What is clostridium difficile?
C. diff is a Gram-positive, anaerobic, spore forming bacterium. It is present in approximately 3-5% of the adult population, remaining dormant in the presence of other normal gut flora. However, this natural balance can be disrupted by the use of antibiotics, resulting in opportunistic infection, causing C. diff (pseudomembranous) colitis.
Which antibiotics are strongly associated with C. diff infection?
How long does it take for symptoms to manifest after antibiotic therapy begins?
C antibiotics
- Co-amoxiclav
- Cephalosporins
- Ciprofloxacin
- Clindamycin
Symptoms typically manifest 5-10 days after antibiotic therapy
Clinical features of C. diff colitis
- Profuse watery diarrhoea
- Colicky abdominal pain
- Fever and rigors in severe cases
Investigations for C. diff colitis
- Arrange blood tests
- FBC (↑WCC), ↑CRP, ↓albumin, U&Es (may be deranged secondary to dehydration)
- Arrange stool testing
- Stool samples should be sent for MC&S including C. diff cytotoxin analysis
- Obtain imaging
- AXR may show colonic dilation
- Consider colonoscopy/flexible sigmoidoscopy
- Not routinely performed but may be useful if there is diagnostic uncertainty
Stepwise management of C. diff colitis
- Infection control
- Patients should be isolated to a side room with barrier nursing precautions
- Alcohol hand gels should be avoided
- Medication review
- Stop all causitive agents, particularly antibiotics and PPI
- Antibiotic therapy
- Offer a 10-14 day course of 400mg oral metronidaxole in non-severe cases
- Severe disease: IV metronidazole + ORAL vancomycin
- Consider surgery
- Surgery may be indicated in fulminant disease
Define coeliac disease
An autoimmune disorder triggered by gluten consumption, resulting in small bowel inflammation and subsequent malabsorption.
Epidemiology of coeliac disease
- Affects 1% of the population
- Bimodal age distribution - first peaking in infancy and also in the fouth to fifth decade of life, though it can present at any age
- Twice as common in women
Clinical presentations of coeliac disease
- GI
- malabsorption (steatorrhoea, abdominal pain, flatus)
- Unexplained weight loss
- Metabolic
- Faltering growth/failure to thrive in infants
- Iron deficiency (microcytic anaemia)
- B12 and folate deficiency (anaemia, polyneuropathy, epilepsy)
- Hypocalcaemia (tetany, osteomalacia, osteoporosis)
- Dermatology
- Dermatitis herpeiformis
- Severe apthous oral ulcers
What is dermatitis herpetiformis?
In what percentage of patients with coeliac disease does this occur?
Pathophysiology of these lesions?
A pruritic, vesicular rash, mainly affecting the extensor surfaces.
Up to 20% of patients with coeliac disease.
Deposition of IgA complexes in the dermis.
Conditions associated with coeliac disease
- Autoimmune
- type 1 DM, thyroid disease, PBC
- Cancer
- lymphoma, breast, small bowel
Investigations for coeliac disease
- Serological testing
- total IgA and IgA anti-tTG are usually raised and are first line options
- IgA anti-endomysial and IgG anti-gliding may be used as alternatives
- Duodenal biopsy
- this gold standard investigation allows for a histopathological diagnosis
- Other tests
- routine FBC may reveal microcytic/macrocyctic anaemia (secondary to iron, B12 or folate deficiency)
- electrolyte imbalance - ↓Ca, ↓Mg, ↓albumin
- HLA genetic testing may be considered if the diagnosis is still unclear
What dietary advice should be given to patient prior to coeliac testing to ensure an accurate result?
Continue a gluten rich diet, with as least one gluten-containing meal per day for at least 6 weeks prior to testing.
Classical histological findings of duodena biopsy for coeliac disease
- Sub-total villous atrophy (loss of finger like projections)
- Crypt hyperplasia
- Inflammatory infiltrate of the lamina propria, primarily comprising lymphocytes
Coeliac disease management
- Strict lifelong gluten free diet
- Offer vitamin and mineral supplements - vitamin B, D and calcium
What is small intestine bacterial overgrowth?
How does it present?
Investigation?
Treatment?
Primarily characterised by an increase in the number of bacteria in the small bowel.
Normally presents with malabsorption symptoms (diarrhoea and steatorrhoea).
Diagnosis confirmed by a hydrogen breath test.
Underlying cause treated if possible. Otherwise a cyclical antibiotic regime.
Causes of SIBO
- Reduced gastric acidity
- Long standing PPI therapy
- Post-gastrictomy
- Reduced gut motility
- Scleroderma
- Diabetic gastroparesis
- Sructural abnormalities
- Post-small bowel resections
- Small bowel diverticulosis
- Small bowel obstruction
What is short bowel syndrome?
Short bowel syndrome refers to extensive bowel failure, most commonly due to massive surgical resections, ischaemic injury or congenital abnormalities.
Symptoms of short bowel syndrome
Diarrhoea and malabsorption are major symptoms
Based on site of resection:
- Proximal bowel
- iron deficiency
- micronutrient deficiency
- Distal ileum
- B12 deficiency
- Interrupts bile salt absorption
- Increased colonic oxalate reuptake
- Colon
- water and sodium loss
- loss of fatty acid absorption
Definition of irritable bowel syndrome
A functional disorder in which abdominal pain or discomfort is associated with defecation and/or a change in bowel habit in the absence of an organic cause.
Epidemiology of irritable bowel syndrome
- More common in women and the younger population (20-30 years)
- Worldwide prevelence of 10-20%
Clinical features of irritable bowel syndrome
Patients usually present with a 6 month history of:
- Abdominal pain or discomfort
- Bloating
- Change in bowel habit
Diagnosis of IBS
- Elicit red flag sings and symptoms requiring urgent secondary care referral
- Unintentional weight loss
- Rectal mass/bleeding
- Family history of bowel/ovarian cancer
- Ageed over 60 with >6 weeks of altered bowel habit
- Use Rome criteria to aid the diagnosis of IBS:
- Abdominal discomfort/pain for ≥12 weeks associated with 2 or 3 of the following:
- Relieved by defecation
- Onset associated with change of bowel frequency
- Onset associated with change of bowel form
- Other supportive symptoms (at least 2):
- Altered stool passage
- Other abdominal symptoms (eg distension)
- Prandial association
- Mucus discharge per rectum
- Abdominal discomfort/pain for ≥12 weeks associated with 2 or 3 of the following:
Management of irritable bowel syndrome
- Lifestyle changes - encourage physical therapy and leisure time
- Dietry change
- encourage regular meal and adequate hydration, avoid high-fibre/starch
- low FODMAP diet
- Consider pharmacological therapy - based on predominant symptoms
- anti-spasmodic, laxatives or antimotility
- amitriptyline may be used as a second line agent
- Consider psychological therapy
- CBT, psychotherapy,
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General surgery24
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Oesophageal disease41
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Disorders of the stomach28
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Diarrhoea, constipation, gastroenteritis37
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C. diff, malabsorption disorders23
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Inflammatory bowel disease24
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Diverticula disease and colonic and anal disorders35
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Jaundice18
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Acute hepatitis23
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Diseases of the pancreas22
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Appendicitis and Small bowel obstruction33
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Acute abdomen28
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LFTs23
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Biliary Tract + Pancreatic Disease36
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Diseases of the Gallbladder24
