Acute Diarrhoea

Question 1

What is severe acute diarrhoea ?

Answer 1

Diarrhoea is defined as an increase in stool volume associated with reduced stool consistency. If it has lasted for less than 2 weeks it is considered acute, and after 2 weeks it is chronic

Question 2

What are the common causes of Diarrhoea?

Answer 2

Acute - Gastroenteritis, Travellers’ diarrhoea, C. diff, Viral (Rotavirus, Norovirus, Adenovirus), Drugs, Ischaemic colitis, Diverticulitis

Chronic – Coeliac, Irritable bowel syndrome, Hyperthyroidism, Crohns, UC, Colorectal cancer (Or Polyps), Chronic Pancreatitis, Lactose intolerance

Question 3

What will you ask about in a history for acute diarrhoea?

Answer 3

Associated Symptoms:
Blood in stool – Infection (Campylobacter, Shigella, Salmonella, E. coli), UC, Crohns, Colorectal cancer, Polyps, C. diff, Ischaemic colitis, Diverticulitis
Mucous in stool - IBS, IBD, Colorectal cancer, Polyps, Diverticulitis
Steatorrhea – Pancreatic insufficiency, Biliary Obstruction
Explosive Diarrhoea – Chorea, Giardia, Rotavirus
Projectile Vomiting (Norovirus)
Bloating and flatus (Giardia, IBS, Coeliac)
Fever – Infective cause or severe inflammatory bowel disease
Specific Abdominal Pain – Diverticulitis (LLQ), Pancreatitis (Epigastric Radiating to the back)
General Symptoms - Nonspecific Abdominal pain, Nausea

Risk Factors:
Infection - Recent travel, Abnormal food, Occupational exposure, Recent Hospital stay, contact with D&V.

Specific Questions to ask:
Asses Severity - how many stools per day and compare to their normal (to gauge severity). Infectious cause more frequent stools
Red Flags for further investigations – Weight loss, Nocturnal Symptoms, Anaemia, Recent Hospital Admission or antibiotic use
Any recent constipation? - Diverticulitis or IBS alternate between the two. Or could be overflow incontinence
Recent hospital/antibiotic treatment - C. diff
Any cardiovascular risk factors? - Ischaemic colitis
Occupational history- Are they allowed back to work and what risk factors have they been exposed too (hospital, care homes, day care etc)

Question 4

What will you look for on examination of a patient with diarrhoea

Answer 4

Examination findings acute: The most important thing is to assess fluid status
End of the bed:
Reduced skin turgidity
Low urine output
Pale
Hands:
Increased capillary refill
Weak peripheral pulses
Cold peripheries
Hypotension
Tachycardia 
Face:
Dry Mucous membranes
Legs: 
Weak peripheral pulses
Cold peripheries
PR:
Feel for any rectal masses or impacted faeces. Also examine for blood/mucous

Examination findings chronic: The most important thing is to assess signs of anaemia (indicating bleeding) and for any signs of an underlying cause 
End of the bed:
Pale – Anaemia 
Hands:
Clubbing – Coeliac, IBD 
Koilonychia – Iron Deficiency Anaemia 
Face:
Goitre – And other signs of hyperthyroidism 
Oral Ulcers – Crohns, Coeliac 
Glossitis – Iron deficiency Anaemia 
Chest:
Raised Virchow’s Node – GI cancers 
PR:
Feel for any rectal masses or impacted faeces. Also examine for blood/mucous

Question 5

What investigations will you order for diarrhoea?

Answer 5

Investigations: Only patients with systemic signs (fever, dehydration, blood) require further investigation, or patients with red flags
Bedside:
Stool cultures (send multiple samples)– A negative stool culture is required for diagnosis, also helps to rule out infective causes.
Test stool sample for C. diff
Full set of observations

Bloods:
FBC - Looking for infection or anaemia (Iron define due to blood loss)
ESR/CRP- Looking for infection/Inflammatory response in IBD
U&E - Looking for dehydration or electrolyte losses
TSH - Rule out hyperthyroidism
Coeliac serology (Anti Tissue Transglutaminase) - Rule out coeliac disease
Faecal Elastase – Rule out Chronic pancreatitis

Imaging:
If severe may consider an Abdominal X-ray
Lower GI endoscopy - Do not do in acute stage if possible as increased risk of perforation

Question 6

What is the emergency treatment of diarrhoea

Answer 6

What is the treatment emergency treatment:
Resuscitation:
A-E approach
Get IV Access/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Assessment with AMPLE history and brief examination
Get help - Medical reg on call
Frequent Observations - Constant or 15 minutely
Patients may need electrolyte/ fluid replacement

Question 7

What is the non emergency treatment of diarrhoea?

Answer 7

What is the non-emergency treatment
Lifestyle:
No food handling until stool samples negative
Oral re-hydration if possible, if not then IV Fluids will be required
Stop any drugs that may be the cause

Medical:
Anti-Diarrhoeal (if needed)- Codeine Phosphate or Loperamide (Imodium) after each loose stool. Careful with use in colitis as can predispose to toxic megacolon
Avoid antibiotics unless systemic features of infection
Anti-Emetic (if very severe) - Metoclopramide
C. Diff infection - Vancomycin and Metronidazole, stop other causative antibiotics and stop all drugs affecting the gut e.g. Opioids and PPI’s