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LMCC Part II > Diarrhea acute/chronic > Flashcards

Diarrhea acute/chronic Flashcards

1
Q

define diarrhea

A

passage of abnormally liquid or unformed stools at an increased frequency

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2
Q

define acute, persistent and chronic diarrhea

A

acute: lasting less than 2 weeks
persistent: 2-4 weeks
chronic: above 4 weeks in duration
* must distinguish between frequent passage of small volumes of stool often associated with rectal urgency and fecal incontinence (involuntary discharge of rectal contents)

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3
Q

what causes most cases of acute diarrhea

A

90% are caused by infectious agents

remaining 10% caused by toxic ingestions, ischemia and medications

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4
Q

list indications for evaluation of acute diarrhea

A

depends on severity and duration

indications:

  1. profuse diarrhea with dehydration
  2. grossly bloody stools
  3. temp at or above 38.5
  4. duration longer than 48 hours without improvement
  5. recent antibiotic use
  6. new community outbreaks
  7. associated with severe abdominal pain in patients older than 50
  8. elderly (above age 70)
  9. immunocompromised patients
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5
Q

what should you think about in a patient presenting with diarrhea and severe abdominal pain, and they are older than 50

A

ischemic colitis

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6
Q

what to ask on history for acute diarrhea

A

onset and duration of symptoms

frequency and characteristics of stool

fever

peritoneal symptoms

nausea/vomiting

occupational exposure

travel history

pets, hobbies

sick contacts

diet–> unpasteurized, raw/uncooked

recent antibiotic use, laxative use

medication history

past medical history

weight loss

steatohhrea vs. leukocytes

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7
Q

what should you ask about the quality of the stool

A

blood?
fatty?
profuse watery?
frequency?

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8
Q

what should you ask specifically on PMHx

A 
cancer
immunosuppression
UC
crohns
surgeries/short gut
chemotherapy
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9
Q

what to look for on physical exam in diarrhea

A

vitals–> signs of dehydration, general appearance

extra-intestinal manifestations of IBD

abdo exam and rectal exam

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10
Q

list some extra-intestinal manifestations of IBD

A

arthritis –usually large joints

ankylosing spondylitis (stiffness, pain in spine, pelvis)

erythema nodosum (raised, tender, red or violet swelling 1.5 cm in diameter usually on legs)

Sweet’s syndrome—tender red nodules on upper limbs, face and neck sometimes with fever

pyoderma gangrenosum–small tender blisters that turn into deep ulcers

sores in mouth

episcleritis–red, sore, inflamed eye

scleritis

uveitis–inflammation of iris

kidney stones

gallstones

anemia

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11
Q

investigations to consider in acute diarrhea

A

CBCD, lytes, creatitine, urea

stool cultures–> C and S, O and P, C diff toxin

abdominal xrays

sigmoidoscopy

colonoscopy

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12
Q

treatment of acute diarrhea

A

fluid and electrolyte replacement therapy–PO vs IV depending on degree of dehydration

in moderately severe nonfebrile and non bloody diarrhea can consider antimotility and antisecretory agents such as loperamide to control symptoms

abx for travellers diarrhea, C diff or specific bacterial agents

diet modification

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13
Q

in which patients might loperamide/other antimotility and antisecretory agents be considered

A

moderately severe NONfebrile and NONbloody diarrhea

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14
Q

what usually causes chronic diarrhea

A

usually due to non infectious causes

diarrhea lasting more than 4 weeks warrants evaluation to exclude serious underlying pathology

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15
Q

what are the 5 classes of causes of chronic diarrhea

A
  1. secretory
  2. osmotic
  3. steatorrheal
  4. inflammatory
  5. dysmotility
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16
Q

list the secretory causes of chronic diarrhea

A 
stimulant laxatives
medications
bile acids
bowel resection (decreased absorption)
bowel obstruction
fecal impaction
hormone producing tumours (carcinoid, vipoma, gastrinoma)
addisons
congenital defects in electrolyte absorption
17
Q

what is the mechanism behind secretory diarrhea? how does it present?

A

due to derangements in fluid and electrolyte transport across the colonic mucosa

characterized by watery, large volume fecal outputs that are typically painless

persists with fasting

no stool/fecal osmolar gap

18
Q

list osmotic causes of chronic diarrhea

A 
osmotic laxatives 
magnesium containing antacids
health supplements
lactase deficiencies 
sorbitol, lactulose, polyethylene glycol
19
Q

what is the mechanism of osmotic diarrhea and how does it present

A

occurs when ingested, poorly absorbed, osmotically active solutes draw fluid into the lumen exceeding the absorptive capacity of the colon

ceases with fasting or with discontinuation of the causative agent

stool/fecal osmolar gap present (above 50mosm/l)

20
Q

list steatorrheal causes of chronic diarrhea

A

intraluminal maldigestion (pancreatic exocrine deficiency, bacterial overgrowth, bariatric surgery, liver disease)

mucosal malabsorption (celiac disease, whipples disease, infections, ischemia)

post mucosal obstruction (lymphatic disease)

21
Q

what is the mechanism of steatorrheal diarrhea and how does it present

A

fat malabsorption may lead to greasy, foul smelling, difficult to flush diarrhea often associated with weight loss and nutritional deficiencies due to concomitant malabsorption of amino acids and vitamins

stool fat exceeds 7g/day

22
Q

list causes of inflammatory chronic diarrhea

A

crohns
UC
immune related (immunodeficiencies, food, allergy, eosinophilic gastroenteritis)
infections (bacteria, viruses, parasites)
radiation injury
malignancies

23
Q

what is the mechanism of inflammatory diarrhea and how does it present

A

usually accompanied by pain, fever, bleeding or other manifestation of inflammation

usually leukocytes present in stool analysis

with severe inflammation you can have anasarca

24
Q

list causes of dysmotility chronic diarrhea

A

IBS
hyperthyroid
drugs–prokinetics
post vagotomy

25
Q

what is the mechanism of dysmotility diarrhea

A

due to rapid transit

26
Q

what to ask specifically on history for chronic diarrhea

A 
B symptoms
systemic symptoms--joint pain, eye redness, mouth ulcers, rashes 
pain aggravated or relieved by BM
resolution with fasting 
occupation or travel exposure
27
Q

what investigations should be considered in chronic diarreah

A 
stool cultures
stool osmolar gap
anti TTG (celiac)
leukocytes in stool
stool fat analysis 
imaging/scopes

LMCC Part II (52 decks)

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