Diarrhea

Question 1

Define diarrhea

Answer 1

Passage of abnormally liquid or unformed stools at an increased frequency (3+/day)

Question 2

Define tenesmus

Answer 2

Painful rectal spasms w/a strong urge to defecate but little passage of stool

Question 3

Define dysentery

Answer 3

Abdominal pain, tenesmus, passage of bloody diarrhea

Question 4

Define hematochezia

Answer 4

Passage of bright red bloody stools

Question 5

What is the MC cause of acute diarrhea?

Answer 5

Infectious

Question 6

Define acute diarrhea

Answer 6

Less than 2 weeks of diarrhea

Question 7

What are the types of acute diarrhea?

Answer 7

• Inflammatory

- Non inflammatory

Question 8

Characteristics of non-inflammatory diarrhea

Answer 8

• Mild and self limited
• Watery
• NOT bloody
• A/w periumbilical cramps and bloating

Question 9

What does N/V with non-inflammatory diarrhea suggest?

Answer 9

Small intestine source (disrupts normal absorption and secretory process)

Question 10

Are fecal leukocytes present or absent in non-inflammatory diarrhea?

Answer 10

NOT present (tissue invasion does not occur)

Question 11

Etiologies of non-inflammatory diarrhea

Answer 11

• Viral (noro, rota)
• Protozoal (giardia, cyclospora)
• Bacterial (preformed enterotoxin production, enterotoxin production)

Question 12

What are common bacterial sources of non-inflammatory diarrhea?

Answer 12

• S. aureus, B. cereus, C. perfringens (preformed enterotoxin production)
• ETEC, vibrio cholerae (enterotoxin production)

Question 13

Define inflammatory diarrhea

Answer 13

• Colonic tissue damage occurs d/t bacterial or toxin invasion
• Fever and bloody/pus diarrhea
• A/w LLQ cramps, urgency, tenesmus

Question 14

What is the volume of inflammatory diarrhea?

Answer 14

Usually SMALL in volume b/c the organisms involve the colon

Question 15

What components are present in inflammatory diarrhea?

Answer 15

Fecal leukocytes or lactoferrin (d/t tissue invasion)

Question 16

Are fecal leukocytes present or absent in inflammatory diarrhea?

Answer 16

YES present, d/t tissue invasion

Question 17

Etiologies of inflammatory diarrhea

Answer 17

• Cytomegalovirus
• Entamoeba histolytica
• EHEC, V. parahaemolyticus, C. diff (cytotoxin production)
• Shigella, C. jejuni, Salmonella (mucosal invasion)

Question 18

What are some non-infectious causes of acute diarrhea?

Answer 18

• IBD/IBS
• Celiac
• Lactose intolerance
• Colorectal cancer
• Malabsorption
• Meds side effects

Question 19

How is mild dehydration characterized?

Answer 19

• Thirst, dry mouth
• Decreased sweat, urine
• Slight weight loss

Question 20

How is moderate dehydration characterized?

Answer 20

• Orthostatic BP changes
• Skin tenting
• Sunken eyes

Question 21

How is severe dehydration characterized?

Answer 21

• Lethargy
• Confusion
• Weak pulse
• Hypotension
• Shock

Question 22

What items should be avoided in the diet of someone with acute diarrhea?

Answer 22

• High fiber foods
• Fats
• Milk products
• Caffeine
• Alcohol

Question 23

What diet is encouraged as treatment of acute diarrhea?

Answer 23

BRAT (bananas , rice, applesauce, toast) diet

Question 24

What is the mainstay of treatment for acute diarrhea?

Answer 24

Rehydration (oral sugar-electrolyte solutions, IV fluids)

Question 25

How do probiotics treat acute diarrhea?

Answer 25

Currently being debated

Question 26

Which pharmacologic agents are given for comfort only in acute diarrhea?

Answer 26

Anti-diarrheal agents

Question 27

When are anti-diarrheal agents used to treat acute diarrhea?

Answer 27

- Mild to moderate - Symptomatic relief only - Opioid agents (like Imodium) - Bismuth subsalicylate (Pepto-Bismol)

Question 28

When should anti-diarrheal agents NOT be used in acute diarrhea?

Answer 28

Do NOT use in pts w/bloody diarrhea, high fever or systemic toxicity

Question 29

Describe antibiotic treatment of acute diarrhea

Answer 29

- Empiric NOT indicated for all pts | - Quinolones are PO drugs of choice

Question 30

Antibiotic treatment of acute diarrhea is recommended for which conditions?

Answer 30

- Shigellosis - Cholera - Extraintestinal salmonellosis - Traveler's diarrhea - C. diff - Giardia - Amebiasis

Question 31

Antibiotic treatment of acute diarrhea is NOT recommended for which conditions?

Answer 31

- Campylobacter - Shig-toxin-producing E. coli - Aeromonas - Yersinia * Except in severe disease

Question 32

What are prophylactic measures of infectious diarrhea?

Answer 32

- Hand hygiene - Travelers eat only hot/fresh food, boiled or treated water - Bismuth subsalicylate - Probiotic (MAY be effective) - Proph abx (not recommended unless at high risk) - Vaccines (rotavirus, S. typhi, V. cholerae)

Question 33

When are prophylactic antibiotics recommended for infectious diarrhea?

Answer 33

NOT recommended unless at high risk

Question 34

Define chronic diarrhea

Answer 34

- Diarrhea that is present for 4+ weeks | - Most are non-infectious

Question 35

Are most chronic diarrhea cases infectious or non-infectious?

Answer 35

Non-infectious

Question 36

Classifications of chronic diarrhea

Answer 36

- Secretory conditions - Osmotic diarrheas - Inflamm conditions - Malabsorptive conditions - Motility disorders - Factitious - Iatrogenic

Question 37

Define secretory chronic diarrhea

Answer 37

- Decreased fluid and electrolyte transport across enterocolonic mucosa - Watery, LARGE volume stools - NO change in symptoms w/fasting

Question 38

What can cause secretory chronic diarrhea?

Answer 38

- Persistent bacterial infections like C. diff, Giardia - Hormone producing tumors - Laxative abuse

Question 39

Define osmotic chronic diarrhea

Answer 39

- Ingestion or malabsorption of an osmotically active substance - Stool volume will DECREASE w/fasting - Osmotic gap present in stool

Question 40

What is the MC cause of chronic diarrhea in adults?

Answer 40

Lactase deficiency

Question 41

What are the MC causes of osmotic chronic diarrhea?

Answer 41

- Carb malabsorption (lactose, fructose) | - Mg containing antacids or laxatives

Question 42

What type of chronic diarrhea presents with large volume of watery stools? No changes in symptoms with fasting?

Answer 42

Secretory

Question 43

What type of chronic diarrhea results in a decrease of stool volume with fasting?

Answer 43

Osmotic

Question 44

Define inflammatory chronic diarrhea

Answer 44

- S/S of inflammation - Positive fecal leukocytes/lactoferrin - Caused by IBD, meds, immunodeficiency, malignancies

Question 45

Define malabsorption chronic diarrhea

Answer 45

- Weight loss, steatorrhea (greasy, foul smelling), and nutritional deficiencies - Osmotic gap present in stool - Positive fecal fat stain

Question 46

What type of chronic diarrhea shows osmotic gap in stool and positive fecal fat stain?

Answer 46

Malabsorption causes

Question 47

What is the MC cause of chronic diarrhea in young adults?

Answer 47

IBS

Question 48

What type of chronic diarrhea would be caused by an underlying systemic disease or prior abdominal surgery?

Answer 48

Motility disorders

Question 49

Define factitious causes of chronic diarrhea

Answer 49

- 15% of unexplained diarrheas - Munchausen's syndrome - Eating disorders

Question 50

What type of chronic diarrhea presents with really greasy, foul-smelling stool?

Answer 50

Malabsorption causes

Question 51

What warrants further evaluation when diagnosis chronic diarrhea?

Answer 51

- Nocturnal diarrhea - Weight loss - Anemia - Positive FOBT

Question 52

What diagnostic test is required in patients with bloody stool?

Answer 52

Colonoscopy with biopsy

Question 53

Treatment of chronic diarrhea

Answer 53

- Depends on underlying disorder | - Fluids and electrolytes for all

Question 54

Meds used for empirical therapy of chronic diarrhea

Answer 54

- Loperamide - Diphenoxylate w/atropine - Codeine and deodorized tincture of opium - Clonidine - Cholestyramine