Diarrhea Flashcards
(22 cards)
What are the symptomatic and physiologic definitions of diarrhea?
Symptomatic: increased frequency, fluidity, or volume or some combination of these
Physiologic: decreased absorption or increased secretion, or usually both, causing greater than 200 mL liquid excretion per day
What are the 7 classifications considered when working through diarrhea?
- Diarrhea versus not diarrhea
- Acute versus chronic
- Infectious versus non-infection
- Osmotic versus Secretory
- Inflammatory versus non-inflammatory
- Large intestine versus small intestine
- Drugs
What are three Not-diarrheas to consider when determining if a patient has diarrhea?
- Pseudo diarrhea : May be liquid or frequent, but not enough volume or frequent enough to total over 200 g/day. Could be associated with rectal urgency in IBS or proctitis
- Fecal Incontinence: involuntary discharge or rectal contents. Most often a neuromuscular disorder or structural ano-rectal problems
- Overflow diarrhea: constipation leads to fecal impaction which leads to watery leakage around the impaction. More common in nursing home patients
What are the duration definitions of acute versus chronic diarrhea?
What are special concerns accompanying these?
Acute diarrhea: less than 2 weeks
90% is infectious
remaining is due to medications, toxic ingestions, ischemia, or food allergies
Chronic diarrhea: over 4 weeks
rarely infectious
What are clinical clues hinting toward infectious diarrhea?
Non-infectious diarrhea?
Infectious
fever
blood or pus
epidemic or travel (ETEC more common in Egypt and South America, Campylobacter more common in Thailand, Salmonella more common in Thaland, Shigella also a disease I guess)
Non-infectious
afebrile
no blood or mucous
sporadic
no travel
What is the difference between osmotic and secretory diarrhea?
How would you expect fasting to affect diarrhea symptoms in both scenarios?
What would you expect of the osmotic gap?
What scenario would cause the pH to drop below 5.6?
Osmotic diarrhea: poorly absorbed osmotically active solutes in the gut
Fasting : diarrhea ceases
Osmotic gap : greater than 50 mOsm/kg
pH less than 5.6 ONLY with carbohydrate malabsorption
Secretory diarrhea: increased chloride and water secretions with/without abnormal active sodium and water absorption
Fasting : diarrhea continues
Osmotic gap less than 50 mOsm/kg
What are some clinical clues distinguishing inflammatory from non-inflammatory diarrhea?
Inflammatory
Also common with infection: frequent, blood, pus, fever
Not commonly associated with infection: abdominal pain, tenesmus, fecal leukocytes (not very sensitive)
Non-inflammatory
Water stools
no blood, pus, fever, or fecal leukocytes
What are some common causes of diarrhea with fecal WBCs?
Crohn’s and ulcerative colitis (more chronic diarrhea)
C dif colitis
Shigellosis, Salmonellosis, Typoid fever
Invasive E. coli
Y. enterocolitica
V. parahemolyticus
What are some common causes of diarrhea without fecal WBCs?
giardiasis
Amebiasis
Viral enteritis
Toxigenic E. coli
Salmonella carrier
What are cliinical clues indicating large intestine problem?
Frequent urges
mushy and dark
rarely foul
LLQ pain
Tenesmus
Small volume
What are some clinical clues pointing to small intestine problem?
Watery and light colored
foul
periumbilical or RLQ pain
large volume
What are some disease processes that a small volume diarrhea could be indicative of?
Small volume
rectal and sigmoid disease - Ulcerative colitis, Ulcerative proctitis, Pseudo-diarrhea
Large volume
Osmotic - Lactase deficiency, laxatives, sprue
Secretory - Cholera, ETEC, Laxatives, Bile Acid Malabsorption
Dysmotility - Postgastrectomy syndrome, carcinoid, laxatives
Altered permeability - sprue
Ileal resection, chrohn’s, J-I bypass, radiation
What are some common causes of drug-induced diarrhea?
Nearly all medications may cause diarrhea
Laxatives
Antacids - magnesium is a stimulant
Antibiotics
Metformin - most common med to cause diarrhea
What are common causes of diarrhea that are contracted at day cares?
Giardia, cryptosporidium, Shigella
What previous surgeries often result in diarrhea?
Small intestinal disruption
Removal of terminal ileum
Cholecystectomy
Gastrectomy
Diarrhea + reactive arthritis
Diarrhea + hemolytic uremic syndrome
Diarrhea + reactive arthritis
salmonella, shigella
Campylobacter
Yersinia
C. dif
Diarrhea + hemolytic uremic syndrome
E.coli 0157: H7
S.typhi, C. jejuni, S. dysenteriae
vomiting/nausea with or without Diarrhea (less than 7 hours after eating)
Diarrhea (>8-14 hours after eating)
N/V with or without diarrhea (<7h)
preformed toxin - S.aureus(tater salad), B.cereus, and Anisakis
emetic syndrome
Diarrhea (>8-14h)
Toxins formed in GI tract - C.perfringens, B.cereus
diarrhea syndrome
What evaluation should be done on an individual with acute non-bloody diarrhea?
What symptoms would increase your liklihood for further testing?
What infections would you be looking for?
What could you take from history to get more clues?
Most acute non-bloody diarrhea is viral, has no complication and resolves on its own. Most don’t require work up and just recommend hydration.
Low fever and mild pain would maybe increase liklihood for infection screening.
ETEC, Giardia, Cryptococcus, C dif, Cholera, Norovirus, Rotavirus
Exposure to contaminated food, water or person. Drugs.
What would you order for a patient with acute bloody diarrhea?
What symptoms would make this more concerning?
What are the big 5 infectious agents you should check for?
What are 3 noninfectious things to check for?
stool culture and a flexible sigmoidoscopy
High fever and severe pain would increase concern
- Salmonella
- Shigella
- Campylobacter
- Ecoli 0157:H7
- Yersinia
Also check for IBD, vascular, or ischemic causes
What are the 3 goals of chronic diarrheal treatment?
- elimate the cause
- firm the stool
- treat the diarrhea-related complications
Diarrhea treatments include…
Bismuth (Kaopectate, Pepto)
Fiber - bulk stool
Loperamide (Imodium)
Atropine/diphenoxylate (Lomotil, prescription)
Octreotide - for severe diarrhea
