WK3 CASE 3

FM&PH – Diarrhoea

In module Family Medicine and Public Health

This case focuses on Sarah who presents to her GP with diarrhoea. One presentation can have several different outcomes and two possible outcomes are explored in this case.

Guidance and Resources – Diarrhoea MED 35

Case Introduction – Diarrhoea MED 35

Further Case Information – Diarrhoea MED 35

Case Conclusion – Diarrhoea MED 35

Formative Assessment – Diarrhoea MED 35

Guidance and Resources – Diarrhoea MED 35

In case FM&PH – Diarrhoea

Learning Resources

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

This case links in with year 4 case 15 about IBS and case about colorectal cancer and that of the traveler diarrhea . It also links in with year 4 cases about diarrhoea in the infectious diseases module and an infectious diarrhoea outbreak in families and children module.

Leaflet describing self-treatment of acute diarrhoea

This leaflet informs patients how to obtain a stool specimen

Patient information leaflet on campylobacter

Form to notify infectious diseases

Notification and reporting of Communicable diseases

Sanitation and Diarrhea

Additional Reading/Resources

· NICE Guidance CG123 Common mental health problems: Identification and pathways to care

· NICE Guidance on referral of suspected cancer, section 1.3 is relevant to this case

· Information for the Royal College of Psychiatrists about Cognitive Behavioural Therapy

· Generalised anxiety disorder (GAD) – Dr Peter Hadad

· Patient information leaflet on campylobacter

CASE COMPONENT

Case Introduction – Diarrhoea MED 35

In case FM&PH – Diarrhoea

Sarah Joseph is a 20 year old student. She presented to her GP with a 10 day history of loose, watery stools.

Choose 5 of the questions below which are most important to establish answers to initially

· Is there any abdominal pain?

Correct answer.

· When was her last period?

· Does she have any weight loss?

· Is there any blood?

Correct answer.

In this early stage of the clinical reasoning process, it is essential for you to know more about the patient’s stool activity, particularly any change in bowel habit and potential red flags such as rectal bleeding. Questions exploring gynaecological and systemic causes can be explored at a later stage.

· Does she have any burning when she passes urine?

· How many times a day is she opening her bowels?

Correct answer.

· Is she vomiting?

Correct answer.

· Does she have any heart burn?

· Can she keep fluids down?

Correct answer.

· Does she sweat, have palpitations and feel hot?

Sarah has sensibly tried to relieve her symptoms herself. What sort of things should Sarah have tried? (Select FOUR)

· Increase her fluid intake

Correct answer.

· Take regular senna tablets

· Wash hands carefully after going to the toilet

Correct answer.

· Increase the intensity of her physical exercise

· Drink oral rehydration salts

Correct answer.

· Avoid preparing food for other people

Correct answer.

· Continue going to University

Patient.info provides further information about acute diarrhoea in adults.

The GP discovers the following:

Sarah has no vomiting or rectal bleeding and has crampy abdominal pains just before she needs to open her bowels. She has not had a fever. She is drinking plenty, is managing small amounts of food and passing urine normally.

She has just returned from a holiday in Gambia and the symptoms developed during her holiday.

She has had no contact with anyone with the same symptoms.

Her grandfather died 6 months ago from bowel cancer.

She is single and her last period was 3 weeks ago.

Sarah is worried that her Grandfather had diarrhoea and was diagnosed with bowel cancer aged 80 years of age.

It is important to know what patients’ thoughts might be on the cause of their symptoms, and to be able to reassure where appropriate. In order to do this, clinicians would complete their assessment, and use guidelines, such as those produced by NICE which will help in this situation to establish ‘red flags’ and when to refer:

The NICE Lower Gastrointestinal Cancers Guidance

Sarah is well hydrated, with a normal pulse, temperature, BP and temperature. She has lost 2 KGs in weight.

She is not pale, dehydrated or jaundiced. On examination, the abdomen is soft and non tender to palpate. There are no masses palpable. There is no palpable liver or spleen and no evidence of abdominal distension.

The GP tells Sarah she has done all the right things to look after herself and advises her to continue with oral rehydration. She explains what to do and when if she does not get better with self-care. She is relieved that she shared her worries about cancer and what the GP has outlined about this.

The following are likely differential diagnoses for Sarah’s symptoms of a sudden 10 day history of diarrhoea:

· Hyperthyroidism

The short history makes this less likely at present

· Diverticular disease

Sarah’s young age makes this less likely

· Inflammatory bowel disease

The short history makes this less likely at present

· Intussusception

Most common in infants

· Bowel cancer

Bowel cancer is less likely diagnosis based on the NICE guidelines as per link above. Cancers with a genetic component can occur at a younger age. Sarah’s grandfather was 80 when he was diagnosed, making genetic causes no more likely for Sarah

· Coeliac disease

The short history makes this less likely

· Traveller’s diarrhoea (eg Giardia)

Correct answer.

She has been to Gambia and symptoms started on holiday

· Bile salt malabsorption

would be a less acute presentation and usually effects slightly older adults

· Anxiety

Correct answer.

a cause of diarrhoea

· Appendicitis

Sarah’s lack of pain makes this less likely

· Gall stones

Sarah’s lack of pain makes this less likely

· Irritable bowel syndrome

Correct answer.

a common cause of diarrhoea

· Viral gastroenteritis

Correct answer.

A common cause of acute diarrhoea

What parts of the clinical examination should the GP specifically look at when examining Sarah? (Select ALL that apply)

· Otoscopy examination

Not necessary in the absence of ear symptoms.

· Temperature

Correct answer.

Gives an indication of general condition and impact of fluid loss.

· General condition

Correct answer.

Gives an indication of whether Sarah looks well and can remain being conservatively treated.

· Weight

Not essential but useful to document a baseline weight in case symptoms were to continue.

· Lower limb reflexes

Not immediately necessary as no relevant symptoms.

· Abdominal examination

Correct answer.

Important to check abdomen is soft and not tender and rule out an acute abdomen.

· Pulse and blood pressure

Correct answer.

Gives an indication of whether Sarah is haemodynamically stable and can remain being conservatively treated.

· Hydration status

Correct answer.

Gives an indication of whether Sarah is able to maintain hydration and can remain being conservatively treated.

Sarah is well hydrated, with a normal pulse, temperature, BP and temperature. She has lost 2 KGs in weight.

What is the most appropriate initial investigation?

· Flexible sigmoidoscopy

This would not usually be done in primary care

· Stool sample for ova, cysts, parasites, culture and sensitivities

Correct answer.

Yes to look for an infectious case which may need a specific treatment

· Full blood count

A reasonable choice but not the first test to choose

· Urine pregnancy test

Not indicated as she has no risk factors for pregnancy

· Renal function tests

Not needed initially as she is not dehydrated

More information:

The GP suggests Sarah’s stool is tested for Ova, cysts and parasites (O,C&P), culture and sensitivity. The GP within this practice area does not have access to faecal calprotectin testing, which is a test which if normal, reduces the likelihood of inflammatory bowel disease.

She gives patient the form and pot, asking Sarah to bring the pot back to the surgery, labelled as soon as possible after producing it. The GP makes sure the practice has the up to date contact details of the patient and asks the patient to ring the practice for the results in 1 week.

NHS Choices: How should I collect and store a stool (faeces) sample?

IN PRACTICE:
Find out how the patients at the GP practice you are placed at obtain the results of their tests.

We use the term “safety netting” for various activities which provide information or systems to protect patients if things do not go to plan. Here, we might use the term to mean discussing with the patient how long her symptoms are expected to last and when and how to present if things persist or get worse. In this case, if her symptoms last another 7-10 days she would be advised to book a face-to-face or telephone appointment for review.

The next part shows two (of many) possible outcomes.

Pathway one

Three days later, the microbiology laboratory rings the surgery to inform them that the stool sample has grown campylobacter. The GP that Sarah saw initially is not in the surgery on that day. However, the duty doctor on-call is able to see the notes that the first GP made and rings Sarah.

Some of disadvantages of a patient not seeing the same GP are lack of continuity of care and pathology results that need action taking may arrive on a day that the requesting GP is absent.

IN PRACTICE:
Find out what systems your GP has in place to cover when less than full time GPs are not at work.

What can practices do to reduce potential harm to patients from lack of continuity of the same GP?

· Robust systems to ensure GP’s work is safely covered when not at their practice

Correct answer.

This would be agreed between the team

· Buddy system with particular doctors assigned to cover for each other when absent

Correct answer.

This is an alternative method by which to ensure all results are actioned on the day, but requires a good understanding between all the GPs in the buddy group

· Good clinical record keeping so doctors can easily see how a patient is being looked after

Correct answer.

Keeping clear records is the essential for safe, high quality patient care

· Asking patients to ring in for results only on days the particular GP is working

This is impractical and results may come in that need action on days the requesting doctor is not present

· Discussion with patient on how to find out a test result

Correct answer.

It is good practice for a GP to explain to the patient during a consultation on the best way to find out about a test result. This helps a patient understand the process of follow up and also shows a transparent approach to dealing with results on behalf of the practice.

· Asking hospital laboratory only to send patients results in on the days the requesting doctor works

This is impractical

· The system flags up abnormal results needing action if requesting doctor is not present

Correct answer.

This ensures that any results requiring immediate attention are dealt with by the duty GP.

· Practice should telephone every patient who has a test done by the GP whether normal or not so that none are missed

Workload pressure in Primary care means that this is unfeasible. Practices would normally ring patients with abnormal results to follow up but also suggest patients ring to find out their results.

· Discussion with a patient on when to seek help if symptoms do not resolve (safety netting)

Correct answer.

Enables a patient to know if they expect to recover on their own and when (and how) to seek help if symptoms worsen or don’t improve.

Sarah tells the second GP her symptoms have subsided and she has had no diarrhoea for 48 hours.

Patient.info: Campylobacter

Based on this information, what should the GP tell Sarah about Campylobacter?

· She will require treatment with antibiotics

· No treatment is usually necessary

Correct answer.

· She should stay away from university for at least 2 weeks

· She should stay away from university until symptom free for 48 hours

Correct answer.

· Campylobacter are a group of bacteria that cause food poisoning, often due to eating undercooked meat

Correct answer.

· Campylobacter is a virus that is highly contagious and easily spread round universities

The GP has a responsibility to inform the following agency about this cause of infectious diarrhoea (Select ONE):

· Household contacts

· DVLA

· Sarah’s university

· Public Health England

Correct answer.

Campylobacter is a notifiable disease, and so the GP must notify Public Health England (PHE). Sarah might then be contacted directly by them for further information or advice about contacting or informing other people or contacts.

The following link provides an example of a form the GP might complete:
https://www.gov.uk/government/publications/notifiable-diseases-form-for-registered-medical-practitioners

An example of a notification form that the GP would complete

As her symptoms have settled down and she has had no further diarrhoea for 48 hours she can return to her normal activities. He warns her sometimes her she may find her bowel habit is a bit looser than normal for a few weeks and to contact her GP back if her symptoms recur or do not settle.

Now consider an alternative outcome…..

Pathway two

One week later Sarah rings the GP surgery for her stool sample result. The GP was sent the result electronically and noted that the result showed no pathogens. The GP marked the result “normal-no further action” and the receptionist tells this to Sarah. Sarah still has loose stools and remembers the GP asked her to rebook if her symptoms persisted. She books a telephone appointment with the GP.

During the telephone consultation, Sarah tells you her diarrhoea has improved but she is still having crampy pains, passing flatus and her stools are looser than normal. She has not lost any more weight. Sarah has gone back to university but is unable to be on the phone long as she has a revision tutorial to attend. The GP recognises Sarah feels anxious about her symptoms and arranges for Sarah to have some blood tests and make an appointment the next week to discuss things further.

The persistence of diarrhoea (3 weeks) makes other diagnoses more likely.

What other diagnoses are possible?

· Gall stones

Sarah’s lack of pain makes this less likely

· Bowel cancer

This is still less likely than other diagnoses given Sarah’s young age.

· Inflammatory bowel disease

Correct answer.

The persistence of symptoms means this needs to be considered

· Traveller’s diarrhoea eg Giardia

Correct answer.

BMJ Best Practice suggests 20-40% of acute infective diarrhoea is undiagnosed despite stool testing. It therefore needs to remain in the differential diagnosis

· Irritable bowel syndrome (IBS)

Correct answer.

This is a common cause of diarrhoea and the persistence of the symptoms increases the chances of it being IBS

· Coeliac disease

Correct answer.

The persistence of symptoms means this needs to be considered

· Bile salt malabsorption

Usually effects slightly older adults

· Diverticular disease

Sarah’s young age makes this less likely

· Hyperthyroidism

Correct answer.

The persistence of symptoms means this needs to be considered

· Viral gastroenteritis

This becomes less likely after symptoms persist for 3 weeks but a post infective IBS can occur

· Anxiety

Correct answer.

Anxiety can cause physical symptoms including diarrhoea

· Intussusception

Most common in infants

· Appendicitis

The lack of pain and continued duration of symptoms makes this unlikely

What tests should the GP arrange, given the persistence of diarrhoea?

· Urine sample

does not have any urinary symptoms

· Ultrasound abdomen

no indication at this stage.

· Flexible sigmoidoscopy

this is not usually performed in primary care

· Chest X-ray

not necessary as there is nothing to suggest a respiratory cause.

· CRP

Correct answer.

may be raised in keeping with inflammatory bowel disease

· ESR

Correct answer.

may be raised in keeping with inflammatory bowel disease

· Full blood count

Correct answer.

a normal haemoglobin and white cell count make malabsorption (coeliac) and inflammatory bowel disease less likely

· Abdominal X-ray

not necessary. Very limited indications for doing a plain abdominal film (suspected bowel obstruction, renal stones).

· Tissue Trans-glutaminase antibodies

Correct answer.

Yes to look for coeliac disease

The GP recognises the symptoms are unpleasant for her and offers her a treatment to improve her symptoms.

What might she be offered?

· Codeine

this is not recommended for diarrhoea in this case

· Hyoscine butylbromide (buscopan)

Correct answer.

These are treatments used in irritable bowel syndrome and reduce abdominal discomfort and smooth muscle spasm.

· Gluten free diet

there is no indication for a gluten free diet without confirmation that a patient has coeliac disease

· Lactulose

this is a laxative

· Mebeverine

Correct answer.

These are treatments used in irritable bowel syndrome and reduce abdominal discomfort and smooth muscle spasm.

The GP decides to give Sarah treatment for her symptoms based on the balance of probability that she has been left with some irritable bowel syndrome (IBS) type symptoms following a self-limiting viral gastroenteritis. Even if the blood tests suggest a different cause, the symptoms can be helped by either of these medications.

There is more information about IBS at NICE (2013) guidance advises on assessment and management.

One week later, Sarah returns to the GP. She has had blood tests done and the results are as follows:

· Haemoglobin 132 (120-145 g/dL)

· WCC 8.4 (4-11 x109/L)

· Platelets 352 (0.4-4.0 mIU/L)

· MCV 83.4 (80-96 fL/rc)

· ESR 6 (<10)

· CRP 1 (<5)

· Na 138 ((133-145mmol/L)

· K 4.5 (3.5-5.4mmol/L)

· Creatinine 80 (50-90 ɲmol/L)

· eGFR >90 (>60mL/min)

· TSH 3.2 (0.4-4.0 mIU/L)

· T3 19 (10-24)

· TTG <0.9 (<0.9)

The GP explains that the tests have come back normal and explains that this makes the working diagnosis of irritable bowel syndrome more likely.

Sarah is relieved all her tests are normal. She admits she had been feeling a bit anxious recently, but has put that down to recent exams which are now finished, so she is sure that she will feel better now. Following discussion, Sarah and her GP decide to continue mebeverine three times daily. Sarah agrees to come back if things do not improve.

CASE COMPONENT

Further Case Information – Diarrhoea MED 35

In case FM&PH – Diarrhoea

Three months later….

Sarah comes back, her diarrhoea symptoms have settled to occasional loose stools and feeling bloated. She is not sleeping well and often finds she feels anxious.

The GP asks her some questions about symptoms of anxiety or depression.

Generalised Anxiety Disorder – Dr Peter Hadad

NICE Guidance CG123 Common mental health problems: identification and pathways to care

Sarah tells the GP she always feels tense and up tight. She takes a long time to get to sleep and wakes up early. She is spending excessive time on her studies as she is worried about falling behind. She is managing to keep up with her studies but is finding it hard to concentrate. She has started seeing her friends less. She drinks alcohol twice a week and will usually have 1 or 2 pints each time she drinks. She used to play badminton but has stopped this over the last few weeks. She still looks forward to seeing her family and her dog when she goes home. She has no thoughts of harming herself.

What screening questionnaires can you use to measure anxiety?

GAD7 and HAD are commonly used, and it is useful for you to see these here and then ask your tutor if they are used in their surgery, and by whom.

GAD7

HAD

PHQ9 - The PHQ9 is not a measurement of anxiety directly but depression with anxiety is common and anxiety can often be caused by an underlying depressive illness.

Sarah’s GAD7 score sheet

Please score her anxiety

The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories as follows and adding together the scores for the seven questions:

· 0 – Not at all

· 1 – Several days

· 2 – More than half the days

· 3 – Nearly every day

Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. (from www.patient.co.uk )

Sarah’s GAD7 scored

This questionnaire shows that Sarah has ‘moderate anxiety’. She fills in the PHQ9 wiht teh G P and her score indicates she is “not depressed” which is also the clinical impression of the GP.

The GP discusses her symptoms with Sarah and talks though the results of the questionnaire. Sarah is not surprised to hear she has anxiety. The GP reassures her that it is a common condition and says there are lots of things she can suggest to help her.

Which of the following could Sarah try to help with her anxiety? (Select ALL that apply)

· Goal setting

Correct answer.

helps to break down large tasks into small manageable chunks

· Avoid going out with friends

this could increase social isolation

· Relaxation CDs

Correct answer.

Unlikely to do any harm

· Antidepressants

Correct answer.

antidepressants are used in anxiety although as her symptoms are not severe, other modalities may be better to try initially

· Advise Sarah to keep her condition a secret

people often feel better when they can share how they are feeling with friends

· Cognitive behavioural therapy (CBT)

Correct answer.

CBT helps change how someone thinks and behaves in order to help them feel better. It recognises the interplay between a trigger for anxiety which leads on to thoughts, emotions, physical feelings and actions.

http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.aspx

· Plan to move house

It is not advisable to plan any big life events if possible when suffering with anxiety

· Restart badminton

Correct answer.

physical exercise and time with friends often helps

Sarah is keen to try CBT and knows a bit about it from her psychology A-level. The GP suggests she talks to her tutor at the University and offers Sarah a referral to the local IAPT service (Increasing Access to Psychological Therapies) who can arrange CBT. However, Sarah knows she can refer herself to the student counselling service through the University which will have a shorter waiting list. CBT can be offered face to face with a therapist, or via a book or computer programme.

IN PRACTICE:
Find out about the access to psychological therapy for patients seen at the GP you are placed with.

CASE COMPONENT

Case Conclusion – Diarrhoea MED 35

In case FM&PH – Diarrhoea

Two months later, Sarah returns having had 8 sessions of CBT via the University counselling service. She feels much better and when she feels her anxiety appearing, she is able to challenge her thoughts and has developed more positive coping mechanisms. She has re-joined the University badminton team and sees her friends more regularly.

CASE COMPONENT

Formative Assessment – Diarrhoea

Which one of the following infectious diseases is not a notifiable disease?

· Mumps

· Scarlet fever

· Salmonella species

· Herpes simplex

· Influenza virus

· Herpes simplex

.Correct answer.

The list of notifiable conditions in the UK can be found via the following link: https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report#list-of-notifiable-diseases

Sarah’s symptoms were not suspicious of bowel cancer because of her age. According to the 2015 NICE guidelines for suspected cancer, the persistence of WHICH of the following alarm symptoms should trigger a 2 week wait referral for suspected lower gastrointestinal cancer?

· Age over 50 with unexplained rectal bleeding

· Age over 40 with unexplained weight loss and abdominal pain

· Age over 40 with change in bowel habit

· Age over 60 with iron deficient anaemia

· Age over 50 with unexplained rectal bleeding

.Correct answer.

· Age over 40 with unexplained weight loss and abdominal pain

.Correct answer.

· Age over 40 with change in bowel habit

.aged over 60 and change in bowel habit

· Age over 60 with iron deficient anaemia

.Correct answer.

Type the letter of the condition below ("A","B","C","D" or "E") in the box beside the relevant clinical scenario.

· A) Irritable bowel syndrome

· B) Coeliac disease

· C) Norovirus

· D) Hyperthyroidism

· E) Colorectal carcinoma

25-year-old man with diarrhoea, weight loss and a positive tissue transglutaminase

70-year-old lady with 6 week history of diarrhoea, weight loss and rectal bleeding

3-year-old with 4 days of diarrhoea who attends nursery

32-year-old man with 3 years of intermittent diarrhoea, bloating, abdominal pain and flatulence

25-year-old man with diarrhoea, weight loss and a positive tissue transglutaminase

70-year-old lady with 6 week history of diarrhoea, weight loss and rectal bleeding

40-year-old lady with diarrhoea, palpitations, weight loss and sweatiness

3-year-old boy with 4 days of diarrhoea who attends nursery

32-year-old man with 3 years of intermittent diarrhoea, bloating, abdominal pain and flatulence

Which neurotransmitters are involved in anxiety?

· Dopamine

· Glucagon

· Noradrenaline

· Gamma-aminobutyric acid (GABA)

· Serotonin

· Dopamine

.Correct answer.

· Glucagon

.This is not a neurotransmitter, but a hormone, involved in regulation of blood glucose.

· Noradrenaline

.Correct answer.

· Gamma-aminobutyric acid (GABA)

.Correct answer.

· Serotonin

.Correct answer.

Which of the following are symptoms of anxiety?

· Itchy teeth

· Itchy skin

· Feeling nauseated

· Palpitations

· Feeling tense and on edge

· Itchy teeth

· Itchy skin

.Correct answer.

· Feeling nauseated

.Correct answer.

· Palpitations

.Correct answer.

· Feeling tense and on edge

.Correct answer.

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