Diarrhea Flashcards by MA CARMELA CONCEPCION SALES

_______ is defined as an intestinal disorder
characterised by abnormal frequency and liquidity of
faecal evacuations

Diarrhoea

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In Australia most infective cases of diarrhea are _____

viral

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Disorders of the ______ tend to produce
diarrhoea stools that are copious, watery or fatty,
pale yellow or green

upper GIT

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______ tends to produce stools that are
small, of variable consistency, brown and may
contain blood or mucus

Colonic disorder

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T or F

Acute gastroenteritis should be regarded as a
diagnosis of exclusion

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Chronic diarrhoea is more likely to be due to

_______than bacillary dysentery

protozoal infection (e.g. amoebiasis, giardiasis or
Cryptosporidium )

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Certain antibiotics can cause an overgrowth
of Clostridium difficile, which produces
__________

pseudomembranous colitis

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Diarrhoea can be classified broadly into

4 types:

— acute watery diarrhoea
— bloody diarrhoea (acute or chronic)
— chronic watery diarrhoea
— steatorrhoea

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Red flag pointers for diarrhoea

Unexpected weight loss
Persistent/unresolved
Fever
Overseas travel
Severe abdominal pain
Family history: bowel cancer, Crohn disease

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Important causes of chronic infectious diarrhea

Giardia lamblia, C. difficile, Yersinia, Entamoeba

histolytica, Cryptosporidium and HIV infection

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In children, ________can present as chronic diarrhoea while intussusception, although not causing true diarrhoea, can present as loose, redcurrant jelly-like stools and should not be misdiagnosed (as gastroenteritis

coeliac disease and fibrocystic disease

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Infection with enterohaemorrhagic strains
of E. coli (e.g. O157:H7, O111:H8) may lead to
the _____ or ______ particularly in children.

haemolytic uraemic syndrome or thrombotic

thrombocytopenic purpura,

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Death cap mushroom (the world’s most lethal)—
_________ —causes severe
gastroenteritis followed by delayed hepatic failure
and AKF

Amanita phalloides

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General pitfalls
• Not considering acute appendicitis in acute
diarrhoea—can be _______
• Missing _______ with spurious diarrhoea
• Failing to consider _________ in an
elderly patient with the acute onset of bloody
diarrhoea stools (following sudden abdominal
pain in preceding 24 hours)

retrocaecal or pelvic appendicitis

faecal impaction

acute ischaemic colitis

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This colitis can be caused by the use of any antibiotic,
especially clindamycin, lincomycin, ampicillin and
the cephalosporins (an exception is vancomycin

Pseudomembranous colitis (antibioticassociated
diarrhoea

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Cause of Pseudomembranous colitis

overgrowth of C. difficile, which
produces a toxin that causes specific inflammatory
lesions, sometimes with a pseudomembrane

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Character of Pseudomembranous colitis

• Within 2 days of taking antibiotic (can start up to
4 to 6 weeks after usage)
• Persists 2 weeks (up to 6) after ceasing antibiotic

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Mx of Pseudomembranous colitis

Cease antibiotic
Mild to moderate: metronidazole 400 mg (o) tds
for 10 days
Severe: vancomycin 125 mg (o) qid for 10 days
(in consultation with specialist

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The________ which is a
very common condition, may reflect underlying
psychological factors and most patients find that
the symptoms are exacerbated by stress

irritable bowel syndrome,

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In children chronic diarrhoea can occur with the socalled
______ characterised
by growth and developmental retardation due to
adverse psychosocial factors

‘maternal deprivation syndrome’,

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Central colicky abdominal pain indicates involvement
of the _____, while lower abdominal pain points
to the_____

small bowel

large bowel

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If small volume, consider ________

of colon; if large volume, consider ______

inflammation or carcinoma

laxative abuse and
malabsorption

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If there is profuse bright red bleeding, consider
____________, and if small
amounts with mucus or mucopus consider
______

diverticulitis or carcinoma of colon

inflammatory bowel disorder

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In______ the stools are distinctively pale,
greasy, offensive, floating and difficult to flush. It is
exacerbated by fatty foods.

steatorrhoea

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______stool is characteristic of cholera and | _______ stool of typhoid fever.

‘Rice water’ ‘pea soup’

Loose with bits of faeces Watery, offensive, bubbly ____ Liquid or semiformed, mucus ± blood_____ Bulky, pale, offensive ______ Pellets or ribbons ____

Colonic disorder Giardia lamblia infection Entamoeba histolytica Malabsorption Irritable bowel syndrome

``` China clay _______ Black stool _____ Pea soup _______ Rabbit pellets ______ Redcurrant jelly________ Rice water ______ Silver stool ______ Toothpaste ______ ```

``` Obstructive jaundice Melaena (blood) in faeces Typhoid fever Irritable bowel syndrome Intussusception Cholera Carcinoma of ampulla of Vater Hirschsprung disease ```

It must be emphasised that______are never indicated for management of acute diarrhoea in infants and children

antimotility | drugs

Common causes of malabsorption syndromes

coeliac disease, chronic pancreatitis and postgastrectomy

Vitamin deficiencies associated with malabsorption

ADEK

What type of anemia associated with malabsorption

Hypochromic or megaloblastic anaemia

What is the pathology causing malabsorption Gluten-sensitive enteropathy (coeliac disease) Tropical sprue Lactose intolerance (lactase deficiency) Crohn disease (regional enteritis) Whipple disease Parasite infections (e.g. Giardia lamblia) Lymphoma

Primary mucosal disorders

Non-GIT presentation of Celiac disease

tiredness.

diarrhoea, weight loss, iron/folate deficiency, abdominal bloating Diarrhoea with constipation (alternating) Pale and thin patient No subcutaneous fat

Coeliac disease

Celiac disease Characteristic duodenal biopsy: ____ (key test

villous atrophy

Ab testing in Celiac disease • _______ (screening—limited) • _______ (>90% sensitivity and specificity _________ (>90% sensitivity and specificity)

IgA antigliadin antibodies IgA anti-endomysial antibodies IgA transglutaminase antibodies

``` Associations of Celiac dse 1 2 3 4 5 6 7 8 9 10 11 12 ```

``` • Iron-deficiency anaemia • Type 1 diabetes • Pernicious anaemia • Primary biliary cirrhosis • Subfertility • Malignancy, especially lymphoma • Dermatitis herpetiformis • IgA deficiency • Autoimmune thyroid disease • Osteoporosis • Neurological (e.g. seizures, ataxia, peripheral neuropathy) • Down syndrome ```

What type of diet in Celiac disease

high complex carbohydrate and protein, low fat, gluten-free (no wheat, barley, rye and oats)

What vaccination in Celiac

Give pneumococcal vaccination (increased risk of | pneumococcus sepsis)

This is a rare malabsorption disorder usually affecting | white males. It may involve the heart, lungs and CNS.

Whipple disease

Causative agent of Whipple disease

It is caused by the bacillus Tropheryma | whipplei.

Type of Arthralgia in Whipple

Arthralgia (migratory seronegative arthropathy | mainly of peripheral joints

Dx of Whipple

* PCR for T. whipplei | * Jejunal biopsy—stunted villi

Tx of Whipple

IV ceftriaxone for 2 weeks then cotrimoxazole or | tetracycline for up to 12 months

This is due to atheromatous occlusion of mesenteric | vessels (low blood flow)

Ischaemic colitis

PE of ischemic colitis

maybe loud bruits over central abdomen | • other evidence of generalised atherosclerosis

Barium enema of ischemic colitis

‘thumb printing’ sign due | to submucosal oedema

Definitive test for ischemic colitis

the definitive test is aortography and selective | angiography of mesenteric vessels

MC cause of diarrhea in children

infective gastroenteritis and antibiotic-induced diarrhoea

__________from gastroenteritis is an important cause of death, particularly in obese infants (especially if vomiting accompanies the diarrhoea

Dehydration

It is an illness of acute onset, of less than 10 days’ duration associated with fever, diarrhoea and/or vomiting, where there is no other evident cause for the symptoms

Acute gastroenteritis

AGE causes ``` Mainly ______ (developed countries) and ______: viruses account for about 80% ```

rotavirus adenovirus

MC bacterial causes Bacterial: _____________. (two commonest), E. coli and Shigella sp.

C. jejuni and Salmonella sp

Diarrhoea often follows acute gastroenteritis when | milk is reintroduced into the diet

Sugar/CHO/Lactose intolerance

Character of stools for Lactose intolerance

Stools may be watery, frothy, smell like vinegar and tend to excoriate the buttocks. They contain sugar.

Study management of acute diarrhea in children

Okay

Simple test for glucose intolerance

Line the napkin with thin plastic and collect fluid stool. • Mix 5 drops of liquid stool with 10 drops of water and add a Clinitest tablet (detects lactose and glucose but not sucrose). • A positive result indicates sugar intolerance.

dx of lactose intoleranc

lactose breath hydrogen test

A clinical syndrome of loose, bulky, non-offensive stools with fragments of undigested food in a well, thriving child. The onset is usually between 8 and 20 months. Associated with high fructose intake (fruit juice diarrhoea).

Toddler’s diarrhoea

This is not as common as lactose intolerance. Diarrhoea is related to taking a cow’s milk formula and relieved when it is withdrawn

Cow’s milk protein intolerance

These disorders, which include Crohn disease and | ulcerative colitis, can occur in childhoo

Inflammatory bowel disorders

Organisms for chronic enteric infection

Responsible organisms include Salmonella sp., | Campylobacter, Yersinia, G. lamblia and E. histolytica.

____________-- can | mimic coeliac disease.

Giardiasis

The symptoms are usually as above but very severe diarrhoea, especially if associated with blood or mucus, may be a feature of a more serious bowel infection such as amoebiasis

Traveller’s diarrhoea

Most traveller’s diarrhoea is caused by ______, which produces a watery diarrhoea within 14 days of arrival in a foreign country.

E. coli

Any traveller with persistent diarrhoea after visiting less developed countries, especially India and China, may have a protozoal infection such as ____ and ________----

amoebiasis or | giardiasis

_______ is characterised by abdominal cramps, flatulence and bubbly, foulsmelling diarrhoea.

Giardiasis

MX of diarrhea in adults How to hydrate (moderate)

use oral rehydrate solution 2–3 L orally | over 24 hours if mild to moderate dehydration

How to hydrate severe dehydration

intravenous rehydration with N saline is | recommended

Abx for Shigella dysentery (moderate to severe

Cotrimoxazole (double strength) 1 tab (o) 12 hourly for 5 days: use in children (children’s doses) or norfloxacin 400 mg (o) 12 hourly for 5 days (preferred for adults) or ciprofloxacin 500 mg (o) bd for 5 days

Abx for Giardiasis

Tinidazole 2 g (o), single dose (may need repeat) or metronidazole 400 mg (o) tds for 7 days (in children: 30 mg/kg/day [to max. 1.2 g/day] as single daily dose for 3 days)

T or F Salmonella enteritis Antibiotics are not generally advisable but if severe or prolonged use:

Abx for Salmonella enteritis

ciprofloxacin 500 mg (o) bd for 5–7 days or azithromycin 1 g (o) day, then 500 mg for 6 days or ceftriaxone IV or ciprofloxacin IV if oral therapy not tolerated

Salmonella is a notifiable disease; infants under____________are at risk of invasive Salmonella infection

15 months

A zoonosis that is usually self-limiting. Antibiotic therapy indicated in severe or prolonged cases

Campylobacter

Abx for Campylobacter

azithromycin 500 mg (o) 12 hourly for 3 days or ciprofloxacin 500 mg (o) 12 hourly for 3 days or norfloxacin 400 mg (o) 12 hourly for 5 days

Usually self-limiting, may need fluid and electrolytes and anti-motility agents. If severe, nitazoxamide What organism?

Cryptosporidium species

Pathogenicity is disputed: give therapy only if severe. Associated with poor hygiene (travel, pets, dam/tank water, oysters).

Blastocystitis hominis (a parasitic infection

Mx of Blastocystitis hominis (a parasitic infection

metronidazole for 7 days

Abx for typhoid/paratyphoid fever

azithromycin 1 g (o) daily for 7 days or (if not acquired in the Indian subcontinent or SE Asia) ciprofloxacin 500 mg (o) 12 hourly for 7–10 days (use IV if oral therapy not tolerated)

If ciprofloxacin is contraindicated (e.g. in children) | or not tolerated, then use:

ceftriaxone 3 g IV daily until culture and | sensitivities available, then choose oral regimens

Tx of Cholera

azithromycin 1 g (child 20 mg/kg up to 1 g)(o) as a single dose or ciprofloxacin 1 g (o) as a single dose

Tx of Cholera For pregnant women and children

amoxycillin (child: 10 mg/kg up to) 250 mg (o) | 6 hourly for 4 days

Ulcerative colitis Begins in rectum (continues proximally)—affects only the colon: it usually does not spread beyond ______

the ileocaecal valve

Ulcerative colitis increased risk of carcinoma after _____

7–10 years

Dx of Ulcerative colitis ________: a sensitive test _________: a granular red proctitis with contact bleeding Barium enema: characteristic changes

Faecal calprotectin Proctosigmoidoscopy

Prognosis of UC

* 5% mortality in an acute attack | * Recurrent attacks common

regional enteritis, granulomatous colitis. The cause is unknown but there is a genetic link.

Crohn disease

Signs of Crohn disease

Signs include perianal disorders (e.g. anal fissure, | fistula, ischiorectal abscess), mouth ulcers

Describe skip areas of crohns

Skip areas in bowel: ½ ileocolic, ¼ confined to | small bowel, ¼ confined to colon, 4% in upper GIT

Sigmoidoscopy findinfs Crohn disease

‘cobblestone’ appearance (patchy | mucosal oedema)

_____: useful to differentiate from UC

Colonoscopy

Tx for UC ________mainly UC): sulfasalazine (mainstay), olsalazine, mesalazine — corticosteroids (mainly for acute flares): oral, parenteral, topical (rectal foam, suppositories or enemas) — for severe disease, ___ and ____

5-aminosalicylic acid derivatives ( immunomodifying drugs (e.g. azathioprine, cyclosporin, methotrexate) and biological agents (e.g. infliximab

Alternating diarrhoea and constipation are wellknown | symptoms of_____ and _____

incomplete bowel obstruction (cancer of colon and diverticular disease) and irritable bowel syndrome

Dx criteria for IBS In the preceding 3 months, the patient has had abdominal discomfort for at least 3 days per month with two of the following three features: 1 2 3

``` • relieved by defecation • onset associated with a change in stool frequency • onset associated with a change in form (appearance) of stool (loose, watery or pellet-like) ```

Red flag pointers for non-IBS disease

* Age of onset >50 years * Fever * Unexplained weight loss * Rectal bleeding * Pain waking at night * Persistent daily diarrhoea/steatorrhoea * Recurrent vomiting * Major change in symptoms * Mouth ulcers * ↑ CRP, ESR * Anaemia * Family history bowel cancer or IBD

What is the FODMAP diet for IBS

fermentable oligosaccharides, disaccharides, monosaccharides and polyols, which are poorly absorbed

________ is a problem of the colon (90% in descending colon) and is related to lack of fibre in the diet. It is usually symptomless

Diverticular disorder

Diverticular DO Sx

* Constipation or alternating constipation/diarrhoea * Intermittent cramping lower abdominal pain in LIF * Tenderness in LIF

Oral antidiarrhoeal drugs are contraindicated | in children; besides being ineffective they may prolong ________

intestinal recovery

_____can readily provoke dystonic reactions | in children, especially if young and dehydrated.

Anti-emetics

Acute diarrhoea is invariably self-limiting (lasts | 2–5 days). If it lasts longer than 7 days, investigate with______

culture and microscopy of the stools

If diarrhoea is associated with episodes of | facial flushing or wheezing, consider

carcinoid | syndrome.

Recurrent pain in the right hypochondrium is | usually a feature of ________

IBS (not gall bladder disease

Recurrent pain in the right iliac fossa is more likely to be______

IBS than appendicitis

Undercooked chicken is a common source of | _____

enteropathic bacterial infection.

Consider_______ if a patient’s diarrhoea | resolves spontaneously on hospital admission

alcohol abuse