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 *.

• Type of motion: steatorrhoea (pale and fatty stools seen in malabsorption), volume.

• Presence of blood in stool.

• Incontinence.

• Nocturnal symptoms *.

• Systemic symptoms *.

• Loss of weight *.

• Presence and location of abdominal pain.

• Contact with potentially infected food/water.

• Systemic disease, e.g. diabetes mellitus, hyperthroidism.

• Immune deficiency, e.g. HIV/AIDS.

• Previous GI surgery.

• Travel history.

• Unwell contacts.

• Medications, e.g. recent antibiotics raise the possibility of Clostridium difficile infection.

• Food sensitivity.

• Family history.

• Sexual history.

A.3 After a full examination, three stool samples for culture, microscopy and Clostridium difficile toxin should be sent. The stool can also be tested for faecal elastase (low in pancreatic insufficiency), calprotectin (a marker of intestinal inflammation and raised in inflammatory bowel disease) or fat quantification (high in malabsorption).

Blood should be sent for full blood count, C-reactive protein, urea and electrolytes, liver function tests, coeliac serology, thyroid function tests, glucose, magnesium, calcium, folate and vitamin B₁₂.

A plain abdominal X-ray can reveal constipation (unreliable), dilated bowel, pancreatic calcification and colonic wall oedema in the context of diarrhoea.

A.4 She is anaemic with a high white cell count. Anaemia is a common finding and should be classified according to the mean cell volume into microcytic (generally iron deficiency), normocytic (often chronic disease) and macrocytic (most commonly deficiency of vitamin B₁₂ or folate). The electrolytes show a low potassium and raised urea. Hypokalaemia is common in prolonged diarrhoea. The elevated urea indicates dehydration.

This is an abdominal X-ray. It shows dilated large bowel and mucosal oedema in keeping with colitis. Mucosal oedema is identified by thickening of the bowel wall and loss of the haustral pattern. The haustra are seen as intermittent ridges arising from the bowel wall and are due to the arrangement of the circular muscle fibres.

A.5 She is most likely to have inflammatory bowel disease. The chronicity of her symptoms make infection less likely. Pain, weight loss and diarrhoea are classical features of Crohn’s disease. Her rash is a typical presentation of erythema nodosum. She is a smoker which is linked to Crohn’s disease.

It is often difficult to distinguish between ulcerative colitis and Crohn’s disease clinically. Clues in the clinical presentation are given in Table 18.3.

Table 18.3 Differentiating ulcerative colitis and Crohn’s disease

Feature	Crohn’s Disease	Ulcerative Colitis
Symptoms	Diarrhoea, abdominal pain, weight loss	Bloody diarrhoea with mucus, urgency, tenesmus
Signs	Fever, fistulae, perianal disease,abdominal masses	Fever, abdominal tenderness
Extra-intestinal	Oral ulceration, erythema nodosum, pyoderma gangrenosum, scleritis, episcleritis, uveitis, gallstones, pauciarticular arthropathy, DVT	Oral ulceration, erythema nodosum, episcleritis, uveitis, gallstones, pauciarticular arthropathy, DVT, primary sclerosing cholangitis

A.6 The immediate issues are her dehydration and pain. She should be given intravenous normal (0.9%) saline with supplemental potassium and probably magnesium. The rate of fluid administration is dependent on the degree of dehydration and any co-existing conditions, e.g. heart failure. She should also be given analgesia. She may require morphine which should be given with an antiemetic but cautiously. Dehydration in addition to Crohn’s disease increases thrombotic tendency. She should receive prophylactic subcutaneous anticoagulation (e.g. enoxaparin) to avoid thrombotic complications. Her loperamide should be stopped as it will make it difficult to monitor stool frequency. A stool chart should be commenced to assess response to treatment.

A.7 The options are:

• Prednisolone 40 mg od orally.

• Hydrocortisone 100 mg qid intravenously.

Intravenous therapy is given to patients with severe symptoms (bowels open >6 times/24 hours, fever, weight loss, abdominal pain and tenderness, intermittent nausea or vomiting, or anaemia) or who are systemically unwell. Oral treatment is reserved for patients with milder symptoms. If patients respond to IV steroids (falling bowel frequency and CRP), they are converted to oral steroids after 5 days and the dose is tapered by reducing by 5 mg weekly.

It is important to measure the blood glucose regularly while patients are taking high-dose steroids to monitor for steroid-induced diabetes mellitus. Patients should also be given a calcium supplement to protect against osteopenia. If steroids are to be used in the longer term then consideration should be given to starting a bisphosphonate to prevent osteoporosis.

A.8 Artificial feeding should be given if inadequate oral nutritional intake has persisted for more than 7–14 days.

Artificial feeding can be given directly into the bowel (enterally) or into a vein (parenterally). Enteral feeding is generally preferred as feeding into the bowel helps to maintain intestinal structure and function. It is also associated with fewer complications than parenteral routes.

The enteral route is contraindicated in ileus, bowel obstruction and persistent vomiting. Enteral feeds are delivered via a nasogastric (NG) tube. Parenteral feeds should be administered via a central line. Complications of parenteral feeding include infection of the central line and refeeding syndrome.

A.9 Medical treatments for Crohn’s disease include:

• Aminosalicylates, e.g. mesalazine.

• Azathioprine/6-mercaptopurine (6-MP).

• Metronidazole.

• Corticosteroids.

• Methotrexate.

• Anti-TNF therapies/biologicals.

She has been treated with steroids but on tapering the dose her symptoms have flared. This is not uncommon. Alternative treatments should therefore be discussed. The usual approach is to increase the steroid dose again and initiate azathioprine or 6-MP treatment. Steroids, though effective, should not be used long term due to their side-effects and so another immunomodulator is introduced. Azathioprine/6-MP has a 60–70% response rate within 3–6 months. An alternative approach would be induction of remission with infliximab.

Slow-release oral aminosalicylates are better than placebo in treating colonic Crohn’s disease although their efficacy is less impressive than other treatments. Their main side-effects are gastrointestinal (heartburn, diarrhoea, abdominal pain) which can limit their utility in this group of patients.

Metronidazole is thought to be of modest benefit in colonic Crohn’s but its long-term use is limited by the risk of peripheral neuropathy. It is most effective in healing perianal complications.

Corticosteroids are mainly used as the initial treatment in Crohn’s disease. This is because 60–80% of patients respond within 10–14 days. An alternative for patients with ileitis and right-sided colonic disease is controlled ileal release budesonide which has high hepatic metabolism and therefore fewer systemic side-effects.

Methotrexate can be used as an alternative to azathioprine/6-MP. It may be most beneficial in patients with associated arthritis. Folic acid should be given daily to limit bone marrow suppression. Other potential side-effects include liver and pulmonary toxicity.

Anti-TNF therapies are established for the treatment of Crohn’s disease. Infliximab is the preparation most commonly used for inflammatory bowel disease. It is a monoclonal antibody against TNF-alpha which is human and mouse in origin. Levels of TNF-alpha correlate with the disease activity of Crohn’s disease.

Infliximab is used to induce and maintain remission in patients with severe active Crohn’s disease and also to treat fistulating Crohn’s disease when treatment with immunomodulating drugs and corticosteroids has failed or is not tolerated and when surgery is inappropriate. It is usually given in a dose of 5 mg/kg at 0, 2, and 6 weeks, followed by 5 mg/kg every 8 weeks. Some patients will develop antibodies to infliximab and this can reduce their clinical response to treatment. Recommended approaches to this are:

• reduce the 8 week reinfusion interval

• double the dose to 10 mg/kg.

If the above fail, use both approaches.

Adalimumab is an alternative anti-TNF treatment which is fully human and is given subcutaneously. It is therefore easier to give on an outpatient basis.

If a patient is taking another treatment agent for Crohn’s disease, e.g. 6-MP/azathioprine/methotrexate, when commenced upon anti-TNF therapy this is generally continued for up to 6 months. This is thought to help reduce the chance of developing antibodies. Dual therapy should not be continued long term due to the potential risks of malignancy such as lymphoma or serious atypical infections.

Adverse effects of these agents include:

• Infusion reactions.

• Infections – reactivation of latent TB is a particular concern and so a chest X-ray should be performed prior to commencing treatment.

• Demyelinating disease.

• Skin reactions.

• Heart failure.

• Liver toxicity.

• Malignancy.

A.10 Patients treated with azathioprine are at risk from dose-related bone marrow suppression and hepatotoxicity. They should have a thiopurine methyl transferase (TPMT) level taken prior to initiation of treatment. This enzyme metabolizes azathioprine and low levels help predict patients at risk of developing bone marrow toxicity. A full blood count should be performed weekly for the first 4 weeks and following this period at least every 3 months. Liver function tests should also be performed at these times.

A.11 An MRI small bowel study or enteroclysis. MRI can detect small bowel disease in areas of the small intestine that are inaccessible to endoscopy. In studies of children with suspected Crohn’s disease, MRI detected ileitis with high sensitivity and specificity. It is being used with increasing frequency to diagnose small bowel Crohn’s disease. It is particularly of use in younger patients as it does not expose them to large doses of radiation. An alternative is a small bowel barium follow through. The patient drinks contrast containing barium and X-rays are taken periodically, highlighting the outline of the small bowel. Typical radiological findings in Crohn’s disease include mucosal irregularity, cobblestoning, stricturing or the presence of fistulae.

This scan shows extensive Crohn’s disease in the terminal ileum, with luminal narrowing.

There are multiple complications that can develop in a patient with Crohn’s disease. These can be separated into problems affecting the bowel secondary to chronic inflammation, extraintestinal conditions, malabsorption and malignancy. Problems affecting the bowel include obstruction secondary to strictures, haemorrhage, fistulae, abscesses, perforation and toxic megacolon.

Malabsorption can result in deficiency of the following:

• Bile salts – resulting in fat malabsorption. This can cause impaired absorption of the fat-soluble vitamins and malnutrition.

• Vitamin B₁₂ – causing pernicious anaemia.

• Vitamin D and calcium – causing bone loss. This, associated with steroid use, puts these patients at risk of osteoporosis.

There is also an increased risk of colon cancer in patients with longstanding Crohn’s colitis.

^* <3 months and presence of these features suggest organic cause more likely.

Revision Points

Crohn’s Disease

Incidence

• 3–14 : 100 000 in the Western world.

Risk Factors

• Higher rates in Caucasians.

• Lower rates in Asia, Africa and South America.

• Increased risk if first-degree relative has Crohn’s.

• Positive association between smoking and Crohn’s.

Histology

• Inflammatory changes involving the full thickness of the bowel wall.

• Focal ulceration.

• Non-caseating granulomas, lymphoid hyperplasia.

• Acute and chronic inflammatory cell infiltration.

• Any part of GI tract from mouth to anus may be involved.

Clinical Features

• Onset 15–40 years with a smaller second peak 50–80 years.

• Colicky abdominal pain/subacute obstruction.

• Sequelae of malabsorption and chronic diarrhoea (e.g. weight loss, low vitamin B₁₂, hypocalcaemia, anaemia, hypomagnasaemia).

• Perianal disease.

• Extraintestinal features include arthritis, episcleritis, erythema nodosum and gallstones.

Diagnosis

• Histological diagnosis is the gold standard.

• Small and large bowel imaging helps identify extent of disease and complications.

Treatment

• Goal is to induce remission.

• Corticosteroids/5-aminosalicylic acid derivatives/azathioprine/methotrexate/anti-TNF-alpha antibodies (infliximab).

• Surgical resection.

• Omeprazole for gastric and duodenal Crohn’s.

Issues to Consider

• How is giardiasis diagnosed and what are its clinical features?

• What are the possible implications of this diagnosis in a 23-year-old woman?

• What steps can be taken in hospitals to minimize the incidence of Clostridium difficile infection?

Further Information

, www.nacc.org.uk.

, www.bsg.org.uk.

, www.gastro.org.

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