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t i o n a l H e a l t h M o d u l e Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine Differential diagnosis in adults presenting with diarrhoea This module considers common causes of diarrhoea in adults and aims to help you in making a differential diagnosis. Diarrhoea is a common symptom and is often a mild and self-limiting ailment. However, we must not forget that it also takes many lives in the young and elderly especially in developing countries. It is important to spot when a serious underlying disease should be suspected, so that you can initiate appropriate investigations and treatment. 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 1 of 49 Pathology slide of jejunal mucosa: villous atrophy and crypt hyperplasia as seen in Coeliac disease. Click to navigate to next page NEXT SLIDE

Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic Navigating this Self Directed Learning (SDL) Module To navigate around this module… Click on each headings of the surgical sieve slide (page 5) VITAMIN CDEFGHI 8 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine We shall be using the surgical sieve to consider the differential diagnosis in adults who present with diarrhoea. 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information Vascular Infective Traumatic Autoimmune Metabolic Iatrogenic Neoplastic 8 This is the surgical sieve which is often used in clinical practice. It is a simple and effective way to construct and organise your differential diagnosis! Congenital Degenerative Endocrine Functional Genetic Hysterical Idiopathic If you see a box like this in the bottom right hand of the slide, You can also navigate by clicking on the headings onthis thebox sidetobar. please use navigate or by clicking the NEXT SLIDE button on the bottom each page. back to theright mainofpresentation. 20. References Sunday, October 25, 2020 Page 2 of 49 you use these …. and please. Or use thecan highlight andside writearrows to navigate totoolbar the nexttopage ( ) or previous page ( ). tool ! on this aid your learning. 8 8 BACK NEXT SLIDE

e a r n i n g O u t c o m e s Learning Outcomes Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine 14. Functional By the end of this module, you should be able to: • • Define diarrhoea Describe the consequences of prolonged diarrhoea Use the “surgical sieve” to create a differential diagnosis in diarrhoea Describe the common and clinically relevant pathogens that cause diarrhoea • Describe the risk factors, symptoms and clinical findings in common causes of diarrhoea • Describe how surgical and pharmacological interventions and stress and anxiety may cause diarrhoea 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 3 of 49 Please use this module to aid your learning in this subject along side other reading materials. Please see the useful information slide at the end of the SDL for recommended sources of information in this subject. NEXT SLIDE

Diarrhoea defined Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic Definition: Diarrhoea is described as frequent bowel evacuation or the passage of abnormally soft or liquid faeces. 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Consequences: Diarrhoea leads to excess losses of fluid, salts and nutrients in the faeces. Severe diarrhoea can lead to significant morbidity and even mortality from dehydration. Prolonged diarrhoea can result in malnutrition. Sunday, October 25, 2020 Page 4 of 49 NEXT SLIDE

Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine 14. Functional VITAMIN CDEFGHI Vascular Inflammatory/infective Traumatic Autoimmune Metabolic Iatrogenic Neoplastic 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information We shall be using the surgical sieve to consider the differential diagnosis in adults who present with diarrhoea. 20. References Sunday, October 25, 2020 Page 5 of 49 Click on each headings of the surgical sieve slide for more information on that topic 8 This is the surgical sieve which is often used in clinical practice. It is a simple and effective way to construct and organise your differential diagnosis! Congenital Degenerative Endocrine Functional Genetic Hysterical Idiopathic GO TO QUESTIONS

Question time Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine 14. Functional What is the likely diagnosis? there may be one or more correct answer 1. A 79 year old woman presents to the GPs complaining of a 6 month history of altered bowel habit. She complains of nausea, smelly diarrhoea and intermittent constipation, with some blood in the stools. 16. Hysterical 17. Idiopathic 20. References Sunday, October 25, 2020 Page 33 of 49 b) Hyperthyroidism c) Bowel tumour d) Diabetic autonomic neuropathy e) Chronic pancreatitis 15. Genetic 18. Questions 19. Useful information a) Bacterial infection Click on the answer to find out if you are correct! 8 f) Chronic mesenteric ischaemia NEXT QUESTION

Question time Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information What is the likely diagnosis? there may be one or more correct answer 2. A woman in her 20’s has a long-standing history of anxiety and depression. She complains of frequent episodes of diarrhoea and sometimes constipation. She says she often feels bloated and she also feels tired a lot. a) Inflammatory bowel disease b) Coeliac disease c) Bowel tumour d) Hyperthyroidism e) Irritable bowel syndrome f) Chronic mesenteric ischaemia 20. References Sunday, October 25, 2020 Page 40 of 49 NEXT QUESTION

Question time Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic Match up the infective agent… 1. Causes a bacillary dysentery 2. A spore-forming pathogen V. cholera C. difficile Norovirus C. jejuni Shigella 10. Neoplastic 11. Congenital 3. Needs intestinal flora for colonisation C. difficile 12. Degenerative E. histolytica Norovirus 13. Endocrine 14. Functional 15. Genetic 4. Likely cause of acute diarrhoea + muscle aches Giardia norovirus V. cholera 5. Infection following clindamycin treatment C. difficile C. jejuni Shigella 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 47 of 49 NEXT QUESTION

Question time Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic and just few more questions… 1. A condition where patients often have co-existing atheromatous disease Chronic pancreatitis Coeliac disease Initiation of metformin 2. Reason for diarrhoea in a recently diagnosed obese diabetic Chronic mesenteric ischaemia Autonomic neuropathy Anxiety about condition 10. Neoplastic 11. Congenital 12. Degenerative 3. Drugs that commonly cause diarrhoea antipsychotics antibiotics opioids 13. Endocrine 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 53 of 49 4. A condition characterised by villous atrophy and crypt hyperplasia in the jejunum, causing malabsorption 5. Which of these statements is true concerning features of Crohn’s disease? Ulcerative colitis The gut lumen is dilated Coeliac disease Commonly the large bowel and rectum is affected Crohn’s disease Fistula formation is common FINISH

Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine The end! Thank you for completing this SDL! I hope that it has helped you to use the surgical sieve to pull together a differential diagnosis! 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 59 of 49 USEFUL INFORMATION

Useful information Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital Chronic mesenteric ischaemia Infective causes of diarrhoea Kumar and Clark, Clinical medicine. www. vascularweb. org/patients/North. Point/Mesenteric_Isc hemia. html Harvey, Champe and Fisher, Lippincotts microbiology. Coeliac disease Conleth Feighery. Clinical review Coeliac disease. www. coeliac. org. uk/coeliac_disease/default. asp Diabetes mellitus Bowel tumours Kumar and Clark, Clinical medicine. http: //www. patient. co. uk/showdoc/27000260 12. Degenerative Kumar and Clark, Clinical medicine. 13. Endocrine www. bowelcancerwales. com/page. cfm/page_ID/2/menu_I D/2/parent_ID/2/title/About_Bowel_Cancer 14. Functional Chronic pancreatitis 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 60 of 49 Thyrotoxicosis Irritable bowel syndrome Inflammatory bowel disease Kumar and Clark, Clinical medicine. www. pancreatitis. org. uk/whatis. htm Underwood, General and systemic pathology. thyroiddisease. org. uk/index. php? option=com_content&task=secti on&id=5&Itemid=30 Kumar and Clark, Clinical medicine. REFERENCES

References Partners in Global Health Education 1. Introduction 2. Learning outcomes 3. Surgical Sieve 4. Vascular 5. Infection 6. Trauma 7. Autoimmune 8. Metabolic 9. Iatrogenic 10. Neoplastic 11. Congenital 12. Degenerative 13. Endocrine 14. Functional 15. Genetic 16. Hysterical 17. Idiopathic 18. Questions 19. Useful information 20. References Sunday, October 25, 2020 Page 61 of 49 Martin, E. A. Oxford concise medical dictionary. 6 th ed. Great Britain. Oxford University Press. 2003. Kumar, P and Clarke, M. Clinical Medicine. 6 th ed. USA. Elsevier Ltd. 2005. Harvey, R. A. , Champe, P. C. , Fisher, B. D. Lippincott’s Illustrated Reviews: Microbiology. 2 nd ed. U. S. A. . Lippincott, Williams and Wilkins. 2007. Underwood, J. C. E. General and systemic pathology. 3 rd ed. China. Churchill Livingstone. 2002. Rang, H. P, Dale, M. M, Ritter, JM. Pharmacology. 4 th ed. Edinburgh. Churchill Livingstone. 1999. Bytzer, P. , Talley, N. J. , Jones, M. P. , Horowitz, M. Oral hypoglycaemic drugs and gastrointestinal symptoms in diabetes mellitus. Alimentary Pharmacology & Therapeutics, 2001; 15: 137– 42. Conleth Feighery. Clinical review Coeliac disease. BMJ, 1999; 319: 236 -9. Binder, H. J. Causes of Chronic Diarrhoea. NEJM, 2006; 355: 236 -9. This module was developed by Esther Godfrey, Medical Student, School of Medicine, Swansea for the Mead. Johnson Alimentary Prize. Many thanks to Dr Stephen Allen, Reader in Paediatrics and Jess Griffiths, Learning Technologist for the template used to build this SDL.