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Diarrhea Flashcards

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1
Q

What are the drugs that commonly cause diarrhea?

A 
Acarbose/miglitol
Abx
Anti-neoplastics
Colchicine
Dig
Laxatives
Synthroid (over replacement)
Metocopramide
NSAIDs
Prostaglandins (misoprostol)
Orlistat
Sorbitol
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2
Q

What is a watery stool?

A

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

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3
Q

What causes watery stools?

A

Vibrio cholera
Non-hemorrhagic E Coli
Rotovirus
Norovirus

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4
Q

What is dysentrey?

A 
Mucus and/or blood in the stool
Many polymorphonucleocytes (PMNs) in stool
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5
Q

What causes dysentery?

A 
Shigella
Salmonella
Campylobacter
Yersinia
Hemorrhagic E Coli
Clostridium difficile
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6
Q

What are the different names for hemorrhagic E Coli?

A

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

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7
Q

What is acute diarrhea?

A

< 3 days duration

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8
Q

What is persistent diarrhea?

A

4 days to 4 weeks?

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9
Q

What is chronic diarrhea?

A

> 4 weeks (rarely infectious, most commonly parasitic)

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10
Q

What are the common populations for shigella?

A

Common in crowded conditions (ie daycare)

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11
Q

What are the common populations for Cryptosporidium parvum?

A

Swimming pools

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

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12
Q

What are the common causes for cryptosporidium parvum, EHEC?

A

Pools

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13
Q

What are the common causes for campylobacter?

A

Exposure to birds, cats, and household chickens

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14
Q

What are the common causes for cholera?

A

Undercooked seafood

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15
Q

What are the common causes for campylobacter, EHEC)

A

Red meat

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16
Q

What are the common causes for EHEC ETEC?

A

Fruits and vegetables

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17
Q

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

A

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

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18
Q

What are anti-diarrheal agents?

A 
Opioid agents
Tincture of opium
Kaolin &amp; Pectin
Bile salt-binding resins
Somatostatin and Octreotide
Fiber supplements
Probiotics
Clonidine
Verapamil
Teduglutide (Gattex)
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19
Q

What is the MOA of opioid agonists in antidiarrheal agents?

A

Decrease motility of intestinal smooth muscle

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20
Q

What are the types of opioid agonists and clinical pearls?

A

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

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21
Q

What are tinctures of opiums?

A

Colloidal bismuth compounds - bismuth subsalicylate

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22
Q

What is the MOA of bismuth subsalicylate?

A

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)

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23
Q

What are ADRs of bismuth subsalicylates?

A

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

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24
Q

What is the MOA of Kaolin and Pectin?

A

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

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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

GI/Hepatic (7 decks)

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