BOWEL DISEASES

DR.HADEEL HUSSEIN MOHAMED AHMED HAMED

 Diarrhea
Definitions:
Diarrhea is defined as the passage of loose or watery
stools, typically at least three times in a 24-hour period .
It reflects increased water content of the stool, whether
due to impaired water absorption and/or active water
secretion by the bowel.
The following definitions have been
suggested according to the duration of
symptoms:

●Acute – 14 days or fewer in duration

●Persistent diarrhea – more than 14

but fewer than 30 days in duration

●Chronic – more than 30 days in

duration
A Simplified 5-Steps Approach to Diarrhea

The initial approach to the patient with diarrhea is to obtain a detailed history
and perform a physical examination.

TABLE 1
The Simplified 5-Steps are:
1. Does the patient really have diarrhea? Beware of fecal incontinence and
impaction.
2. Rule out medications as a cause of diarrhea (drug-induced diarrhea).
3. Distinguish acute from chronic diarrhea.
4. Categorize the diarrhea as inflammatory, fatty, or watery.
5. Consider factitious diarrhea.
Acute or Chronic?
• If acute (<2wks)
Suspect gastroenteritis— any risk factors: Travel?
Diet change? Contact with D&V? Any fever/pain?
HIV; or on acid suppressants, eg PPI?

• Chronic diarrhoea
Alternating with constipation suggests irritable bowel
.
Loss of weight, nocturnal diarrhoea, or anaemia
mandate close follow-up (coeliac/UC/Crohn’s?).
1. Inflammatory diarrhea
It is characterized by frequent, small-volume, bloody
stools and may be accompanied by tenesmus, fever, or
severe abdominal pain.

Inflammatory diarrhea is suspected with the demonstration

of leukocytes or leukocyte proteins (eg, calprotectin or
lactoferrin) on stool examination.
Other laboratory studies that may indicate an
inflammatory diarrhea include elevated C-reactive
protein level or sedimentation rate and low serum
albumin level
Inflammatory diarrhea conditions:
• Inflammatory bowel disease (Crohn disease or ulcerative
colitis),
• Ischemic colitis
• Infectious processes, such as C difficile, cytomegalovirus,
tuberculosis, or Entamoeba histolytica.
• Radiation colitis
2. Fatty stools
They are suggested by a history of weight loss, greasy or
bulky, floating stools that are difficult to flush, and oil in
the toilet bowl that requires a brush to remove.

A common misconception is that floating stools are

indicative of steatorrhea. Floating stools indicate gas
production by colonic bacteria, not steatorrhea.
The basic mechanisms of chronic fatty diarrhea are
malabsorption and maldigestion.

Fat malabsorption results from inadequate mucosal

transport, and fat maldigestion results from defective
hydrolysis of triglycerides.
Malabsorption is caused by mucosal diseases, most
commonly celiac disease.

Maldigestion results from pancreatic exocrine insufficiency

(eg, chronic pancreatitis) or inadequate duodenal bile acid
concentration (eg, small intestinal bacterial overgrowth
[SIBO] or cirrhosis).

A simple test to screen for excess fecal fat is a Sudan stain,

which will detect most cases of clinically significant
steatorrhea.
3. Watery diarrhea
IT can be further classified as osmotic or secretory in origin.

• Osmotic diarrhea is due to the ingestion of poorly

absorbed ions or sugars.

• Secretory diarrhea is due to disruption of epithelial

electrolyte transport.
The way to distinguish an osmotic from a secretory
process is by response to fasting.

An essential characteristic of osmotic diarrhea is

that stool volume decreases with fasting, whereas
secretory diarrhea typically continues unabated
with fasting.
4. Factitious Diarrhea
Factitious diarrhea is an intentionally self-inflicted
disorder. The most frequent cause of factitious diarrhea
is surreptitious laxative ingestion.
CT = computed tomography; EUS = endoscopic ultrasonography; SIBO = small intestinal
bacterial overgrowth.
Causes
Common causes
• Gastroenteritis
• Traveller’s diarrhoea
• C. difficile
• IBS
• Colorectal cancer
• Crohn’s;
• UC;
• Coeliac.
Less common causes (Esp. if painful)
• Microscopic colitis13
• Chronic pancreatitis
• Bile salt malabsorption
• Laxative abuse
• Lactose intolerance
• Ileal/gastric resection
• Overflow diarrhoea
• Bacterial overgrowth.
Non-GI or rare causes
• Thyrotoxicosis
• Autonomic neuropathy
• Addison’s disease
• Ischaemic colitis
• Tropical sprue
• Pellagra
• Gastrinoma
• VIPoma14
• Carcinoid
• Amyloid.
Drugs induced diarrhoea
• Antibiotics • PPI
• Propranolol • NSAIDS
• Cytotoxics • Digoxin
• Laxatives • Alcohol.
Symptoms & Signs

Signs and symptoms associated with diarrhea:

• Abdominal cramps or pain
• Bloating
• Nausea
• Vomiting
• Fever
• Blood in the stool
• Mucus in the stool
• Urgent need to have a bowel movement
Look for:
• Dehydration: Lethargy, depressed consciousness, dry
mucous membranes, decreased urine output and
peripheral edema
Diagnosis
• Fecal laboratory studies include the following:
Examination for ova and parasites
Leukocyte count

• Stool cultures

• CBC & Inflammatory markers

• Serum albumin levels: Low in protein-losing
enteropathies from enteroinvasive intestinal
infections (eg, Salmonella spp, enteroinvasive E
coli)

• Intestinal biopsy: May be indicated in the

presence of chronic diarrhea.
Management
Acute-onset diarrhea is usually self-limited.

Management is generally supportive: In most cases, the best

option for treatment of acute-onset diarrhea is the early use of
oral rehydration therapy (ORT). IV fluids with appropriate
electrolyte replacement may be needed.
Pharmacotherapy

• Vaccines (eg, rotavirus) can help increase resistance

to infection.

• Antimicrobial and antiparasitic agents may be used

to treat diarrhea caused by specific organisms
and/or clinical circumstances.
 Traveller’s diarrhea

• Diarrhoea affects 20–60% of travellers.

• High-risk areas: South Asia, Central andSouth America, Africa.
• Major cause = enterotoxigenic E. coli.
• Prevention: Boil water, cook thoroughly, peel fruit and
vegetables. Hand washing with soap may decrease risk.
Presentation:
Most diarrhoea is during first week of travel. Symptoms are often
unreliable indicators of aetiology but the following may be indicative:

• Enterotoxigenic E. coli: watery diarrhoea preceded by cramps and

nausea.
• Giardia lamblia: persistent diarrhoea, upper GI symptoms, eg bloating,
belching.
• Campylobacter jejuni and Shigella: bloody diarrhoea, colitic symptoms,
urgency, cramps.

Duration of diarrhoea: most <1wk. Investigate if >14d or dysentery

Differential diagnosis of persistent diarrhoea =
• Giardia (most common diagnosis),
• Entamoeba histolytica,
• Shigella.
Do not forget: malaria, HIV.
Treatment:
• Oral rehydration.

• Antimotility agents, eg loperamide, bismuth

subsalicylates. Avoid if severe pain or bloody diarrhoea
as may indicate invasive colitis.
• Antibiotics: usually not indicated .
✓ Ciprofloxacin 500mg BD for 3d ,
✓ Rifaximin 200mg TDS for 3d,
✓ Azithromycin 1g single dose or 500mg OD for 3d.
Celiac Disease (Sprue)
Celiac disease, also known as celiac sprue or gluten-sensitive
enteropathy, is a chronic disorder of the digestive tract that
results in an inability to tolerate Gluten is a protein commonly
found in wheat, rye, and barley.

When patients with celiac disease ingest gluten, an

immunologically mediated inflammatory response occurs that
damages the mucosa of their intestines, resulting in
maldigestion and malabsorption of food nutrients.
Signs and symptoms
Gastrointestinal symptoms

• Diarrhea - 45-85% of patients

• Flatulence - 28% of patients

• Borborygmus (rumbling or gurgling noise made by the movement of

fluid and gas in the intestines).- 35-72% of patients
• Weight loss - 45% of patients; in infants and
young children with untreated celiac disease,
failure to thrive and growth retardation are
common

• Weakness and fatigue - 78-80% of patients;

usually related to general poor nutrition

• Severe abdominal pain - 34-64% of patients

Extraintestinal symptoms may include:
• Anemia - 10-15% of patients

• Osteopenia and osteoporosis - 1-34% of patients

• Neurologic symptoms - 8-14% of patients; include motor weakness,

paresthesias with sensory loss, and ataxia; seizures may develop
• Skin disorders - 10-20% of patients; including dermatitis
herpetiformis, involving the extensor surfaces of the extremities,
trunk, buttocks, scalp, and neck

• Hormonal disorders - Including amenorrhea, delayed menarche, and

infertility in women and impotence and infertility in men

• A bleeding diathesis is usually caused by prothrombin deficiency, due

to impaired absorption of fat-soluble vitamin K.
Physical examination
A physical exam may reveal the following:

• A protuberant and tympanic abdomen

• Evidence of weight loss
• Orthostatic hypotension
• Peripheral edema
• Ecchymoses
• Hyperkeratosis or dermatitis herpetiformis
• Cheilosis and glossitis
• Evidence of peripheral neuropathy
• Chvostek or Trousseau sign (seen in calcium deficiency)
Diagnosis
• Low Hb
• Low B12
• Low ferritin.
• Antibodies: anti-transglutaminase is single preferred test
• IgA antibodies
• While on a gluten-containing diet: Upper GI Endoscopy and
duodinal biopsy expect to show subtotal villous atrophy,
increased intra-epithelial WBCS + crypt hyperplasia
(diagnostic)
• HLA DQ2 and DQ8 genotyping may help.
Management
✓ The primary treatment of celiac disease is dietary.

Lifelong gluten-free diet— Rice, maize, soya, potatoes, and

sugar are OK.
Limited consumption of oats (≤50g/d) may be tolerated
in patients with mild disease. Gluten-free biscuits, flour,
bread, and pasta are prescribable. Monitor response by
symptoms and repeat serology.

A small percentage of patients with celiac disease fail to

respond to a gluten-free diet. In some patients who are
refractory, corticosteroids may be helpful.
Complications
• Hyposplenism

• GI T-cell lymphoma (rare; suspect if

refractory symptoms or weight loss)

• Increase risk of malignancy (lymphoma,

gastric cancer, oesophageal and colorectal
cancer)
Inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of

inflammatory conditions of the colon and small intestine.

The two major types of inflammatory bowel disease are

ulcerative colitis (UC), which is limited to the colonic
mucosa, and Crohn disease (CD), which can affect any
segment of the gastrointestinal tract from the mouth to
the anus, involves "skip lesions," and is transmural.
Symptoms
• Episodic or chronic diarrhoea ( Bloody diarrhoea mainly
in UC )
• Colicky abdominal pain
• Urgency/ tenesmus,
• Proctitis (inflammation of the mucous membrane that
lines the rectum)
• Systemic symptoms in attacks: fever, malaise, anorexia,
loss of weight
Signs
• May be none.

• In acute, severe disease there may be more frequent

diarrhoea, fever, tachycardia, and a tender distended
abdomen.

• In Chron’s, there may be abdominal tenderness/mass; perianal

abscess/ fistulae/skin tags; anal strictures.
• Extraintestinal signs:
✓ Clubbing
✓ Aphthous oral ulcers;
✓ Erythema nodosum ,
✓ pyoderma gangrenosum;
✓ Conjunctivitis; episcleritis; iritis;
✓ Large joint arthritis; sacroiliitis; ankylosing spondylitis;
✓ PSC associated with UC;
✓ Nutritional deficits.
Erythema nodosum Nail Clubbing
Pyoderma gangrenosum
Causes
IBD is a complex disease which arises as a result of the
interaction of environmental and genetic factors leading to
immunological responses and inflammation in the intestine.
Associations
CD: Smoking, higher risk ≈3–4; NSAIDS may exacerbate disease.

UC: is 3-fold as common in non-smokers and the symptoms may

relapse on stopping smoking.
Tests
• Blood: FBC, ESR, CRP, U&E, LFT, blood culture.

• Stool microscopy and culture to exclude Campylobacter, C.

difficile, Sal monella, Shigella, E. coli, amoebae.

• Faecal calprotectin: A simple, non-invasive test for GI

inflammation with high sensitivity.
• Serology tests: CD ASCA (Anti-
Saccharomyces cerevisiae antibody )

UC pANCA
(perinuclear anti-neutrophil cytoplasmic
antibody )
• AXR: No faecal shadows; mucosal thickening/
islands ; colonic dilatation

• Lower GI endoscopy (Colonoscopy) and

biopsy
Ulcerative colitis Chrons disease
Lead pipe appearance Cobble stone appearance
Complications

Ulcerative colitis complications:

• Acute:
✓ Toxic dilatation of colon (colonic diameter >6cm) with risk of
perforation;
✓ venous thromboembolism: give prophylaxis to all inpatients
✓ Low K+

• Chronic: Colonic cancer

Chron’s complication
✓ Small bowel obstruction; toxic dilatation (colonic diameter
>6cm, toxic dilatation is rarer than in UC);
✓ Abscess formation (abdominal, pelvic, or perianal);
✓ Fistulae (present in ~10%), eg entero-enteric, colovesical
(bladder), colovaginal, perianal, enterocutaneous;
✓ Perforation
✓ Colon cancer
✓ PSC
✓ Malnutrition.
Treatment
Goals are to induce, then maintain disease remission.

• Pharmacological
✓ 5-Aminosalicylic acid derivatives ( for UC )
✓ Corticosteroid agents
✓ Immunosuppressant agents
✓ Biologic agents, including tumor necrosis factor (TNF)
inhibitors (eg, infliximab, adalimumab, certolizumab
pegol);
✓ H2-receptor antagonists
✓ Proton pump inhibitors
✓ Antidiarrheal agents (loperamide, cholestyramine)
✓ Anticholinergic antispasmodic agents (eg, dicyclomine,
hyoscyamine)

• Surgery
Irritable bowel syndrome (IBS)

IBS denotes a mixed group of abdominal symptoms for which no organic

cause can be found.

IBS is a type of functional gastrointestinal (GI) disorder. These conditions,

also called disorders of the gut-brain interaction, how to do with problems
in how your gut and brain work together.

These problems cause your digestive tract to be very sensitive. They also
change how your bowel muscles contract. The result is abdominal pain,
diarrhea and constipation.

Prevalence 10–20%; age at onset: <40yrs; F:M ≥2:1.

Diagnosis
Only diagnose IBS if recurrent abdominal pain (or discomfort)
associated with at least 2 of:
• relief by defecation
• altered stool form
• altered bowel frequency (constipation and diarrhoea may
alternate).
Other features:
urgency; incomplete evacuation; abdominal
bloating/distension; mucus PR; worsening of symptoms after
food.

Symptoms are chronic (>6 months), and often exacerbated

by stress, menstruation, or gastroenteritis (post-infectious
IBS).
Think of other diagnoses if:
• Age >60yrs;
• History <6 months;
• Anorexia;
• Loss of weight;
• Waking at night with pain/diarrhoea;
• Mouth ulcers;
• Abnormal CRP, ESR.
Diagnosis
No specific laboratory or imaging tests can diagnose
irritable bowel syndrome. Diagnosis should be based on
symptoms, the exclusion of worrisome features, and the
performance of specific investigations to rule out organic
diseases that may present similar symptoms.
Treatment:
Should focus on controlling symptoms,
• lifestyle/dietary measures,

pharmacotherapy if required:
• Constipation: ensure adequate water and fiber intake and promote physical
activity; Simple laxatives

• Diarrhoea: avoid sorbitol sweeteners, alcohol, and caffeine; reduce dietary

fibre content; encourage patients to identify their own ‘trigger’ foods; try a
bulking agent ± loperamide 2mg after each loose stool.
•
Colic/bloating: oral antispasmodics: mebeverine 135mg/8h or
hyoscine butylbromide 10mg/8h (over the counter).

• Psychological symptoms/visceral hypersensitivity: cognitive

behavioural therapy , hypnosis, and tricyclics, eg
amitriptyline 10–20mg at night
Gastrointestinal malabsorption
Malabsorption is a state arising from abnormality in absorption of
food nutrients across the gastrointestinal (GI) tract. Impairment can
be of single or multiple nutrients depending on the abnormality. This
may lead to malnutrition and a variety of anaemias.
Causes
In the UK commonly : Coeliac disease; chronic pancreatitis;
Crohn’s disease.

Rarer:
• Decrease Bile:
primary biliary cholangitis; ileal resection; biliary obstruction;
colestyramine.

• Pancreatic insufficiency:
pancreatic cancer; cystic fibrosis.
• Small bowel mucosa:
Whipple’s disease ; radiation enteritis; tropical sprue;
small bowel resection; brush border enzyme deficiencies
(eg lactase insufficiency); drugs (metformin, neomycin,
alcohol); amyloid .

• Bacterial overgrowth:
spontaneous (esp. in elderly); in jejunal diverticula;
postopblind loops. DM & PPI use are also risk factors.
Try metronidazole 400mg/8h PO.
• Infection: giardiasis; diphyllobothriasis (B12
malabsorption); strongyloidiasis.

• Intestinal hurry: post-gastrectomy dumping; post-

vagotomy; gastroj ejunostomy.
Signs and symptoms
• Gastrointestinal manifestations
Diarrhea, steatorrhoea, weight loss, flatulence,
abdominal bloating, abdominal cramps, and pain may
be present.

• Deficiency signs:
✓ Anaemia (low Fe, B12, folate);
✓ bleeding disorders (low vit K);
✓ Oedema (low protein);
✓ metabolic bone disease (low vit D);
✓ neurological features, eg neuropathy.
Tests
• FBC (low or high MCV); low Ca2+; low Fe; low B12 +
folate; high INR; lipid profile; coeliac tests.

• Stool: Sudan stain for fat globules; stool microscopy

(infestation); elastase.

• Breath hydrogen analysis: For bacterial overgrowth.

• Endoscopy + small bowel biopsy.

Whipple Disease

Whipple disease is a systemic disease most likely caused by a

gram-positive bacterium, Tropheryma whipplei.

The first descriptions of the disorder described a malabsorption

syndrome with small intestine involvement, but the disease also
affects the joints, central nervous system, and cardiovascular
system.
How is Whipple’s disease diagnosed?
OGD and biopsy

How is Whipple’s disease managed or treated?

It can take a long time to get rid of the bacteria that cause
Whipple’s disease. Treatment includes:

• Antibiotics
• Fluid and electrolytes replacement
• Vitamins and nutrients.
Tropical Sprue
Tropical sprue (TS) is a syndrome characterized by acute or
chronic diarrhea, weight loss, and malabsorption of nutrients.
It occurs in the Far and Middle East and Caribbean—the cause
is unknown and it may be caused by environmental factors.

Diagnosis
• OGD and biopsy

Treatment
• Supportive treatment
• Tetracycline 250mg/6h PO + folic acid 5mg/d PO for 3–
6mnths may help.
Small intestinal bacterial overgrowth

Small intestinal bacterial overgrowth (SIBO), also termed

bacterial overgrowth, or small bowel bacterial overgrowth
syndrome (SBBOS), is a disorder of excessive bacterial growth
in the small intestine.
Diagnosis
• The gold standard being an aspirate from the jejunum that
grows in excess of 100.000 bacteria per milliliter
• Breath hydrogen analysis

Risk factors
• dysmotility;
• Anatomical disturbances in the bowel, including fistulae,
diverticula and blind loops created after surgery, and resection
of the ileo-cecal valve;
• Gastroenteritis-induced alterations to the small intestine
• Use of certain medications, including proton pump inhibitors.
Treament
• Antibiotics: metronidazole 400mg/8h PO.
• Fluid and electrolytes replacement
• Vitamins and nutrients.
Constipation

• Constipation reflects pelvic dysfunction or increase

transit time.

• It is the passage of ≤2 bowel motions/wk, often

passed with difficulty, straining, or pain, and a sense
of incomplete evacuation.

• F:M≈2:1.
Causes
General
• Poor diet ± lack of exercise
• Poor fluid intake/dehydration
• Irritable bowel syndrome
• Old age
• Anorectal disease (Esp. if painful.)
• Intestinal obstruction

Metabolic/endocrine
• Hypercalcaemia
• Hypothyroidism (rarely presents with constipation)
• Hypokalaemia
Drugs
• Opiates (eg morphine, codeine)
• Anticholinergics (eg tricyclics)
• Iron
• Some antacids, eg with aluminium
• Diuretics, eg furosemide
• Calcium channel blockers.

Neuromuscular
• Systemic sclerosis
• Diabetic neuropathy.

Other causes
• Chronic laxative abuse
Tests
• None in young, mildly affected patients.

• Investigate if :
✓ Loss of weight,
✓ Abdominal mass,
✓ +PR blood,
✓ Iron deficiency anaemia.

Blood: FBC, ESR, U&E, Ca2+, TFT.

✓ Colonoscopy: If suspected colorectal

malignancy.
Treatment
• Often reassurance, drinking more, and
diet/exercise advice is all that is needed.
• Treat the cause
• Stimulant laxatives
• Stool softeners:
Thank you
……………………………