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Diarrhea Flashcards

1
Q

What constitutes diarrhea?

A

> 200 grams or 200 mL per 24 hour period

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2
Q

Malabsorptive diarrhea

A

Inadequate nutrient absorption
Associated with steatorrhea
Relieved by fasting

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3
Q

Exudative diarrhea

A

Due to inflammatory disease
Purulent, bloody stools
Continue during fasting

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4
Q

What constitutes a normal bowel movement?

A

One BM every 3 days to 3 BM every day

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5
Q

What are some history clues to investigate with diarrhea?

A
  1. Consistency
  2. Urgency
  3. Incontinence
  4. Nocturnal BM
  5. Flatuphobia
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6
Q

Diarrhea due to small bowel disease

A

Watery diarrhea, large volume, less frequent
Abdominal cramping, bloating, gas and weight loss
Evidence of malabsorption, vitamin or nutrient deficiencies
Fever is rare
Rare stool WBCs or occult blood

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7
Q

Diarrhea due to large bowel disease

A 
Inflamed dysfunctional colon/rectum cannot perform this function
Frequent, small, regular stools 
Tenesmus (rectal "dry heaves") 
Painful BM 
Fever, bloody, mucoid stools 
RBCs and WBC on stool smear
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8
Q

Osmotic diarrhea

A

Small intestine and colon cannot maintain an osmotic gradient against serum
Unabsorbed ions remain in the lumen –> pull water into the lumen of bowel
Maintain intraluminal osmolality = 290 mOsm/kg

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9
Q

What are some things that may cause osmotic diarrhea?

A

Ingestion of poorly absorbed ions or sugars or sugar alcohols – Mannitol, sorbitol, magnesium, sulfate and phosphate

Monosaccharides but not disaccharides can be absorbed

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10
Q

Disappears with fasting

A

Osmotic diarrhea

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11
Q

Secretory diarrhea

A

Many causes –> net secretion of anions (chloride/bicarb) or inhibition of net sodium absorption
Most common cause is infection
Enterotoxins
Endocrine tumors

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12
Q

What constitutes acute, persistent and chronic diarrhea?

A

Acute: 28 days

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13
Q

What are some causes of acute diarrhea?

A 
Infection -- bacteria, parasites, protozoa, viruses
Food allergies
Food poisoning
Medications
Initial presentation of chronic diarrhea
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14
Q

What are some causes of chronic fatty diarrhea?

A 
Malabsorption syndromes
Mesenteric ischemia
Mucosal diseases (celiac, Whipple's) 
Short bowel syndrome
Small intestinal bacterial overgrowth
Maldigestion
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15
Q

What are some causes of inflammatory chronic diarrhea?

A 
Diverticulitis 
Infectious disease
Invasive bacterial/parasitic infections
Pseudomembranous colitis
IBD
Crohn's
Ulcerative colitis
Neoplasia
Lymphoma
Radiation colitis
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16
Q

What are some main things you must address during the history in a patient who presents with diarrhea?

A 
Assess volume status (symptomatic, orthostatis, fluid intake) 
Try to assess constancy 
Frequency 
Abdominal Pain 
Tenesmus
Nocturnal waking
Blood in stool (never normal)
Flatuphobia
17
Q

What are some medications that may cause diarrhea?

A

NSAIDs and Olmesartan (anti-htn) – sprue like illness

18
Q

What are some possible causes if diarrhea presents with a fever?

A 
Invasive bacteria
Enteric viruses
Cytotoxic organism (C. diff or Entamoeba histolytica)
Ischemia
IBD
19
Q

What are some causes if diarrhea begins w/i six hours?

A

Suggests ingestion of toxin

Staph aureus or Bacillus cereus

20
Q

What are some of the causes of diarrhea if it began within 8-15 hours?

A

Suggests infection with Clostridium perfringens

21
Q

What are some of the possible causes of diarrhea if it began more than 14 hours?

A

Result of viral or bacterial infection, non-specific

22
Q

How should you focus your physical exam with a patient who is presenting with diarrhea?

A

Initially focus on volume status
Check for signs of other systemic disease – DH in Celiac disease or EN in arthritis/IBD
Abdominal tenderness/mass
Rectal exam for (fistula, blood stool)

23
Q

When do you order a stool sample for pathogens?

A

When a patient is very ill or has risk factors for infection

24
Q

When do you use ELISAs or DFA microscopy on stool samples?

A

To test for Giardiasis and Cryptosporidium
-Sensitivities greater than 90%
-Specificities approaching 100%
Useful if proper history or immune compromised

25
Q

What is the osmotic gap?

A

Osmotic gap = Serum Osm - Est Stool Osm (290)

The osmolality of colonic fluid contents is in equilibrium with body fluids (290 mOsm/kg)

26
Q

What is the osmotic gap like in secretory vs osmotic diarrhea?

A

In secretory diarrhea – the osmotic gap is small (100 mOsm/kg)

27
Q

What does it mean if the osmotic gap is negative?

A

There is a poorly absorbed multivalent anion, such as phosphate or sulfate

The measured stool osmolality is of little value – stool osmolality tends to rise once the stool has been collected b/c of continuing bacterial fermentation in vitro.

28
Q

How can you test for surreptitious laxative ingestion?

A

There will be a large osmotic gap – suggesting magnesium ingestion
Or a negative osmotic gap
Stool can be analyzed for laxatives by chemical or chromatographic methods

29
Q

What are some common causes of chronic diarrhea that should be pursued early?

A

Celiac disease (caucasians)
Thyroid disease
IBD
IBS

30
Q

When is it appropriate to pursue endoscopy for chronic diarrhea?

A

Persistent and chronic with significant lab abnormalities – obtain biopsies of even normal appearing mucosa is essential

31
Q

What does a 72 hour stool collection for fecal fat determine?

A

7-14 grams considered abnormal but not diagnostic

>14 grams considered indicative of fat malabsorption

GI (34 decks)

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