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Flashcards in Diarrhea and Constipation Deck (62):
1

What is the definition of constipation?
2

1. Passage of stool infrequently or with difficulty.
2. Stool frequency of less than three per week.

2

Characteristics passing the stool in constipation?
3

1. Straining
2. Hard Stool
3. Incomplete evacuation

3

1. What is the most common etiology of constipation?
2. What leads to this? 3

1. Lifestyle

2.
-Inadequate fiber in diet
-Inadequate hydration
-Inactivity

4

Fiber promotes what?
3

1. normal transit time,
2. frequent stools,
3. lower use of laxatives.

5

Medications that cause constipation?
9

1. Opiates/narcotics
2. Antidepressants
3. Calcium channel blockers
4. Antipsychotic
5. Antiparkinsonian agents
6. Anticholinergics
7. Calcium, iron supplements
8. Antispasmodics
9. Antacids (calcium and aluminum)

6

Structural Abnormalities that could lead to constipation
5

1. Carcinoma
2. Ischemia
3. Volvulus
4. Megacolon
5. Anorectal disorders

7

Anorectal disorders that lead to consitpation? 3

1. Prolapse
2. Rectocele
3. Pelvic floor dysfunction

8

Metabolic causes of constipation?
7

1. Hypokalemia
2. Hypomagnesemia
3. Hypothyroidism****
4. Hyperparathyroidism
5. Porphyria genetic hemoglobin disorder
6. Addison’s disease
7. Hypercalcemia

9

Neurologic causes of constipation?
7

1. Parkinson’s
2. Multiple Sclerosis
3. Automonic neuropathy
4. Hirschprung disease
5. Chagas disease
6. Spinal cord lesions
7. Cerebrovascular disease

10

Systemic causes of constipation? 4

1. Amyloidosis
2. Scleroderma
3. Polymyositis
4. Pregnancy

11

Surgical causes of constipation? 4

Psychiatric causes of constipation? 2

Surgical
1. Abdominal
2. Pelvic
3. Colonic
4. Anorectal

Psychiatric:
1. Depression
2. Eating disorders

12

Examination of constipation?
3

1. Full history
2. Full physical exam
3. DRE - Stool for occult blood

13

In patients less than 50y/o with no alarm symptoms, may start what?

empiric therapy

14

Further treatment should be performed on patients with any of the following:
6

1. Over age 50
2. Severe constipation
3. Signs of an organic disorder
4. Hematochezia
5. Weight loss
6. Positive FOBT

15

Consitipation evaluation?
4

1. KUB (abdominal xray),
2. Barium enema or
3. colonoscopy
4. Blood Tests
5. Colonic Transit Study

16

What blood tests would you do to work up constipation?
6

1. Glucose
2. CBC --anemia detect colorectal neoplasm
3. Thyroid***
4. Calcium
5. Magnesium
6. Phosphorous

17

Colonic transit study is used for what?

To observe transit time in patients with refractory constipation not responding to conservative measures.

18

Management first and foremost for constipation is what?

prevention

19

Patient education for constipation
3

1. Exercise:
key stimulus to colon peristalsis and defecation encourage and enable patient to be mobile, or be in upright position.

2. Fluid intake:
constipated stools are low in water content.

3. Fiber intake:
acute constipation low on fiber diet, chronic constipation responds poorly to fiber.

20

Treatment types of constipation?
4

1. Stool softeners (surfactants)
2. Laxatives
3. Opiod-receptor antagonists
4. Digitial disimpaction

21

What are the types of laxatives? 3

1. Bulk
2. Osmotic
3. Stimulant laxatives

22

What are the stool softener medications?2

1. Colace (docusate sodium)
2. Docusate calcium

23

What are the drugs in the following categories:
1. Bulk 4
2. Osmotic 5
3. Stimulant laxatives 2
4. Opioid-receptor antagonist 1

1. Bulk laxatives
-Psyllium
-Methylcellulose
-Fibercon (polycarbophil)
-Benefiber (wheat dextran)

2. Osmotics
-Lactulose
-Sorbitol
-Polyethylene glycol
-Magnesium Citrate
-Magnesium Sulfate (caution in renal impairment)

3. Stimulant laxatives
-Bisacodyl
-Senna

4. Methylnaltrexone

24

Opioid-receptor antagonist
(Methylnaltrexone) is approved for who?
2

What does it not affect?

Approved for
1. palliative care pts,
2. pts on chronic opiod tx,

doesn’t effect central analgesia

25

What is the definition of diarrhea?
2

1. increase in daily stool weight above 200-300g/24hrs
2. Clinically: increase in stool liquidity and/or frequency

26

1. In developed countries
Normal stool weight of an adult human is less than _____ g/d

2. Stool water accounts for ___ to __ % of weight

3. Normal bowel frequency ranges from what to what?

4. Greater then __ x a day is considered abnormal

1. 200
2. 60, 85

3. three times a week to three times a day

4. 3

27

Diarrhea PP. Describe the following reasons that contribute to constipation:

1. Osmotic?

2. Secretory?

3. Motility?

1. non-absorbable substance draws out excess water into the intestines & increases stool weight and volume

2. mucosal secretion of fluid & electrolytes secondary to bacterial enterotoxins, neoplasms or exotoxins

3. food is not mixed properly, digestion is impaired and motility is increased; secondary to resection of the small intestine, surgical bypass of an area of intestine or diabetic neuropathy

28

1. What is acute diahhrea?
2. Persistant?
3. Chronic?

1. Acute — ≤14 days in duration
2. Persistent diarrhea — more than 14 days in duration
3. Chronic — more than 30 days in duration

29

1. Clinical Manifestations of diarrhea: 3

2. Acute diarrhea is usually due to what?

1.
-Fever
-Cramping pain
-If severe, can get dehydrated, especially in children or elderly

2. Acute usually due to infections with viruses and bacteria and are self-limited

30

What is chronic diarrhea usually secondary to? 3

Chronic usually secondary to
1. irritable bowel syndrome (IBS), 2. inflammatory bowel disease, or 3. malabsorption syndromes

31

Acute Infectious Diarrhea
1. Viral causes? 4
2. Bacterial? 5
3. Protozoa? 4

1. Viral
-Norovirus
-Rotavirus
-Adenoviruses
-Astrovirus

2. Bacterial
-Salmonella
-Campylobacter- Guiene Barre
-Shigella
-enterotoxigenic E. coli,
-C. difficile

3. Protozoa
-Cryptosporidium- most common parasitic cause of acute foodborne diarrhea in the US
-Giardia
-Cyclospora
-entamoeba
(wet mount for protozoa)

32

Acute Diarrhea noninfectious etiologies? 3

1. Drugs
2. food allergies
3. disease states such as thyrotoxicosis and the carcinoid syndrome.

33

Acute diarrhea: Indications for diagnostic evaluation?
9

1. Profuse watery diarrhea with signs of hypovolemia

2. Passage of many small volume stools containing blood and mucus

3. Bloody diarrhea

4. Temperature ≥38.5ºC (101.3ºF)

5. Passage of ≥6 unformed stools per 24 hours or a duration of illness >48 hours

6. Severe abdominal pain

7. Hospitalized patients or recent use of antibiotics

8. Diarrhea in the elderly (≥70 years of age) or the immunocompromised

9. Systemic illness with diarrhea, especially in pregnant women (in which case listeriosis should be suspected)

34

Chronic Diarrhea etiology?
7

1. Medications
2. Osmotic
3. Secretory
4. Inflammatory
5. Malabsorptive
6. Motility Disorders
7. Chronic Infections

35

Osmotic diarrhea
1. Clues to diagnosis? 2
2. Causes of this? 3

1. CLUES:
-Stool volume decreases with fasting
-increased stool osmotic gap

2.
-Medications:
-Disaccharidase deficiency: lactose intolerance
-Factitious diarrhea

36

1. Meds that cause osmotic diarrhea?

2. Who often has Disaccharidase deficiency?

3. Factitious diarrhea from?

1. Meds
-antacids,
-lactulose,
-sorbitol

2. Lactose intolerance

3. magnesium (antacids, laxatives)

37

Secretory diarrhea
1. Clues?
2. Causes? 5

1. CLUES:
-Large volume (> 1 L/d)
-little change with fasting;
-normal stool osmotic gap

2.
-Hormonally mediated:
-Factitious diarrhea
-Villous adenoma
-Bile salt malabsorption
-Medications

38

1. Hormone mediated secretory diarrhea can be caused by? 3

2. Factitious secretory diarrhea can be caused by? 4

3. Why does Villous adenoma cause constipation?

4. What bile salt malabsorption problems cause secretory diarrhea? 3

1.
-carcinoid,
-medullary carcinoma of thyroid (calcitonin),
-Zollinger-Ellison syndrome (gastrin)

2.
-(laxative abuse);
-phenolphthalein,
-cascara,
-senna

3. Secretes K+ rich fluid

4.
-ileal resection;
-Crohn ileitis;
-postcholecystectomy

39

Peritoneal signs are what?

rebound sign for distention is an example

40

Inflammatory conditions that cause chronic diarrhea:
1. Clues? 3
2. Causes? 3

1. CLUES:
-Fever,
-hematochezia,
-abdominal pain

2.
-Inflammatory Bowel Disease:
-Malignancy:
-Radiation enteritis

41

1. What are the inflammatory bowel diseases that cause chronic diarrhea? 2

2. Malignancies that can cause inflammatory chronic diarrhea? 2

1.
-Ulcerative colitis
-Crohn’s disease

2.
-lymphoma,
-adenocarcinoma (with obstruction and pseudodiarrhea)

42

Malabsoprtion syndromes that cause chronic diarrhea:
1. Clues? 3
3. Causes? 4

1. CLUES:
-Weight loss,
-abnormal laboratory values
-fecal fat > 10 g/24h

2.
-Small bowel mucosal disorders
-Lymphatic obstruction
-Pancreatic disease
-Bacterial overgrowth

43

Malabsoprtion syndromes that cause chronic diarrhea:
1. Small bowel disorder causes? 7
2. Lymphatic obstruction? 6
3. Pancreatic disease? 2
4. Bacterial overgrowth? 4

1.
-celiac sprue,
-tropical sprue,
-Whipple disease,
-eosinophilic
-gastroenteritis,
-small bowel resection (short bowel syndrome),
-Crohn’s disease

2.
-lymphoma,
-carcinoid,
-infectious (tuberculosis, MAI),
-Kaposi sarcoma,
-sarcoidosis,
-retroperitoneal fibrosis

3.
-chronic pancreatitis,
-pancreatic carcinoma

4.
-motility disorders (diabetes, vagotomy),
-scleroderma,
-fistulas,
-small intestinal diverticula

44

Motility disorders causing chronic diarrhea:
1. Clues? 2
2. Causes? 3

1. CLUES:
-Systemic disease or
-prior abdominal surgery

2.
-Postsurgical
-Systemic disorders
-Irritable bowel syndrome

45

Motility disorders causing chronic diarrhea:
1. Postsurgical causes?3
2. Systemic causes?3

1.
-vagotomy,
-partial gastrectomy,
-blind loop with bacterial overgrowth

2.
-scleroderma,
-diabetes mellitus,
-hyperthyroidism

46

The diarrhea workup: History?
4

1. Travel,
2. longevity of symptoms,
3. family history,
4. food intake and relationship to onset.

47

The diarrhea workup: Fecal analysis?
6

1. Fecal leukocytes (invasive infection)
2. Fecal Occult blood
3. Fecal Fats
4. Enteric Pathogen cultures
5. Clostridium difficile (C. diff) toxin
6. Ova & Parasites

48

1. What does fecal leuks indicate?

2. When do you find this? 2

1. Presence indicated bowel mucosal inflammation,

2. which occurs in
-Invasive bacterial enteritis
-Ulcerative colitis.

49

Fecal Occult Blood
1. Immunochemical tests for fecal blood(FIT or iFOBT) for hemoglobin are more specific than guaiac tests because why?

2. Hemoccult
What do we need to do to make results significant?

1. they respond only to human globin and do not detect upper gastrointestinal bleeding

2. + result obtained on multiple specimens performed on excessive days

50

Stool for culture and sensitivity?
3

1. Enterococcus
2. E-coli
3. Clostridium

51

Stool for ova and parasite?
3

What do you want to treat all these with?

1. Salmonella
2. Shigella
3. Giardia

Cipro

52

C-diff Toxin Assay: How does C-Diff cause diarrhea?

C-diff multiplies and releases toxin that causes necrosis of the colonic epithelium which causes the diarrhea.

53

Fecal fat- Quantitative stool fat
4

1. Confirms steatorrhea
2. Sprue
3. Crohn’s
4. Whipples Dz

54

1. Colonoscopy with mucosal biopsy to exclude what? 3

2. Upper Endoscopy when what is suspected such as celiac sprue or whipple disease?

1.
-IBD,
-Microscopic Colitis
-Colonic Neoplasia

2. small intestine disorder

55

Further studies for diarrhea?
1

24 hour stool collection

56

Treatment of diarrhea

5

1. Fluid replacement
2. Antibiotic therapy
3. Bismuth subsalicylate (Pepto-Bismol, OTC)‏
4. Opiate antidiarrheal agents
5. Cholestyramine (Questran)‏

57

What diseases do we make sure to give antibiotics to for diarrhea?
5

1. shigellosis,
2. traveler's diarrhea,
3. pseudomembranous enterocolitis,
4. cholera, and
5. parasitic diseases

58

What are the Opiate antidiarrheal agents?
2

Used to treat what?

1. Diphenoxylate (Lomotil) and
2. Loperamide (Immodium)‏

Mild to moderate secretory diarrhea

59

Cholestyramine (Questran)‏ is used to treat diarrhea caused by what?

diarrhea caused by ileal bile salt malabsorption

60

Whats the difference between IBS and IBD?

IBS- no constitutional symptoms
constipation and diarrhea

IBD- ulcerative colitis and chrohns
-blood
-mucus
-constitutional syndromes
-abdominal pain
-weight loss

61

1. Anemia?
2. Albumenia?
3. SED rate?

1. blood loss- colon cancer
2. malabsoprtion syndrome
3. cancer or inflammatory disease

62

Homemade fluid replacement for diarrhea patient?
4

1. Half tsp of salt
2. 1 tsp baking soda
3. 8 tsp of sugar
4. 8 oz of OJ diluted in a liter of water