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Flashcards in Diarrhea Deck (79):
1

What are the drugs that commonly cause diarrhea?

Acarbose/miglitol
Abx
Anti-neoplastics
Colchicine
Dig
Laxatives
Synthroid (over replacement)
Metocopramide
NSAIDs
Prostaglandins (misoprostol)
Orlistat
Sorbitol

2

What is a watery stool?

Does not have blood or mucus in it
Profuse fluid and electrolyte loss
Fever mild or absent
None or few fecal polymorphonucleocytes (PMNs) in stool

3

What causes watery stools?

Vibrio cholera
Non-hemorrhagic E Coli
Rotovirus
Norovirus

4

What is dysentrey?

Mucus and/or blood in the stool
Many polymorphonucleocytes (PMNs) in stool

5

What causes dysentery?

Shigella
Salmonella
Campylobacter
Yersinia
Hemorrhagic E Coli
Clostridium difficile

6

What are the different names for hemorrhagic E Coli?

EHEC
STEC
O157
Do not treat w/abx, makes it worse

7

What is acute diarrhea?

< 3 days duration

8

What is persistent diarrhea?

4 days to 4 weeks?

9

What is chronic diarrhea?

> 4 weeks (rarely infectious, most commonly parasitic)

10

What are the common populations for shigella?

Common in crowded conditions (ie daycare)

11

What are the common populations for Cryptosporidium parvum?

Swimming pools
Immunocompromised patients including household contacts, sexual partners, healthcare workers, and daycare workers

12

What are the common causes for cryptosporidium parvum, EHEC?

Pools

13

What are the common causes for campylobacter?

Exposure to birds, cats, and household chickens

14

What are the common causes for cholera?

Undercooked seafood

15

What are the common causes for campylobacter, EHEC)

Red meat

16

What are the common causes for EHEC ETEC?

Fruits and vegetables

17

What is the non pharmacologic management of non-infectious diarrhea?

Rehydration
Maintenance of water and electrolytes
As bowel movements decrease, a bland diet is begun

18

What are anti-diarrheal agents?

Opioid agents
Tincture of opium
Kaolin & Pectin
Bile salt-binding resins
Somatostatin and Octreotide
Fiber supplements
Probiotics
Clonidine
Verapamil
Teduglutide (Gattex)

19

What is the MOA of opioid agonists in antidiarrheal agents?

Decrease motility of intestinal smooth muscle

20

What are the types of opioid agonists and clinical pearls?

Loperamide - does not cross the BBB, so no analgesic properties or risk for addiction
Diphenoxylate/Atropine - CV controled substance, no analgesic properties but at high doses CNS effects and opioid dependence can occur. Atropine is included in the product to discourage OD

21

What are tinctures of opiums?

Colloidal bismuth compounds - bismuth subsalicylate

22

What is the MOA of bismuth subsalicylate?

Reduces stool frequency and liquidity in acute infectious diarrhea, due to salicylate inhibition of intestinal prostaglandin and chloride secretion. Bismuth has direct antimicrobial effects and binds enterotoxins (useful in traveler's diarrhea)

23

What are ADRs of bismuth subsalicylates?

Makes the tongue and stool black (harmless), avoid in renal insufficiency, caution in patients taking warfarin

24

What is the MOA of Kaolin and Pectin?

Kaolin - Hydrated magnesium aluminum silicate (clay)
Pectin - An indigestible carbohydrate derived from apples
Both - Act as absorbents of bacteria, toxins, and fluid decreasing stool liquidity and number

25

What drugs should not be given within 2 hours of other medications (which they may bind)?

Kaolin and pectin
Bil salt-binding resins

26

What are the bile salt-binding resins?

Cholestyramine/colestipol

27

What is the MOA of bile salt-binding resins?

Bind to bile salts to decrease colonic secretory diarrhea caused by excess fecal bile acids

28

What are the uses of bile salt-binding resins?

Fecal incontinence, liver dysfunction induced pruritus

29

What are the ADR of bile salt-binding resins?

Bloating
Flatulence
Constipation
Fecal impaction

30

What is the MOA of somatostatin and octreotide?

Inhibits gastrin, cholecystokinin, glucagon, growth hormone, insulin, secretin, vasoactive intestinal peptide, and 5-HT

31

What is the clinical pearl for somatostatin and octreotide?

Useful for secretory tumors that cause diarrhea (example pancreatic tumors)

32

When are fiber supplements most beneficial?

Hep C patients

33

What are types of fiber supplements?

Psyllium
Polycarbophil
Methylcellulose

34

What is the MOA for Fiber Supplements?

Alters texture of stool by gel formation and increased viscosity, improves water retention by stool

35

What are the ADRs for Fiber supplements?

Bloating
Abdominal fullness
Discomfort

36

What are the clinical pearls for fiber supplements?

Avoid in patients with a suspected bowel stricture
Useful for diarrhea with enteral nutrition, protease inhibitor induced diarrhea, chronic diarrhea of unknown etiology

37

What is the MOA of probiotics?

Live microorganisms that replace or re-establish a healthy microbiome

38

What are the ADRs of probiotics?

Generally considered safe
Caution is warranted in patients who are immunocompromised or in an ICU setting

39

What is clonidine's MOA?

Stimulates alpha-2-adrenergic receptors on enterocytes increasing fluid and electrolyte absorption and inhibiting secretion

40

What are the uses of clonidine in diarrhea?

Diarrhea associated with:
Narcotic withdrawal
Diabetic diarrhea
Chom
Graft vs host disease diasrrhea
Secretory diarrhea of unknown etiology

41

What are ADRs of clonidine?

Hypotension

42

What is the MOA of verapamil?

Blocks calckum channels to prevent calcium from stimulating electrolyte secretion

43

What is verapamil rarely used?

Hypotension

44

What is the MOA of teduglutide?

GLP-2 analog which prevents intestinal losses by increasing intestinal and portal blood flow and inhibiting gastric acid secretion

45

What is the use if teduglutide?

Approved for patients who have short bowel syndrome who are dependent on parenteral nutrition

46

Which bacteria are seeing FQ resistance world wide?

Campylobacter and Salmonella

47

What are the most common pathogens associated with traveler's diarrhea?

ETEC
Shigella
Campylobacter
Salmonella

48

What are the most common locations to get traveler's diarrhea?

Latin America
Southern Europe
Africa
Asia

49

How to prevent traveler's diarrhea?

Avoid high risk foods/beverages

50

What can be used for prophylaxis of traveler's diarrhea?

Bismuth sunsalicylate

51

What is the treatment for traveler's diarrhea?

Typically self-limiting (3-5 days)
Hydration
Antimotility agents (loperamide or diphenozylate)
Abx
Bismuth subsalicylate is an option

52

What is Clostridium difficile infection (CDI)?

G+ spore-forming bacteria
Produces toxins A and B that cause illness

53

How is CDI transmitted?

Fecal-oral route
In healthcare: environmental surface contamination and hand carriage

54

What are CDI risk factors?

Exposure to abx
Exposure to organism
Age > 65
Others: GI tract surgery, PPIs, IBD

55

What are high risk abx for CDI?

Clindamycin
2nd and 3rd generation cephalosporins
FQs
Carbapenems
Beta lactams

56

What are s/sx of CDI?

Foul smelling, watery stools
Abdominal pain
Low-grade fever
Malaise and anorexia

57

What are IDSA/SHEA guidelines for mild/moderate CDI?

WBC < 15,000 and SCR < 1.5x pre-CDI level

58

What are IDSA/SHEA guidelines for severe CDI?

WBC >/= 15,000 or SCR >/= 1.5 x pre-CDI level

59

What are IDSA/SHEA guidelines for severe/complicated CDI?

Severe plus hypotension/shock, ileus, megacolon

60

What are ACG guidelines for mild/moderate CDI?

Albumin >/= 3 or WBX = 15,000 and NO ab tenderness

61

What are ACG guidelines for severe CDI?

Ablumin < 3 PLUS WBX > 15,000 or ab tenderness

62

What are ACG guidelines for severe/complicated CDI?

Attrutable to cDI: ICU admission, hypotension, fever > 38.5C, ileus/ab distention, mental status changes, WBC > 35,000 or < 2,000, lactate > 2.2

63

What is the diagnosis for CDI?

Real-time PCR for toxin B (repeat test after engative result if high suspicion)
Endoscopy (not common)
Ribotyping

64

Who should be tested for CDI?

Only stool from patients with diarrhea
All patients with IBD hospitalized with a disease flare or who suddenly develop diarrhea in the ambulatory setting
Pregnant females who develop diarrheal illness

65

What are CDI infection controls and preventions?

Abx stewardship program is recommended
Insufficient evidence that probiotics prevent CDI
Private room or in a room with another patient with documented CDI
Contact precautions and hand hygeine
Disinfection of surfaces with chlorine agents

66

What are ACG guideliens for treatment of mild-moderate CDI?

Flagyl 500 mg Po TID x 10

67

What are the IDSA/SHEA guidelines for treatment of mild-moderate ICD?

Flagyl 500 mg Po TID x 10-14 days

68

What are ACG guidelines for treatment of severe ICD?

Vanc 125 mg PO QID x 10 days

69

What are the IDSA/SHEA guidelines for treatment of severe ICD?

Van 125mg po QID x 10-14 days

70

What are ACG guidelines for treatment of severe/complicated CDI?

Vanc 500mg PO QID +
Flagyl 500mg IV q8h +
Vanc 500 mg per rectum in 500ml QID

71

What are the IDSA/SHEA guidelines for treatment of severe/complicated CDI?

Vanc 500mg PO QID +
Flagyl 500mg IV q8h
(Vanc 500 mg per rectum in 500ml QID if complete ileus)

72

What are the ACG guidelines for treatment of recurrent CDI events?

Initial - repeat course
2nd episode - Vanc taper
3rd episode - fecal transplant

73

What are the IDSA/SHEA guidelines for treatment of recurrent CDI events?

Initial - repeat course
Mutlitple - vanc taper

74

What is considered a recurrent CDI event?

Repeated episode within 8 weeks

75

What is the MOA of flagyl?

Inhibition of bacterial protein synthesis

76

What are common ADRs of flagyl?

Metallic taste
Disulfuram reaction (avoid EtOH)
Nausea (take with food)
Vomiting
Tingling in hands/feet

77

What is the MOA of Vanc?

Inhibits bacterial cell wall synthesis

78

What is fidaxomicin's MOA?

Inhibits RNA polymerase to cause cell death

79

What type of agent should be avoided in CDI?

Anti-peristaltic agents
If used, must be accompanied by abx