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At the heart of general practice since 1960

Choose and Book should have been split in two

Chronic diarrhoea is one of the commonest reasons for referral to a gastroenterology clinic, but much of the initial assessment and management can easily be done in primary care ­ as Dr Mike Cohen

illustrates with four case studies

PATIENT 1

Elderly patient with weight loss, weakness and aches and pains

An 82-year-old man was referred with diarrhoea. Initially he described alternating diarrhoea and constipation, but more recently had experienced putty-coloured stools that were difficult to flush away. He had recently been diagnosed with hypothyroidism.

He was losing weight and becoming increasingly weak, and complained of pain in his rib girdle, shoulder and back. His muscles ached. One year earlier he was able to play two rounds of golf a week ­ at the time of presentation he could walk about 50-100 yards with the help of a stick. He also had difficulty getting out of a chair unaided.

His results were Hb 10.6, MCV 110, serum folate 1.2ng/nL (normal range 2-20), ferritin 4ng/nL (normal range 15-260), alkaline phosphatase 243, albumin 33, corrected calcium 2.06, vitamin D <13 and="" magnesium="" 0.58.="" he="" had="" high="" levels="" of="" iga="" antigliadin="" antibodies="" and="" tissue="" transglutaminase="" levels="" were="">

Upper-GI endoscopy showed scalloping of the duodenal folds. Duodenal biopsies showed subtotal villous atrophy and infiltration of the lamina propria with inflammatory cells compatible with a diagnosis of coeliac disease.

Diagnosis

This man had coeliac disease with co-existing malabsorption. As a result he had developed osteomalacia, which explained his bone pain, myalgia and proximal muscle weakness. There is also an association between coeliac disease and hypothyroidism.

Treatment

He and his wife saw the dietitian and were informed about the condition and given advice regarding a lifelong, gluten-free diet. He was encouraged to join Coeliac UK, then issued with some prescriptions from his GP for gluten-free products.

He was also started on vitamin D supplements, iron supplements and folic acid. These should be continued until the patient is well-established on a gluten-free diet, which is usually for the first three months.

It is also recommended that patients have DEXA scans for osteoporosis at the time of diagnosis and consideration should be given to bone protection. Research to date recommends that the best treatment for the prevention of osteoporosis in coeliac disease is a gluten-free diet.

PATIENT 2

Pensioner with COPD exacerbation

A 68-year-old man was admitted to hospital with an exacerbation of COPD. He was treated with bronchodilators and intravenous ampicillin. His chest symptoms improved. Subsequently he developed crampy abdominal pains and watery diarrhoea.

Diagnosis

Stool samples were positive for C difficile toxin, and culture identified this organism. Flexible sigmoidoscopy reveals a yellowish, patchy membrane overlying an intensely inflamed mucosa ('snow-capped mountain sign'). C difficile colitis occurs when the normal bowel flora is altered, usually by antibiotics with activity against anaerobes. Subsequent nosocomial colonisation ensues and C difficile produces enterotoxins.

The antibiotics most commonly implicated are the penicillins, cephalosporins and clindamycin.

Those patients most at risk are the elderly, those with colonic disease (such as inflammatory bowel disease) or another severe, underlying disease.

Treatment

The treatment is to withdraw the offending antibiotic and treat with metronidazole or oral vancomycin. This patient responded well to a 14-day course of oral vancomycin. He was subsequently discharged home.

However, relapse and recurrence may occur in up to 20 per cent of patients. In those with the severe form, dehydration, renal failure, septicaemia, toxic megacolon and even death can occur.

The treatment of recurrent infection can be difficult. The goal of initial treatment is to eliminate the bacteria and vegetative spores. Tapering the dose of vancomycin or metronidazole over four-six weeks has been shown to be effective.

Cholestyramine to reduce the effect of the toxin, brewer's yeast (Saccharomyces boulardii) and probiotics may help restore normal bowel flora.

A novel but aesthetically unattractive method has also been devised where bowel flora (faeces) homogenised in sterile saline are infused into the colon in an attempt to restore normal bowel flora.

A 35-year-old woman was referred with recurrent abdominal pain and watery diarrhoea. The pain occurred about five or six times each month and was relieved by opening her bowels. There was no weight loss, no blood in her stools and no nocturnal symptoms. She complained of an 'early morning rush' to the toilet and frequently felt bloated. Her abdomen was frequently 'gurgly'. She had abdominal pain as a child and she said her symptoms were exacerbated when she felt stressed.

Examination was normal, and in the last few months stool culture, FBC and viscosity and barium enema had been normal also.

Diagnosis

The most likely diagnosis was IBS. Little bellyachers grow into bigger bellyachers and suffer more anxiety-related symptoms. The emphasis in this case was towards a positive diagnosis based on clinical grounds. The key symptoms of IBS are pain, constipation, diarrhoea and abdominal bloating. The Rome II criteria are specific for IBS.

This young woman had typical symptoms. However, older patients (>45 years) with new-onset symptoms and patients at any age with either alarm features or a strong family history of GI disease should be investigated and referred for specialist assessment to exclude serious disease. Patients are often distressed by their symptoms and it is important to consider symptoms in the context of the patient as a whole.

Treatment

Treatments are targeted towards reducing pain (antispasmodics and peppermint), relieving constipation (fibre and adequate fluid intake) and reducing diarrhoea.

In this patient loperamide was tried with only a modest effect, but subsequently colestyramine was very helpful. This drug binds bile acids, which may be responsible in part for causing diarrhoea in IBS.

A significant number of patients have chronic symptoms and are referred to secondary care where colonoscopy is often performed to exclude inflammatory bowel disease. It is, of course, important to reconsider the diagnosis of IBS if the clinical picture changes.

PATIENT 4

Man returns from skiing

holiday with 'bug'

A 35-year-old man saw his GP with a 10-day history of loose stools and abdominal cramps. He had just returned from a skiing holiday in France. He had not been taking any medication and had no contact with anyone with diarrhoea. He was well hydrated and examination of his abdomen was normal.

Diagnosis

Stool microscopy revealed cysts of Giardia lamblia. Subsequently his wife developed the same symptoms and was found to have the same diagnosis.

Treatment

Treatment is with either metronidazole (2g daily for three days, or 400mg tds for five days) or tinidazole as a single dose 2g with food. Giardiasis occurs in holiday and business travellers, children in day-care centres and those with immunoglobulin deficiency states. It is a luminal parasite that resides predominantly in the proximal small intestine. It has been shown to cause partial villous atrophy, mucosal inflammation and inhibition of pancreatic enzyme activity.

The clinical spectrum ranges from asymptomatic carriage to persistent diarrhoea with intestinal malabsorption. Commonly patients complain of loose, watery stools with bloating and flatulence.

Cysts are found in about 50 per cent of infected individuals, but sometimes duodenal aspiration and/or biopsy are needed to clinch the diagnosis. Empirical treatment is often given if a patient has typical clinical features and a history of foreign travel.

Mike Cohen is a GP in Westbury on Trym and a GP specialist in gastroenterology at Southmead Hospital, North Bristol NHS Trust

PATIENT 3

Woman with intermittent

abdominal pain

An 82-year-old man was referred with diarrhoea. Initially he described alternating diarrhoea and constipation, but more recently had experienced putty-coloured stools that were difficult to flush away. He had recently been diagnosed with hypothyroidism.

He was losing weight and becoming increasingly weak, and complained of pain in his rib girdle, shoulder and back. His muscles ached. One year earlier he was able to play two rounds of golf a week ­ at the time of presentation he could walk about 50-100 yards with the help of a stick. He also had difficulty getting out of a chair unaided.

His results were Hb 10.6, MCV 110, serum folate 1.2ng/nL (normal range 2-20), ferritin 4ng/nL (normal range 15-260), alkaline phosphatase 243, albumin 33, corrected calcium 2.06, vitamin D <13 and="" magnesium="" 0.58.="" he="" had="" high="" levels="" of="" iga="" antigliadin="" antibodies="" and="" tissue="" transglutaminase="" levels="" were="">

Upper-GI endoscopy showed scalloping of the duodenal folds. Duodenal biopsies showed subtotal villous atrophy and infiltration of the lamina propria with inflammatory cells compatible with a diagnosis of coeliac disease.

Diagnosis

This man had coeliac disease with co-existing malabsorption. As a result he had developed osteomalacia, which explained his bone pain, myalgia and proximal muscle weakness. There is also an association between coeliac disease and hypothyroidism.

Treatment

He and his wife saw the dietitian and were informed about the condition and given advice regarding a lifelong, gluten-free diet. He was encouraged to join Coeliac UK, then issued with some prescriptions from his GP for gluten-free products.

He was also started on vitamin D supplements, iron supplements and folic acid. These should be continued until the patient is well-established on a gluten-free diet, which is usually for the first three months.

It is also recommended that patients have DEXA scans for osteoporosis at the time of diagnosis and consideration should be given to bone protection. Research to date recommends that the best treatment for the prevention of osteoporosis in coeliac disease is a gluten-free diet.

PATIENT 2

Pensioner with COPD exacerbation

A 68-year-old man was admitted to hospital with an exacerbation of COPD. He was treated with bronchodilators and intravenous ampicillin. His chest symptoms improved. Subsequently he developed crampy abdominal pains and watery diarrhoea.

Diagnosis

Stool samples were positive for C difficile toxin, and culture identified this organism. Flexible sigmoidoscopy reveals a yellowish, patchy membrane overlying an intensely inflamed mucosa ('snow-capped mountain sign'). C difficile colitis occurs when the normal bowel flora is altered, usually by antibiotics with activity against anaerobes. Subsequent nosocomial colonisation ensues and C difficile produces enterotoxins.

The antibiotics most commonly implicated are the penicillins, cephalosporins and clindamycin.

Those patients most at risk are the elderly, those with colonic disease (such as inflammatory bowel disease) or another severe, underlying disease.

Treatment

The treatment is to withdraw the offending antibiotic and treat with metronidazole or oral vancomycin. This patient responded well to a 14-day course of oral vancomycin. He was subsequently discharged home.

However, relapse and recurrence may occur in up to 20 per cent of patients. In those with the severe form, dehydration, renal failure, septicaemia, toxic megacolon and even death can occur.

The treatment of recurrent infection can be difficult. The goal of initial treatment is to eliminate the bacteria and vegetative spores. Tapering the dose of vancomycin or metronidazole over four-six weeks has been shown to be effective.

Cholestyramine to reduce the effect of the toxin, brewer's yeast (Saccharomyces boulardii) and probiotics may help restore normal bowel flora.

A novel but aesthetically unattractive method has also been devised where bowel flora (faeces) homogenised in sterile saline are infused into the colon in an attempt to restore normal bowel flora.

A 35-year-old woman was referred with recurrent abdominal pain and watery diarrhoea. The pain occurred about five or six times each month and was relieved by opening her bowels. There was no weight loss, no blood in her stools and no nocturnal symptoms. She complained of an 'early morning rush' to the toilet and frequently felt bloated. Her abdomen was frequently 'gurgly'. She had abdominal pain as a child and she said her symptoms were exacerbated when she felt stressed.

Examination was normal, and in the last few months stool culture, FBC and viscosity and barium enema had been normal also.

Diagnosis

The most likely diagnosis was IBS. Little bellyachers grow into bigger bellyachers and suffer more anxiety-related symptoms. The emphasis in this case was towards a positive diagnosis based on clinical grounds. The key symptoms of IBS are pain, constipation, diarrhoea and abdominal bloating. The Rome II criteria are specific for IBS.

This young woman had typical symptoms. However, older patients (>45 years) with new-onset symptoms and patients at any age with either alarm features or a strong family history of GI disease should be investigated and referred for specialist assessment to exclude serious disease. Patients are often distressed by their symptoms and it is important to consider symptoms in the context of the patient as a whole.

Treatment

Treatments are targeted towards reducing pain (antispasmodics and peppermint), relieving constipation (fibre and adequate fluid intake) and reducing diarrhoea.

In this patient loperamide was tried with only a modest effect, but subsequently colestyramine was very helpful. This drug binds bile acids, which may be responsible in part for causing diarrhoea in IBS.

A significant number of patients have chronic symptoms and are referred to secondary care where colonoscopy is often performed to exclude inflammatory bowel disease. It is, of course, important to reconsider the diagnosis of IBS if the clinical picture changes.

PATIENT 4

Man returns from skiing

holiday with 'bug'

A 35-year-old man saw his GP with a 10-day history of loose stools and abdominal cramps. He had just returned from a skiing holiday in France. He had not been taking any medication and had no contact with anyone with diarrhoea. He was well hydrated and examination of his abdomen was normal.

Diagnosis

Stool microscopy revealed cysts of Giardia lamblia. Subsequently his wife developed the same symptoms and was found to have the same diagnosis.

Treatment

Treatment is with either metronidazole (2g daily for three days, or 400mg tds for five days) or tinidazole as a single dose 2g with food. Giardiasis occurs in holiday and business travellers, children in day-care centres and those with immunoglobulin deficiency states. It is a luminal parasite that resides predominantly in the proximal small intestine. It has been shown to cause partial villous atrophy, mucosal inflammation and inhibition of pancreatic enzyme activity.

The clinical spectrum ranges from asymptomatic carriage to persistent diarrhoea with intestinal malabsorption. Commonly patients complain of loose, watery stools with bloating and flatulence.

Cysts are found in about 50 per cent of infected individuals, but sometimes duodenal aspiration and/or biopsy are needed to clinch the diagnosis. Empirical treatment is often given if a patient has typical clinical features and a history of foreign travel.

Mike Cohen is a GP in Westbury on Trym and a GP specialist in gastroenterology at Southmead Hospital, North Bristol NHS Trust

Useful website

The Primary Care Society for Gastroenterology www.pcsg.org.uk has been developed to promote the society and facilitate networking for GPs and others interested in all clinical, research and educational aspects of gastroenterological disorders and in particular their management in primary care

Find the full version of this article in The Practitioner with your copy of Pulse next week

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