Acute Diarrhea

Question 1

Diarrhea vs acute Diarrhea vs chronic Diarrhea

Answer 1

Diarrhea: > 3 loose stools per day

Acute Diarrhea: < 2 weeks duration

Chronic Diarrhea: > 3 weeks duration

Question 2

Gastroenteritis

Answer 2

diarrhea w/ nausea & vomiting

Question 3

Dysentery

Answer 3

diarrhea w/ blood, mucus, pus

Question 4

Osmotic diarrhea / secretory diarrhea

Answer 4

Osmotic Diarrhea (sorbitol): solutes in lumen draw/keep water in lumen

Secretory Diarrhea (Cholera): intestinal secretion of solutes and water into lumen

Question 5

when to use diagnostics for diarrhea

Answer 5

Diagnostics: reserved for severe dehydration or illness, persistent fever, bloody stool, immunosuppression, cases of suspected nosocomial infection or outbreak

Question 6

antibiotics should be considered for which pathogens

Answer 6

shigella, campylobacter, Clostridioides difficile, traveler’s diarrhea, protozoal infections

Question 7

noninfectious / infectious diarrhea / infective colitis

Answer 7

Noninfectious diarrhea: lack of constitutional symptoms

Infectious diarrhea: large volume (often watery) stool, constitutional symptoms, nausea/vomiting/abdominal cramps (gastroenteritis)

Infectious colitis: fever, tenesmus, and dysentery

Question 8

Non-inflammatory Diarrhea

general
Sx and pathogens

Answer 8

Usu viral (some bacterial, parasitic)
Intestinal secretion, mucosa intact (cells are not damaged)
No fever, no blood in stool
No fecal leukocytes

Norovirus, rotavirus, Cholera, enterotoxigenic E coli, Staph aureus, Giardia…

Question 9

inflammatory diarrhea

General
Sx and pathogens

Answer 9

Usu invasive, toxin-producing bacteria
Mucosa damaged (hence blood and WBCs)
Fever, bloody stool
Fecal leukocytes

Shigella, Campylobacter, C diff, some Salmonella, Shiga-toxin E coli

Question 10

High Yield Associations of Diarrhea

Daycare

Answer 10

Rotavirus common
Multiple pathogens possible

Question 11

High Yield Associations of diarrhea

Travel

Answer 11

Enterotoxigenic E coli (ETEC)
Norovirus outbreaks on cruise ships (and locally)

Question 12

High Yield Associations of diarrhea

Animals

Answer 12

Animals
Turtles, reptiles = Salmonella

Question 13

High Yield Associations of diarrhea

Food and water

Answer 13

Foods
Eggs & Dairy = Salmonella

Water (Camping)
Streams = Giardia

Question 14

Toxin-mediated “Food Poisoning”

Answer 14

Bacterial toxin
abrupt onset (1-8 hours after ingestion)
vomiting prominent (diarrhea minimal)
resolution usually < 24 hours

Question 15

E. Coli (ETEC) Classic “Traveler’s Diarrhea”

Answer 15

Contaminated food / water

Symptoms:
anorexia, cramps, watery diarrhea, low grade fever
may be nausea & vomiting—not prominent
no pus or bloody stools

Question 16

Rotavirus

general

this baby needs IV hydration, ER time

Answer 16

Common cause of acute diarrhea hospitalizations in children

Winter prevalence

Viral shedding: 21 days

Acute onset, may be fever

vaccine available

Question 17

Noravirus

General

Answer 17

Common cause of
diarrheal epidemics

Acute onset:
nausea & vomiting
watery diarrhea
abdominal cramps
lasts 1-3 days

Question 18

If blood is present you culture, possible offenders?

Answer 18

Campylobacter
Salmonella
Shigella
E. coli / E. coli O157:H7

Question 19

Campylobacter

general and Sx

Answer 19

Common Bacterial Pathogen
contaminated food (poultry)
contact with fecal material/animal-to-person

Symptoms:
diarrhea +/- blood
abdominal cramps / pain
fever
usually self-limited—may not require antibiotics

Question 20

Salmonella

General and Sx

Answer 20

Common in children < 4 years old
contaminated food (poultry)
infected animals (turtles)

Symptoms:
fever
diarrhea +/- blood
abdominal cramping/pain
usually self-limited—usually does not require antibiotics

Question 21

Shigella

general and Sx

Answer 21

“Shiga toxin”— toxic to enterocytes

Symptoms:
fever
abdominal cramps/pain
tenesmus–mucoid stools +/- blood
abx shorten duration of illness, limit fecal shedding

Question 22

E. Coli O157: H7 (Shiga toxin)

general and Sx

Answer 22

Contaminated food / water

Symptoms:
bloody diarrhea– not typical Traveler’s Diarrhea
severe abdominal cramps
high fever (> 101.3)
do not use abx, abx increase risk of complications (HUS)

Question 23

Clostridium difficile (C diff)

general

Answer 23

Associated with antibiotic use
Major diarrhea cause in pts hospitalized >3 days (consider in all hospitalized patients with unexplained leukocytosis)

Greenish, foul, watery diarrhea 5–15 x daily, rarely bloody;
PE: normal or mild LLQ tenderness.

Question 24

C diff

PE findings

Answer 24

PE: normal or mild LLQ tenderness.
Severe/fulminant: profuse diarrhea (≥ 30 stools/day); PE: fever; hemodynamic instability; abdominal distention, pain, tenderness

Question 25

# C Diff Labs

Answer 25

Labs suggestive of severe = WBC >30,000, albumin < 2.5 (due to protein-losing enteropathy), elevated serum lactate, rising Cr Stool toxin/antigen assay

Question 26

# C diff CT

Answer 26

Noncontrast abdominal CT scans if severe/fulminant to look for colonic dilation and wall thickening

Question 27

Question 28

Answer 28

C diff increases risk for toxic mega colon

Question 29

# C diff Tx

Answer 29

Complex antibiotic decision tree Prevention: minimize antibiotic use, don’t suppress gastric acid

Question 30

parasites

Answer 30

Contaminated food, water, person Gradual onset, can be chronic Watery, persistent, non-bloody diarrhea Vomiting not prominent Malabsorption Foul smelling stool Weight loss Giardia, Entamoeba histolytica, Cryptopsporidium

Question 31

Symptoms that call for workup / culture

Answer 31

Usually not, but some exceptions: weight loss / dehydration bloody diarrhea severe abdominal pain recent abx use immune suppressed/ associated illness/ elderly high fever (> 101.3) Shigella, campylobacter, C diff, severe traveler's diarrhea, protozoal infections – NO ANTIOBIOTICS for E. Coli O157: H7

Question 32

Workup options

Answer 32

Stool culture, Giardia antigen testing, O&P Fecal leukocytes/Fecal lactoferrin C diff testing CBC with diff Electrolytes Renal function testing

Question 33

Tx options for diarrhea

Answer 33

Oral rehydration therapy/early refeeding for dehydration IV fluids as needed Avoid antimotility agents if bloody diarrhea Probiotics? may shorten duration of sx | probiotics should be 11 billion CFU

Question 34

Anti-motility Meds

Answer 34

For symptomatic relief if: no significant fever non-bloody stools Agents: Loperamide (OTC) Pepto-Bismol (OTC) Kaopectate (OTC) Lomotil (Rx) = narcotic + atropine

Question 35

# Diarrhea when to admit

Answer 35

ADMIT if: Severe dehydration / unstable VS Bloody diarrhea with anemia Severe abdominal pain & recent abx use Significant comorbidities

Question 36

Question 37

# N/V general

Answer 37

Acute symptoms = usually infectious, inflammatory, or iatrogenic Most infections self-limiting and require minimal intervention; iatrogenic causes resolved by removing offending agent

Question 38

# N/V Chronic Sx

Answer 38

Chronic symptoms - variety of conditions GI: obstruction, functional disorders, organic diseases CNS: increased intracranial pressure (typically additional neurologic signs) Pregnancy - most common endocrine cause of nausea, consider in any woman of childbearing age Metabolic abnormalities, psychiatric diagnoses Evaluation: focus on detecting emergencies or complications that require hospitalization

Question 39

# N/V when cause is not certain

Answer 39

When cause not certain, empiric therapy with antiemetic is appropriate Initial diagnostic testing should be limited to basic labs and plain radiography. Further testing, such as EGD or CT of abdomen, should be determined by clinical suspicion based on complete Hx and PE

Question 40

Colic

Answer 40

Sharp, localized abdominal pain that increases, peaks, and subsides Associated with numerous diseases of hollow viscera Mechanism of pain: smooth muscle contraction proximal to partial or complete obstruction (gallstone, kidney stone, small bowel obstruction) Location may help diagnose cause Absence of colic useful for ruling out acute cholecystitis (only < 25% of patients with acute cholecystitis present without RUQ colic)