UCHID 2019

1. Head of Gastroenterology , Hepatology Department
Qabbary Specialized Hospital

3. Diarrhea:
An increase in the fluidity , frequency (3 motions /d)
and the volume of daily stool output(>200 g/d)
Acute Diarrhea : <14 days
Persistent Diarrhea : 14-30 days
Chronic Diarrhea : > 30 days

4. Pathophysiology of Diarrhea:
1- Osmotic Diarrhea . In which there is increased amounts of
poorly absorbable osmoticaly active solutes in the gut lumen
2- Secretory Diarrhea in which there is increased Cl. And water
secretion
3- Exudation of mucus , blood and proteins from sites of active
inflammation in to the bowel lumen.
4- Abnormal intestinal motility

5. British Society of Gastroenterology
Arasaradnam RP, et al. Gut 2018
British Society of Gastroenterology
Arasaradnam RP, et al. Gut 2018

6. ETIOLOGY
British Society of Gastroenterology
Arasaradnam RP, et al. Gut 2018

10. INDICATIONS FOR REFERRAL TO
A GASTROENTEROLOGIST
GIT

11. Indications for referral include anyone of the following:
• Alarm features
• Severe diarrhea
• Suspected inflammatory bowel disease
• Inconclusive diagnosis after initial evaluation
• Failure to respond to empiric therapy
Referral to a gastroenterologist may also be appropriate in patients who require
long-term management for the underlying cause (eg, inflammatory bowel
disease, chronic pancreatitis)

12. INITIAL EVALUATION
— The initial evaluation of patient with chronic diarrhea includes history, physical
examination, and laboratory testing to determine whether the patient has any alarm
findings which help to distinguish organic from functional diarrhea
and characterizing the diarrhea in order to direct the need for additional evaluation.
Evaluation for alarm features
— Alarm features in patients with chronic diarrhea may be suggestive of an underlying
organic etiology .These features include the following
• Age of onset after age 50 years
• Rectal bleeding or melena
• Nocturnal pain or diarrhea
• Progressive abdominal pain
• Unexplained weight loss, fever, or other systemic symptoms
• Laboratory abnormalities (iron deficiency anemia, elevated C-reactive protein or fecal
calprotectin)
• Family history of inflammatory bowel disease (IBD) or colorectal cancer

13. RECOMMENDATIONS
1. Stool and laboratory tests should be the initial step for the evaluation of clinical
scenarios suggestive of infectious diarrhea.
2. In patients with chronic unexplained diarrhea, we suggest colonoscopy with
random biopsies of the right and left side of the colon. Sigmoidoscopy is an
alternative option, although this may miss right-sided organic disease.

14. 3. We recommend intubation of the terminal ileum during colonoscopy for patients
undergoing evaluation of chronic diarrhea. There are insufficient data to determine
whether biopsy of an endoscopically normal-appearing terminal ileum should be
routinely performed, but the yield of this is likely low.
4. We recommend EGD with small-bowel biopsy in patients with chronic diarrhea or
suspected malabsorption and inconclusive evaluation after colonoscopy with biopsy
and in patients with positive celiac serology.
5. We recommend obtaining a minimum of 4 duodenal biopsy specimens for
evaluation of suspected celiac disease.
6. Enteroscopy is not recommended for the routine evaluation of chronic diarrhea but
may be useful for evaluation of small-bowel disease when other investigations are
nondiagnostic.
7. VCE is not recommended for the routine evaluation of chronic diarrhea.
8. In patients with HIV and diarrhea, we suggest either flexible sigmoidoscopy or
colonoscopy if laboratory evaluation is nondiagnostic.

16. Diarrhea continues to be a prevalent symptom in patients with inflammatory
bowel disease (IBD)
Mechanisms of Diarrhea in IBD
 Inflammation (Inflammation causes denudation of the epithelium, which results in
leakage of plasma and blood and increased secretion of water and electrolytes. )
 stimulation of anion secretion and impaired absorption. --- inhibition of fluid
and electrolyte absorption
 Malabsorption
 Extensive ileal disease or ileal resection usually
results in bile acid malabsorption inadequately compensated by hepatic
synthesis.

17. Clinical presentation
A. History
Signs and symptoms
Crohn’s diseaseUlcerative Colitis
Fatigue,Wt loss, persistant abd.
Pain.
In More extensive involvement ->
blood in stool
bile acid malabsorbtion
Cholesterol galstones
Patients with Proctitis:
tenesmus,urgency,mucus and
bloody stool
In More extensive involvement: -
 wieght loss ,fever,bloody
diarrhea

18. Growth retardation and failure to develop sexual maturity
Patients with CD may present with inflammatory,obstructive,fistulizing or
preanal disease. Fistulas may be with
• Another loop
• The bladder
• Vagina
• Skin
Extraintestinal manifestations
Onset and course
Both UC ,CD typically begin in childhood or early adulthood, although UC
may develop in any age
Asecond peak in the incidence of CD occure in elderly
Most patient of UC experience intermittent exacerbation and remission

20. Physical examination
General
 Patients with IBD often are thin and undernourished.
 Pallor due to Anemia of blood loss and chronic disease
 Tachycardia may result from dehydration and blood loss
 Low grade Fever may present
 Extraintestinal manifestations of IBD may be evident
 Clubbing of fingernails of chronic disease , prephral edema due to
hypoalbuminamia
Local
 Mild to moderate abdominal tenderness over the distended segment in UC
 A tender mass in the right lower quaderant in CD
 Abd. Distention, rebound tenderness absence of bowel sounds and high fever
suggest Toxic megacolon or Abcess
 P/R bloody stool or frank blood in UC
perianal scarring or fistula in CD

21. Diagnostic studies.
- IBD is diagnosed based on integration of clinical ,endoscopic, histopathological and
radiological data
- Laboratory data are non specific and markers of chronic inflammatory may be normal in
mild or moderate disease.
- Infective causes of diarrhea should be excluded including C. difficile &CMV.
- Initial investigations should include
Laboratory Studies
Anemia , leukocytosis , thrombocytosisCBC
May be elevated in active diseaseESR & CRP
ASCA+/pANCA –predicted Crohn’s dis.
ASCA-/pANCA + predicted UC.
Serologic examination of
blood
Stool Analysis
Fecal calprotectin (relapse if above 200 ,remission if below
150 )
Examination of stool

22. Ilio-colonoscopy and upper GI Endoscopy
 Colonoscopy with intubation of the terminal ileum is
useful in evaluation
 Colonoscopy is not recommended in severly active
disease for fear of perforation
Ulcerative colitis

24. Diagnosis – radiology (imaging)
- Radiology and endoscopy are complementary techniques to define the
site and extent of the disease
- Radiology has a more evident role in CD than in UC
 Bowel lesions out of reach of the endoscope (10%).
 Penetrating lesions as fistulas, phlegmons or abscesses (15%).
- Radiological tools include:
 Trans – abd US (high frequency, contrast enhanced, Doppler).
 Cross-sectional imaging (CT & MR enterography) represent the current standard (3)
 PET
 Barium studies, not preferred currently (low sensitivity).
 Plain film radiography (bowel obstruction).

25. Diagnosis – Endoscopy & histopathology
 UC
- Endoscopy features:
Endoscopic changes characteristically commence at the anal verge and
extend proximally in a continuous confluent and concentric fashion
with involvement of the rectum with clear demarcation between
healthy & inflammed mucosa
- Histopathological features: (3)
 A minimum of two biopsies from at least 5 sites around the colon (including
the rectum and ileum).
 Characterized by:
 Mucosal atrophy
 Crypt architectural distortion
 Transmucosal inflammation with basal plasmacytosis (earliest diagnostic
feature).

26. Diagnosis – Endoscopy & histopathology
 CD
- Endoscopy features:
 Skip lesions
 Aphthus ulcers
 Cobble stone appearance
 Perianal lesions
- Histopathological features: (same rule of biopsies as UC)
 Granuloma (epithelioid histocytes
“monocytes/macrophages”)
 Focal crypt architectural abnormalities.
 Patchy chronic mucosal inflammation (plasma cells &
lymphocytes).