The document discusses gastrointestinal disorders, focusing on altered bowel habits including constipation and diarrhea. It details definitions, causes, pathophysiology, symptoms, diagnosis, and management of these conditions, highlighting irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Additionally, it outlines prevention strategies and complications related to gastrointestinal diseases.

1. Dr. Rajib Hossain
Registrar – Medicine Department
TMSS Medical College & RCH
ALTERED BOWEL HABITS:

2.  CONSTIPATION:
 This disorder can mean different things to different people.
 Normal bowel habit ranges from 3 times/day to once every 3 days.
 Constipation is the passage of stool <3 times/week, or stools
that are hard or difficult to pass.
 A thorough history should include the following:

3. Causes of constipation:
•Low-fiber diet
•Physical immobility
•Functional bowel disease
•Drugs (eg. opiates, antidepressants).
•Metabolic and endocrine diseases (e.g. hypothyroidism, hypercalcemia, hypokalemia)
•Neurological disorders (eg. autonomic neuropathy, multiple sclerosis)
•Anorectal disease – eg. anal fissure
•Habitual neglect
•Depression

4.  DIARRHOEA:
This is defined as an increase in stool volume (> 200 ml daily) & frequency (3/day).
There is also a change in consistency to semi-formed or liquid stool.
According to WHO – As having three or more loose or liquid stools per day or as
having more stools then is normal for that person.

5.  HIGH RISK GROUPS
Prematurity
Lack of breast feeding
Immunodeficient conditions
Malnutrition
Lack of personal hygiene
Poor socio-economic status

6.  PATHOPHYSIOLOGY:
Etiological factors attack to the intestinal mucosa.
Bowel mucosa secretes excessive amounts of fluid into the gut lumen.
Large amount of water,nutrients and vitamins are lost from the body.
Excessive sodium loss results in hyponatremia.
Movement of water from extracellular to intracellular compartment.
Reduces extracellular volume.
Decreased blood volume results in weak thready pulse,low blood pressure,cold
extreamities, shrinkase of skin.
Filtration of urine is reduced due to low and hydrostatic pressure in renal glumeruli.
Potassium and bicarbinate are lost in diarrhoeal stool.
Acidosis may result with dehydration.

7.  HISTORY:
Onset & Duration:
Acte: <4 Weeks
Chronic: > 4 Weeks
Frequency & Volume
Color,consistency,offensive smell,ease of flushing
Diarrhoea disturb the patients sleep
blood, mucus or pus
Associated pain or colic or Fever
Nausea,Vomiting & weight loss
Urine Output
During Fasting
- No change in secretory diarrhoea – eg.E. coli, Staph. Aureus
- Disappears on fasting: osmotic diarrhoea

8. Past Medical History:
- Lactose intolerance
- IBS, IBD – ulcerative colitis
- Hyperthyroidism
Drug history:
- Taking any Antibiotic
- Certain drugs & food allergy.
Personal History:
- Malnutrition, Poor personal hygine
- Immunocompromised state like HIV infection.

9. Alcohol
Social History – Family and community
Traveling History
Occupation History

10.  ETIOLOGY:
Intestinal infection with various organisms.
Bacteria: Escherichia coli,Vibrio cholera,Shigella species,Chlostridium difficile.
Virus: Rotavirus, Adenovorus,cytomegalovirus.
Protozoa: Gierdia intestinalis, Entamoeba histolytica.
Helminths: Strongyloidiasis,Angiostrongyliasis
Systemic infections like urinary tract infection or otitis media.
Certain drug and food allergy
Malnutrition & Malabsorption
Immunocompromised state like HIV infection
Diarrhoe is more common in artificial feeding.

11.  CLINICAL FEATURES:
Frequent Loose watery stool, may be greenish or yellowish in colour with offensive
smell, may contain mucous, pus or blood, may expelled with force,procede by
abdominal pain or cramps.
Frequency of stools may be 2 to 20 per day or more.
 Irritability,lethergy,delirium,stuper,flaccidity
Signs of dehydration
Weak & thready pulsae,hypotension,tachycardia,rapid respiration
Kassamaul breathing in acidosis
Cold extremities with collapse
Decreased or absent urine output

12.  ASSESSMENT OF DEHYDRATION:
Dehydration is excess loss of fluid more than fluid intake.
 Clinical features of dehydration:
- Sunken fontanelle
- Sunkene eyes
- No tears from eyes
- Reduced level of conciousness
- Reduced capillary refill time
- Dry mucous membrane
- Reduced skin turger
- Tachypnea
- Hypotention
- Oliguria

13. Assessment No dehydration Some dehydration Severe dehydration
Look at
General condition
Eyes
Tears
Mouth and tongue
Thirst
Well alert
Normal
Present
Moist
Drinks normally,no
thirst
Restless,irritable
Sunken
Absent
Dry
Drinks eagerly,thirsty
Lethergic/unconcious
Sunken
Absent
Very dry
Unable to drink or
drinking poorly
Feel
Skin pinch Goes back quickly Goes back slowly Goes back very slowly

14. Difference
Large Bowel Dirrhoea Small Bowel Diarrhoea
 Small volume stools
 Frequent
 Presence of blood & mucus
 Pain over lower abdomen
 Painful bowel movement with tenesmus
 Associated hypogastric cramps
 RBCs and inflammatory cells in stools
 Large volume stools
 Watery
 Presence of undigested food
 Abdominal cramping,bloating and gas
formation
 Fever uncommon
 No tenesmus
 No inflammatory cells in stools

15.  WHAT IS NOT A DIARRHOEA:
Frequent formed stools
Pasty stools in breastfed child
Stools during or after feeding
Pseudodiarrhoea: Small volume of stool frequntly (IBS)

16.  PHYSICAL EXAMINATION:
 Signs:
- Bed side Clues
- Skin turgor, Dry mucous
membrane
- Mental status
- Acidotic breathing
- Speech
- Pulse
- Blood Pressure

17. ABDOMEN PROPER:
Inspection:
Abnormal Shape: Distended & Lean & thin – hyperthyroidism.
Movement Restricted: Colorectal Ca
Palpation:
Abdominal Tenderness -
Hepatomegaly – Colorectal Ca

18. PHYSICAL EXAMINATION:
Percussion:
01. Abdomen:
Localized Dullness (Colorectal Ca)
Shifting Dullness (Ascites – Intestinal TB)

19.  PHYSICAL EXAMINATION:
Auscultation: Abdomen
1. Decreased bowel sound:
Ascites due to Intestinal TB, Colorectal Ca

20. TESTS AND DIAGNOSIS:
Investigation:
- CBC with ESR
- Urine R/E
- Abdomen X- ray in errect posture
- USG of W/A
- Stool for OBT & C/S
- CT Abdomen
- Endoscopy

21.  CLASIFICATIONS OF DIARRHOEA:
1.Acute Diarrhoea: < 4 Weeks
2.Chronic Diarrhoea: > 4 Weeks

22. Acute Diarrhoea (< 4 Weeks)
- Food poisoning
- Dysentery (amoebic/bacillary)
- IBD (First attack)
- Colitis
- Pseudomembranous colitis
- Ischaemic colitis
- Yersinia enterocolitica colitis

23. 3.) Chronic Diarrhoea ( > 4 weeks):
• Malabsorption – coeliac disease, chronic pancreatitis and Crohn’s disease
• Intestinal TB
• Diabetic Diarrhoea
• Thyrotoxicosis
• Laxative abuse, antibiotics, antihypertensive & alcohol.

24. ASSOCIATED SYMPTOMS:
Chronic bloody diarrhoea:
- Recurrent amoebic dysentery
- IBD
- Colorectal Ca.
Diarrhoea alternating with constipation:
- Intestinal TB
- IBS
- Chronic amoebic dysentery
- Colorectal Ca.

25.  COMPLICATIONS:
• Dehydration
• Hypokalaemia
• Hypovolemic Shock
• Sodium level low (Urine)
• Hypomagnesemia

26.  PREVENTION OF DIARRHOEA:
Sanitation
Hand washing
Safe Drinking water
Oral rehydration solution (ORSD)
Vaccine – eg. Rota virus Vaccine.
Nutrition – Zinc supplementation
Exclusive breast feeding of child
Probiotics

27.  IRRITABLE BOWEL SYNDROME (IBS):
Irritable Bowel Syndrome (IBS) is a functional bowel disorder characterized by
altered bowel habits, abdominal pain and absence of detectable organic pathology.

28. The diagnostic criteria of IBS:
Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months
associated with two or moreof the followings:
1. Improvement with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (appearance) of stool.

29. The clinical features of IBS
- Colicky abdominal pain
- Altered bowel habit
- Abdominal distension
- Rectal mucus
- Feeling of incomplete defecation.

30.  The characteristics of pain in IBS:
Recurrent abdominal pain which is usually colicky or'cramping' in nature, felt in
the lower abdomen andrelieved by defecation
THe negative criteria of IBS:
Negative criteria of IBS-
- Age> 40 years
- Weight loss
- Nocturnal symptoms
- Blood in stool.

32. Traits IBS IBD
Types of disease Functional bowel disorder Inflammatory
Ulcer in the GIT No Yes
Predominant clinical
features
Altered bowel habit
and abdominal pain
Blood diarrhea
Complications Less More
Treatment Reassurance,medical and psychotherapy Prompt medical and surgical
treatment
 The difference between IBS and IBD:

33. Investigation:
 Stool for R/E & OBT – to see ova,cyst,parasite,occult blood.
 USG of whole abdomen
 Barium enema
 Sigmoidoscopy and colonoscopy
 CT scan or MRI of Abdomen.
 Thyroid Function Tests

34.  IBD means inflammatory bowel disease.
 Ulcerative colitis and Crohn's disease are included under IBD.
 Ulcerative colitis are continuous mucosal and submucosal inflammation.
 Crohn’s disease are non-continuous or discrete transmural inflammation.
 Bloody diarrhoea is the most common presentation of ulcerative colitis.
 INFLAMMATORY BOWEL DISEASE (IBD):

36. Ulcerative Colitis Crohn’s Disease
Risk Factor More common in non-smokers More common in smokers
Anatomical Distribution Colon only; begins only anorectal margin with
variable proximal extention
Any part of gastrointestinal tract; perianal
disease common; patchy distribution – ‘skip
Lesion’
Presentation Bloody diarrhoea Variable; pain, Diarrhoea,weight loss
common
Histology Inflammation limited to mucosa, crypt distortion,
cryptitis, crypt abscesses, loss of goblet cells
Submucosal or transmural inflammation
common; deep fissuring ulcers,fistulas;
patchy changes; granulomas.
Management 5-ASA, Corticosteroids; azathioprine; colectomy is
curative.
Corticosteroids; azathioprine;
methotrexate,biological therapy (Anti –
TNF); nutritional therapy; Surgery for
complications is not curative
Difference between Ulcerative Colitis & Crohn’s Disease:

37. Investigation:
 CBC – Anemia, Normocytic – may be megaloblastic due to Vitamin B12 Deficiency
 ESR & CRP – Both High
 Stool for R/E & C/S – exclude infectious cause.
 USG of whole abdomen
 Barium follow through or small bowel enema – Narrowing of the affected segments
(string sign) in crohn’s disease
 Endoscopy and colonoscopy with Biopsy
 Capsule endoscopy – small bowel disease
 CT scan or MRI of Abdomen.

39.  THE FEATURES OF SEVERE ULCERATIVE COLITIS
- Stool frequency >6 stools/day
- Blood in Stool +++
- Fever > 37.5°, 2 days out of 4
- Increased Heart rate > 90/min
- ESR >30 mm/hour
- Anemia <10 gm/dl Hb
- Albumin < 30 gm/L

40. Complications of Inflammatory Bowel Disease:
 Intestinal:
- Life-threatening colonic inflammation (Toxic Megacolon)
- Abscess
- Fistulas
- Haemorrhage
- Colonic perforation
- Ca. Colon
 Extraintestinal:
- Uveitis, Conjunctivitis
- Arthralgia, Ankylosing spondylitis
- Cholangitis
- Cirrhosis
- Venous Thrombosis

41. RECTAL BLEEDING AND MELENA:
There are many causes of rectal blood loss but as always, a detailed history will help.
Determine the following:
• Amount - Small amounts can appear dramatic, coloring toilet water red.
• Nature of the blood (red, brown, black)
• Is it mixed within the stool or is it on the stool?
• Is it spattered over the bowl or with the stool, or only seen on the paper?
• Any associated features (Mucus may indicate inflammatory bowel disease or colonic cancer.)

42. MELENA:
This is jet-black, tar-like, and pungent-smelling stool representing blood from the upper GI
tract (or right side of the large bowel) that has been altered by passage through the gut.
The presence of melena is often asked about in hospitalized patients, but those who have
smelled true melena rarely forget the experience!
Ask about iron supplementation or bismuth-containing compounds.These cause blackened
stools but without the melena smell or consistency.

43. MUCUS
This is a clear, viscoid secretion of the mucus membranes.
• It contains mucus, epithelial cells, leukocytes, and various salts suspended in water.
The presence of mucus in or on stools may indicate the following:
• Inflammatory bowel disease
• Solitary rectal ulcer
• Small or large bowel fistula
• Colonic villous adenoma
• Irritable bowel syndrome

44. Flatus
Small amounts of gas frequently escape from the bowel via the mouth (eructation) and anus.
A notable excess of this is a common feature of both functional and organic disorders of the
gastrointestinal tract.
It is often associated with abdominal bloating and caused by the fermentation of certain
foods by colonic flora.
Excessive flatus is a particular feature of the following
• Hiatal hernia
• Peptic ulceration
• Chronic gallbladder disease
• Air-swallowing (aerophagy)
• High-fiber diet

45. •Haemorrhoids
•Anal fissure
•Colonic carcinoma
•Colonic polyp
•Inflammatory bowel disease
•Ischemic colitis
•Small bowel disease (eg.Tumor, diverticulae, Intussusception, Crohn’s Disease)
•Haemobilia (bleeding into the biliary tree)
 Causes of lower GI bleeding:

46. THANK YOU…