Incubation <24h

• Viruses

• Salmonella

• Campylobacter

• E.Coli enterohemorhagic

• Yersinia enterocolitica

• Giardia intestinalis

Page 6: GI diseases II. - uniba.sk

Acute diarrhea Diagnosis

• Diagnosis is clinical

• Evaluate for hypovolemia

• BP<90 mmHg, pulse<120/min

• Oliguria

• Capullary refill tie >3s

• Cold and pale extremities

• Marble skin

• Hypokaliemia

• Abdominal palpation

• Sensibility diffuse due to air

Page 7: GI diseases II. - uniba.sk

Acute diarrhea Diagnostic workup

• Not indicated unless:

• Blood in the stool, dysenteric syndrome = organic origin

• Signs of sepsis (>39˚C), septic shock, hypothermia

• Severe dehydration

• Cardiac valve disease, elderly, comorbid

• Persisting diarrhea > 3 days

• Full blood count, CRP, stool culture focused on Salmonella, Shigella, Campylobacter, Yersinia, E.Coli 0157

• Dehydration , Na, K , Cl

• Blood in the stool > 4 days, sigmoidoscopy

• Sepsis - hemoculture

Page 8: GI diseases II. - uniba.sk

Acute diarrhea Therapy

• Symptomatic

• Rehydration

• Correction of electrolytes

• Spontaneous evolution is favorable

• < 5 days

• In patients with sepsis, or risk factors and severe condition

• Bacterial or parasitic agent is identified

• Antibiotics could be prescribed for Campylobacter, Yersinia

• Ciprofloxacin 2x500 mg 3-5 days

• Macrolides (Camppylbacter)

• Antiparasitic drug for Amoeba, Gardia

• Metronidazol

Page 9: GI diseases II. - uniba.sk

Nosocomial acute diarrhea

• Risk factors

• antibiotics,

• age,

• time in the hospital,

• source of infection in the proximity

• Clostriudium difficile

• Giardia

• Multiresistant microbes

• Klebsiella

• Enterococci

Page 10: GI diseases II. - uniba.sk

Travellers diarrhea

• During travel or after returning from a trip

• Dysbiosis (loose stools) is frequent, short and benign

• Higher probability of parasitic infection

• Amoeba

• Depending on the country

Page 11: GI diseases II. - uniba.sk

Acute diarrhea post-antibiotic

• 10% of patients receiving antibiotics have some transit modification

• Usually bening diarrhea after 3-5 days

• No fever, spontaneously terminates

• No therapy

• 10% of post antibiotic diarrhea

• Clostriudiumm difficile (pseudomembranous colitis)

• Klebsiella oxytoca (bloody diarrhea)

Page 12: GI diseases II. - uniba.sk

• Toxin A or B in the stool

• Glutamate dehydrogenase

• Only the presence of Clostridium diff. does not confirm the diagnosis

• Th: vancomycin orally 4x/day (500 mg -2 g/d)

Clostridium difficile colitis

Page 13: GI diseases II. - uniba.sk

Chronic diarrhea

Page 14: GI diseases II. - uniba.sk

Chronic diarrhoe

Definition • >3 stools / day

• > 4 weeks

• Rectal syndrome • Frequent urgency for passing stool

• Non-fecal content (bloody, mucus)

• Sign of organic rectal disease • Cancer

• Inflammation

To be differentiated from

• Fecal incontinence

• False diarrhea of constipation • Exsudation of the mucosa in contact with

hard stool, explosive evaluation, liquid with some small parts of hard stool

Page 15: GI diseases II. - uniba.sk

Mechanisms and causes of chronic diarrhea

Motoric

Osmotic

Malabsorbtion

Secretory

Exsudative and inflammatory

Page 16: GI diseases II. - uniba.sk

Mechanisms and causes of chronic diarrhea

Motoric d. • No gut anatomic lesion

• Morning and after meals

• In groups

• Accelerated transit time

• Irritable bowel (IBS-D)

• Autonomic neuropathy • Hyperthyroidism • Endocrine tumors

• VIP, medullary thyroid cancer

Page 17: GI diseases II. - uniba.sk

Mechanisms and causes of chronic diarrhea

Osmotic d. • No gut anatomic lesion

• Liquid stool • Lactose intolerance

• Magnesium

• Laxative use

• Ingestion of polyols

Page 18: GI diseases II. - uniba.sk

Malabsorption d.

Mechanisms and causes of chronic diarrhea

• Celiac disease • Crohn’s disease of small bowel • Postradiation enteritis

• Intestinal resection

• Exocrine pancreatic insufficiency

• Short bowel syndrome

• Lymphoma

• Chronic bowel ischemia • Posprandial pain

• Small intestinal bacterial overgrowth

• Whipple disease

Page 19: GI diseases II. - uniba.sk

Secretory d. • Liquid, hypovolemia, hypokaliemia

• Colitis • Microscopic colitis

• Lymphocytic, colagenous

• Infection in immunocompromised • Giardia intestinalis • Cryptosporidium • Isospora belli

• Neuroendocrine tumors (gastrinoma, VIPoma)

• Mastocytosis

Mechanisms and causes of chronic diarrhea

Page 20: GI diseases II. - uniba.sk

Exsudative d. • ulcers on the GI mucosa

• exsudation of blood, lymph, proteins

• IBD • Crohn’s disease • Ulcerative colitis

• Lymphoma

• Lymphangiectasia

• Malignant compression of lymph ducts

Mechanisms and causes of chronic diarrhea

Page 21: GI diseases II. - uniba.sk

Investigations for chronic diarrhea

Clinical and laboratory

• History • Timeline and trendline

• Physical examination • Herpetiform dermatitis • Goiter • Nails and hair abnormalities • Lymphadenoapthy • Hypotension • Flush

Laboratory exams • Blood

• Electrolytes • B12, folate • IgA anti-transglutaminase Ab • ASCA, pANCA antibodies • TSH • Chromogranin • Gastrin

• Stool • ova and parasites • elastase • calprotectin

Page 22: GI diseases II. - uniba.sk

Investigations for chronic diarrhea

Endoscopy

• Colonoscopy

• Enteroscopy

• Capsule enteroscopy

• EUS

• Upper GI endoscopy

Page 23: GI diseases II. - uniba.sk

Investigations for chronic diarrhea

Cross sectional imaging

• Ultrasound

• CT and MRI enterography

• CT scan and MRI

Page 24: GI diseases II. - uniba.sk

Constipation

Page 25: GI diseases II. - uniba.sk

Constipation

• Definition 1. Less than 3 stools per week 2. Sensation of incomplete evacuation 3. Both 1. and 3.

• A. Habitual • Occasional • Pregnancy and lactation • Travel

• B. Secondary - organic

• C. Idiopathic - functional • Slow transit • Dyschesia

• difficulties in stool evacuation

Page 26: GI diseases II. - uniba.sk

False diarrhea of constipation

• Fecalome in rectum • False diarrhea

• Frequent passage of liquid stools or mucus

• Risk factors • Chronic constipation

• Elderly

• Use of opiates

• Immobilisation

• Diagnosis • Digital rectal examination

Page 27: GI diseases II. - uniba.sk

B. Secondary constipation

Causes of secondary constipation • Colonic or anal stenosis

• Colic or extra-colic cancer • Post-colitis stenosis

• IBD, NSAID, Radiation, Diverticulitis, Volvulus

• Pelvic floor abnormalities • Rectocele

• Systemic disease • Neurological (Parkinson, CVA, SM) • Metabolic (DM, low thyroid, SS, low Ca, Mg)

• Drugs • Antidepressants, opiates….

Page 28: GI diseases II. - uniba.sk

Causes of functional consipation

• Slow transit

• Idiopathic (IBS-C)

• Pelvic floor dysfunction • Static or dynamic

C. Idiopathic “functional” constipation

Page 29: GI diseases II. - uniba.sk

Constipation

Investigations

• A: Habitual: usually not needed

• B: Secondary: absolutely indicated • Colonoscopy

• CT scan abdomen+pelvis

• Laboratory studies (TSH, A1C, Ca, CRP…)

• C: Idiopathic: functional studies

• Rectal manometry

• Dynamics of evacuation (Xray,MRI)

• Transit of markers

Page 30: GI diseases II. - uniba.sk

Constipation Management

Osmotic laxatives

• Lactulose

• Macrogol

• Magnesium

Therapy

• A: Habitual • Fiber 15g/day • Physical activity • Hydration

• B: Secondary • Treatment of the cause

• C: Idiopathic • Laxatives (osmotic) • Behavioral therapy • Pelvic floor surgery

Page 31: GI diseases II. - uniba.sk

Diverticulosis

Page 32: GI diseases II. - uniba.sk

Diverticulosis

• Diverticuli of the colonic wall • Frequent

• Age related

• Mainly left colon

• Usually asymptomatic • Symptomatic diverticulosis ?

• Complications • Bleeding

• Diverticulitis

• Bowel perforation

Page 33: GI diseases II. - uniba.sk

Diverticulosis Complications

Acute diverticulitis • Acute inflammation of the bowel wall –

sigmoiditis

• Clinical • Left lower quadrant or epigastric pain • Constipation • Bowel stenosis • Fever

• Investiation • Ultrasound, CT scan, blood tests (Leu, CRP)

• Treatment • Rehydration • +/- antibiotics

Page 34: GI diseases II. - uniba.sk

Diverticulosis Complications

Acute diverticular bleeding • Severe arterial lower GI bleeding

• Risk factors • Anticoagulants and antiaggregants • Comorbidity

• Chronic renal or cardiac disease

• Clinical • Enterorhagia • Hypotension, tachycardia

• Investigations • Blood count

• Treatment • Correction of volume • Preparation for colonoscopy – macrogol orally

Page 35: GI diseases II. - uniba.sk

Diverticulosis Complications

Perforation of the colon

• Acute abdominal pain

• Fever

• Signs of peritonitis

• Life threatening

Page 36: GI diseases II. - uniba.sk

FUNCTIONAL GI DISORDERS

Page 37: GI diseases II. - uniba.sk

Dyspepsia

DISCOMFORT OR PAIN FOLLOWING A MEAL OR DURING DIGESTION

ABNORMAL SENSATION FROM THE DIGESTIVE TRACT (MAŘATKA)

😕

Page 38: GI diseases II. - uniba.sk

Dyspepsia

upper dyspepsia

lower dyspepsia

Page 39: GI diseases II. - uniba.sk

Upper dyspepsia: causes

Upper dyspepsia Organic dyspepsia Secondary dyspepsia GE reflux Functional dyspepsia

Page 40: GI diseases II. - uniba.sk

Functional dyspepsia Rome IV criteria

1. Epigastric pain syndrome Ulcer-like dyspepsia

Pain or epigastric burn

2. Postprandial distress syndrome Dysmotility-like dyspepsia

Postprandial fullness

Early satiety

Page 41: GI diseases II. - uniba.sk
Page 42: GI diseases II. - uniba.sk

Dyspepsia Investigations

Necessary Alarm symptoms

• Age above 55, new onset dyspepsia

• Family history of upper gi cancer

• Weight loss – unwanted

• GE bleeding

• Dysphagia

• Odynophagia

• Unexplained iron def. anemia

• Vomiting

• Palpable mass

• Lymphadenopathy

• Jaundice

Not necessary

• No alarm symptoms

Page 43: GI diseases II. - uniba.sk

Management

Epigastric pain syndrome

H.Pylori test (stool) and H.Pylori • eradication if positive

Therapeutic trial • acid supressing therapy • sucralphate – may help • anti-spasmodics – may help

When ineffective • Endoscopy, • USG abdomen

Postprandial distress syndrome

Lifestyle changes

• Weight correction, small meal portions, less fatty meals, no NSA, no gas containing beverages, low coffein,

• Reducing some types of food: garlic, onion, black pepper, spices

• No smoking and alcohol

High placebo effect using any type of therapy Pharmacologic therapy

• Prokinetics – itopride, domperidone, metoclopramide

Page 44: GI diseases II. - uniba.sk

Dyspepsia lower: causes

Lower dyspepsia Organic cause (IBD, cancer....) Chronic diarrhea (malabs, coeliac.) Secondary causes (gynec, urol, other) Irritable bowel dyndrome (IBS)

Page 45: GI diseases II. - uniba.sk

Irritable bowel syndrome - IBS

Definition

Abdominal pain

Relief after defecation of loose stool

Provoked in the morning or after a meal

Variants

IBD-D, diarrhea

IBS-C, constipation

IBS-M, mixed type

Page 46: GI diseases II. - uniba.sk

Irritable bowel syndrome Mechanisms

Associated with microbiome

• Dysbiosis from the “western food”

Associated with gut neurons

• Post infectious IBS • Destruction of some myenteric

plexus neurons by toxins

Lowered pain theshold from the GI tract

Page 47: GI diseases II. - uniba.sk

Irritable bowel syndrome Investigations

Needed when • Unintentional or unwanted weight-loss

• Rectal syndrome – frequent, false need to pass stool

• Blood in the stool

• Change in stool consistency > 6 weeks in >60 years

• Anemia

• Palpable abdominal mass

• Family history of colorectal cancer

• Typical history and no alarm symtoms

Not needed

Page 48: GI diseases II. - uniba.sk

Management

Management • Empathy, education, understanding

• Life-style chages • weight loss

• physical exercise • reduction in coffeine, alcohol and fat

• increased consumption of fiber in constipation

• low FODMAP diet in diarrhea

• Drugs • Antispasmodics • Anti-motility agents

• Anti-bloating agents

• Antidepressant