A lady with diarrhoea and abdominal pain

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Problem 18 A lady with diarrhoea and abdominal pain

Jonathan Mitchell, Philip Clelland

A 23-year-old lady attends your surgery. She gives a 2-month history of worsening diarrhoea. She is opening her bowels eight times a day and twice at night. The stools are loose with mucus but no blood. She has lost 4 kg in weight and has not eaten properly for 2 weeks. The diarrhoea is associated with cramping abdominal pains and malaise. She has spent 6 months in India working for a charity and returned 2 months ago. She had several short spells of diarrhoea while there.

She has previously been diagnosed with irritable bowel syndrome by her GP. She takes the oral contraceptive pill only but was prescribed antibiotics 10 weeks ago for a chest infection. She smokes four cigarettes per day and drinks 10 units of alcohol each week. She is currently working in a care home but has had to take time off due to her current symptoms. She is not in contact with her family.

Q.1

What are the differential diagnoses for her current symptoms?

Q.2

What other questions would you ask?

Observations are within normal limits. Examination reveals mild right-sided abdominal tenderness only. Rigid sigmoidoscopy is unsuccessful due to patient discomfort.

Q.3

What initial tests would you perform as her GP?

You prescribe loperamide. Blood tests are shown below. An abdominal X-ray is shown in Figure 18.1. Stool microscopy and culture are negative.

Figure 18.1

Investigation 18.1 Summary of results

Q.4

What is your interpretation of the blood tests? What does the X-ray show?

Three days later her symptoms are worse. She is now pyrexial and although her abdomen is soft she is much more tender in the lower abdomen. She also has a tender rash on her lower legs.

Q.5

What is the likely unifying diagnosis?

You discuss her case with the on-call gastroenterologist who advises urgent admission to hospital. On arrival she has acute abdominal pain, is pyrexial and tachycardic.

Q.6

As the admitting doctor, what treatment would you initiate?

She is transferred to the gastroenterology ward later that day. A flexible sigmoidoscopy without bowel preparation is performed and biopsies taken. This shows severe colitis with mucosal granularity and loss of vascular pattern, contact bleeding and aphthous ulceration.

She is reviewed by the gastroenterologist and started on steroids.

Q.7

What dose, type and route of steroid would you give? What else should be measured while taking high-dose steroids?

She is monitored closely with daily blood tests and a scan is performed of her abdomen. She is also reviewed by the on-call surgical team.

She is reviewed by a dietician who starts a feeding programme.

Q.8

What routes of feeding do you know? Which would be the best option for this patient?

She improves and after 5 days is discharged home on oral prednisolone. This is to be tapered by 5 mg each week. She is followed up 2 weeks after discharge in the outpatient clinic. Biopsies taken at the time of the sigmoidoscopy show transmural inflammation and non-caseating granulomata. The features are consistent with Crohn’s disease.

When she is reviewed in clinic her stool frequency has increased to five times and her cramping abdominal pain has returned on reducing her prednisolone dose.

Q.9

What treatments may be discussed with her?

She is commenced on azathioprine and an appointment made for 2 months’ time. She is told to have her blood tests monitored closely.

Q.10

What blood tests should she have and why?

She is followed up for several years and her symptoms remain controlled. At a clinic appointment 3 years later she has developed abdominal pain and bloating after eating. This is sometimes accompanied by vomiting. The gastroenterologist sends her for a scan (shown in Figure 18.2).

Figure 18.2

Q.11

What type of scan is this? What complication has developed? How can this be managed?

Answers

A.1 Diarrhoea means different things to different people. A working definition is >3 loose stools in a 24-hour period.

Diarrhoea can be divided into acute or chronic. Acute is classified as lasting less than 14 days. It is usually secondary to infection which can be further subdivided by the presence of blood as shown in Table 18.1 below.

Table 18.1 Infectious causes of diarrhoea

Acute Diarrhoea With Blood	Acute Diarrhoea Without Blood
Shigellosis	Viruses
Escherichia coli 0157	Escherichia coli
Campylobacter	Cholera
Salmonella	Protozoa
Amoebic dysentery	Strongyloides
Antibiotic associated diarrhoea	Food toxins
Schistosoma (rarely)	Malaria
	Milder infection with Shigella/Salmonella/Campylobacter

Infections are often self-limiting and rarely require antibiotics.

Chronic diarrhoea can be classified by its pathophysiology. There is overlap between aetiologies (Table 18.2):

• Osmotic: poorly absorbed osmotically active solute in faecal matter.

• Secretory: abnormal intestinal epithelial cell ion transport.

• Inflammatory: inflammation and ulceration of mucosa impairing absorption and causing loss of proteins and solutes.

• Altered motility: theoretically, enhanced intestinal motility is implicated in diarrhoea but there is a limited evidence base.

Table 18.2 Types and causes of diarrhoea

A.2 Key questions when assessing patients with diarrhoea are:

• Patient age.

• Duration *.

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