Grand round presentation

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Grand round presentation Anthony Li
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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

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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

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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

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Mrs J D 54 yrs ?

• allergies
• NKDA
• FH
• ?
• SH
• occupation - home helper
• smoker - 10/day
• no EtOH
• x3 children at home 18yrs, 15yrs, 12yrs

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Mrs J D 54 yrs ?

• O/E
• General
• thin
• no jaundice / anaemia / clubbing /
  lymphadenopathy
• RS
• NAD
• CVS
• NAD
• Breasts
• NAD

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Mrs J D 54 yrs ?

• O/E
• GI
• non-distended
• visible SB segmentation centrally
• tender RUQ over GB - no guarding
• no palpable masses
• BS normal
• DRE tender left lateral pelvic wall but NAD
• pale steatorrhoeic stool

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Initial investigations

• sigmoidoscopy
• 2 - 3 small telangiectases between 12 - 15 cms,
  otherwise normal to 15cms
• bloods
• FBC, UEs, 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

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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-

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Widespread dilated loops matted together
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transverse barring from thickened valvulae
conniventes- stack of coin appearance
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Mucosal irregularities with narrowing of lumen
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ITS ALL ABOUT THIS! DEB GHOSH GASTRO SPR
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Any Guess?

• A 54 yr old lady presents with chronic diarrhoea
  with thickened SI mucosa, stricture and matted
  loops

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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

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• LATE ONSET RADIATION ENTERITIS

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OVERVIEW OF MANAGEMENT OF DIARRHOEA FOR NON
-GASTROENTEROLOGIST
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What is diarrhoea?

• Abnormal passage of 3 or more loose or liquid
  stools per day for gt 4weeks and / or a daily
  stool weight greater than 200g/day

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1001 causes of Chronic diarrhoea
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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
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Major causes

• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic infections
• Malabsorption syndromes

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Major causes

• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic infections
• Malabsorption syndromes

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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

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Minor causes

• Ischaemic colitis
• Drugs
• Neoplastic
• Motility disorders
• Radiation enteritis

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Minor causes
Lymphoma Villous adenoma Gastrinoma VIPoma carcino
id

• Ischaemic colitis
• Drugs
• Neoplastic
• Motility disorders
• Radiation enteritis

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Minor causes

• Ischaemic colitis
• Drugs
• Neoplastic
• Motility disorders
• Radiation enteritis

Post surgical states- vagotomy/gastrectomy Endocri
ne- DM/Hyperthyroidism/carcinoid Infiltrative SI
disease- scleroderma
OCTT- Ba studies Radionucleotide scintigraphy
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Minor causes

• Ischaemic colitis
• Drugs
• Neoplastic
• Motility disorders
• Radiation enteritis

Radiation of more than 50Gy Ileum and rectum
mostly Mucosal damage and SBBO
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• Understanding of patients complain of diarrhoea
• consistency
• frequency of stools
• urgency or faecal soiling    
• Stool characteristics
• presence of visible blood- IBD or cancer
• greasy stools that float and are malodorous
  -fat malabsorption
•     

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• Duration of symptoms, nature of onset (sudden or
  gradual)
• The volume of the diarrhoea
• voluminous watery diarrhoea -small bowel
• small-volume frequent diarrhoea -colon
• Occurrence of diarrhoea during fasting or at
  night- secretory or organic diarrhoea

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• 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

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• 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

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Physical examination

• rarely 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.

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Basic laboratory evaluation

• FBC
• Thyroid function tests
• ESR/CRP
• U/E
• Total protein and albumin, and
• Ferritin/ folate/B12/Ca
• Stool culture and microscopy

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Further investigation as per BSG protocol
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Further investigation as per BSG protocol
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Further investigation as per BSG protocol
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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 )

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• RADIATION ENTEROCOLITIS

Dr.E.M.Phillips
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Historical aspects

• Self exposure
• Deep tissue traumatisation from Roentgen
  ray exposure
• Walsh,D Br Med J 1897 272 273
• Animal experiments
• Roentgen ray intoxication. Warren S, Whipple
  GH
• J Exp Med 1922 35 187 202
• Post radiotherapy pathology 38 patients
• Warren 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 patients
• DeCosse JJ et al. Natural history management
  of radiation induced
• injury of the gastrointestinal tract Ann Surg
  1969 170 369 - 384

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Symptoms

• Early
• During therapy and up to six months
• Late
• Five to 31 years after radiotherapy
• Peak onset 12 15 years after

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Early

• Symptoms
• Diarrhoea
• Colic
• Nausea

• Mucosal Pathology
• Decrease
• enterocyte turnover
• villous height
• Increase
• enterocyte death
• mucosal oedema
• inflammatory infiltrate
• with mucosal slough

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Inflamm infiltrate and oedema
Withering of crypts
Cystic dilatation of crypt
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Late

• Symptoms
• SB
• Diarrhoea/malabsorpn
• Blind loop syndrome
• Subacute obstruction
• Colon tenesmus mucus
• Both haemorrhage,
• fistula
• perforation

• Pathology
• Arteriolar
• endothelial spasm, damage obliterative
  vasculitis
• Submucosa to serosa
• ischaemia, ulceration, and perforation increase
  in bizarre fibroblasts stricture, webs and
  fistula

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Chronic Radiation Proctitis
Vascular ectasia
Thickening of lamina propria with fibrosis
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Associated factors

• Causal
• Radiotherapy
• High dose DXT
• Total volume gut irradiated (e.g. para-aortic
  nodes incl.)
• Low body weight
• Surgery
• Adhesions
• Also relates to severity of in-therapy toxicity

• Not associated
• Vascular risk factors
• Diabetes
• Hypertension
• Dyslipidaemias
• (Smoking??)
• Concomitant chemo.
• Pelvic sepsis

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Dose of rads. damage

• Minimal tolerated dose
• gives 5 radiation enterocolitis within 5 years
• SB Trans. colon rectosig.
• Rads. 4000 5500 5000
• Increased
• Rads. for 6000 7500 7000
• high risk
• tumour
• Gives 50 radiation enterocolitis within 5 years
• Roswit B et al. Amer. J Roentgenology 1972
  114 460

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Surgery radiation damage

• Chronic radiation ileitis n97
• 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

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Majority of patients with radiation
enterocolitisare tumour free
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Prognosis of Rad. enterocolitis

• ca. 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

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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

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