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Lecture 2: Diarrhea/Constipation Flashcards

1
Q

In what demographic is especially diarrhea concerning in?

A

Infants

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2
Q

What are the 3 duration types of diarrhea?

A
  • Acute < 2 weeks
  • Persistent 2-4 weeks
  • Chronic > 4 weeks
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3
Q

What is the primary cause of acute diarrhea?

A

Infectious agents

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4
Q

What are the two ways acute diarrhea agents are transmitted?

A
  • Fecal oral transmission
  • Disturbance of GI flora due to ABX
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5
Q

Who are the 5 high risk groups for acute diarrhea?

A
  1. Traveler’s (E. coli + giardia)
  2. Food at a picnic, banquet, or restaurant
  3. Immunodeficient
  4. Daycare attendees and their family
  5. Institutionalized persons
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6
Q

How does inflammatory diarrhea present?

A
  • Bloody
  • Feverish
  • LLQ Cramps

Dysentery

Need stool cultures

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7
Q

How does noninflammatory diarrhea typically present?

A
  • Watery
  • Nonbloody
  • Periumbilical cramps

We only evaluate if severe or > 7 days.

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8
Q

How does a small bowel infection typically present in terms of diarrhea?

A
  • Abd cramping
  • Bloating, gas
  • Wt loss
  • Watery diarrhea

Fever is rare

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9
Q

What is the MCC of watery diarrheas?

A

Enteric viruses

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10
Q

What is the MCC of large, inflammatory diarrheas?

A

Bacterial pathogens

Large bowel infection

Bacteria are bigger than viruses = bigger diarrhea?

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11
Q

What are the only virus and only protozoan that cause inflammatory idarrhea?

A
  • CMV
  • Entamoeba histolytica
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12
Q

If acute diarrhea present 1-6 hrs post exposure, what are the likely culprits?

A
  • Staph
  • B Cereus
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13
Q

What pathogens cause diarrhea over a 1 week after exposure?

A
  • Cryptosporidium
  • Giardia
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14
Q

What are the likely pathogens if the history suggests exposure to a daycare, mountain stream, or community swiming pool?

A
  • Giardia
  • Cryptosporidium
  • Entamoeba
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15
Q

How are norovirus and enteric viruses typically transmitted?

A

Household/community spread

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16
Q

When does C diff associated diarrhea typically occur?

A

2 weeks - 1 month post ABX therapy

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17
Q

What are the most common ABX implicated in C diff diarrhea?

A
  • Fluoroquinolones
  • Clindamycin
  • Cephalosporins
  • PCNs
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18
Q

What would prompt us to hospitalize a patient for diarrhea?

A
  • Severe dehydration
  • Organ failure
  • Marked abdominal pain
  • AMS
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19
Q

What is the workup for most acute noninflammatory diarrheas?

A

* No diagnostic investigation!
* 90% are self-limited.

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20
Q

If we have persistent diarrhea, what labs do we order?

A
  • Fecal leukocyte
  • Stool culture
  • Stool for O & P
  • Stool for C. diff
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21
Q

What is the recommended diet for someone with persistent diarrhea?

A
  • Bananas
  • Rice
  • Applesauce
  • Toast

BRAT

Also soup and crackers

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22
Q

What is the home DIY Liquid IV recipe?

A
  • 1/2 tsp salt
  • 1 tsp baking soda
  • 8 tsp sugar
  • 8 oz OJ
  • 1L water dilution
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23
Q

How does loperamide work?

A

GI Opioid agonist that inhibits peristalsis.

Contraindicated in inflammatory diarrhea.

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24
Q

How does pepto-bismol work?

A
  • Reduce gut secretions
  • Avoid in preggos and children.
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25
How does diphenoxylate/atropine work?
Anticholinergic | Contraindicated in acute and inflammatory diarrhea. ## Footnote RISK: TOXIC MEGACOLON
26
What are the empiric ABX therapy for diarrhea?
* First-line: Cipro or Levofloxacin for 3 days * Alternatives: Bactrim DS or Doxy
27
What are osmotic diarrheas and what resolves it?
* Carb malabsorption * Laxative abuse * Malabsorption * **RESOLVES DURING FASTING** ## Footnote Resolution from fasting = osmotic diarrhea
28
What causes secretory disorders in chronic diarrhea?
* Endocrine tumors * Bile salt malabsorption | **NOT RESOLVED BY FASTING**
29
What are the two common inflammatory conditions that can result in chronic diarrhea?
* Ulcerative colitis * Crohn disease | Subtypes of IBD
30
What characterizes a malabsorptive condition?
* Wt loss * Osmotic diarrhea * Steatorrhea * Nutritional deficiencies
31
What is the MCC of chronic diarrhea in young adults?
IBS
32
What kind of disorder is IBS and how does it present?
Motility disorder. * Lower abd pain * Altered bowel habits * NO evidence of serious organic disease
33
What are the 5 MC pathogens associated with chronic diarrhea?
1. Giardia 2. E. histolytica 3. Cyclospora 4. Intestinal nematodes 5. C. diff
34
What two systemic conditions can cause chronic diarrhea?
* Thyroid disease (hyper = hypermotility) * Diabetes
35
What stool appearance is more suggestive of malabsorption? Inflammatory?
* Malabsorption: Greasy, malodorous * Inflammatory: Blood or pus
36
What specific serologic test might we look for in chronic diarrhea?
Celiac disease serology
37
What is the MOA of loperamide and diphenoxylate?
* MOA: Opioid receptor agonists to slow peristalsis.
38
When should you NOT use loperamide or diphenoxylate?
* Bloody/inflammatory diarrhea * C. diff related diarrhea * Pts < 2 yrs | Anything that slows gut motility is a nono in bloody diarrhea
39
What is the MOA of bismuth and common reactions to it?
* MOA: Reduces secretions, some antimicrobial effect. * Causes **black stool and black tongue**
40
What is octreotide and how does it work?
* Used for chronic, secretory diarrhea * Inhibits intestinal fluid secretion and stimulates absorption. ## Footnote Secretory diarrhea = Does NOT resolve with fasting. Secretory disorders are characterized by increased secretion and poor absorption, so octreotide does the opposite.
41
What is the main concern with using octreotide?
Inhibition of many hormone productions. | Caution in DM, thyroid, pancreas, kidney, liver, or arrhythmias.
42
What is cholestyramine used for and how does it work?
* Indications: Chronic secretory or malabsorptive diarrhea * Binds intestinal bile acids | Also lowers cholesterol! ## Footnote chole = bile acid and cholesterol
43
What do hyoscyamine and dicyclomine do?
* Relaxes intestinal smooth muscle * Inhibits spasms and contractions * Mainly used for diarrhea associated with IBS | Antispasmodics
44
Who should antispasmodics NOT be used in?
* Toxic megacolon * IBD
45
Who is constipation MC in?
Elderly women
46
What is constipation?
* Infrequent stools < 3 a week * Hard stools * Excessive straining * Sense of incomplete evacuation
47
How long is average colonic transit time?
35 hours
48
What are the two MCC of constipation?
* Inadequate fiber or fluid intake * Poor bowel habits
49
What would prompt us to further workup constipation?
* Severe constipation or **age over 50.** * Hematochezia, wt loss, positive FOBT * FMHx of colon cancer or IBD * Refractory constipation
50
What does fiber do?
Promotes intestinal motility by absorbing water into stool.
51
What exactly do stool softeners do?
Emollient that covers stool to soften it.
52
What is the concern with using mineral oil as a stool softener?
Absorption of key nutrients.
53
What do osmotic laxatives do?
* Increase secretion of water into the lumen * Soften stool and promote defecation * Works within 24 hours
54
What is used as a bowel cleanser and when?
* Osmotic laxatives * Polyethylene glycol (PEG) * Mag citrate * Sodium phosphate (fleet enema) * Prior to colonoscopy or bowel surgery
55
When are stimulant laxatives used and what do they do? | Bisacodyl, Senna, Cascara
* For patients with poor response to osmotic agents. * Used as a rescue agent, **not daily** * Stimulation of fluid secretion and colonic contraction
56
What are the main concerns with using stimulant laxatives?
* Not for long-term or daily use * Electrolyte abnormalities
57
What is the order of preference in pharmacologic managment of constipation?
1. Fiber supplements 2. Stool softeners 3. Osmotic laxatives 4. Stimulant laxatives
58
What 5 conditions may predispose someone to fecal impaction?
1. Medications 2. Severe psychiatric disease 3. Prolonged bed rest 4. Neurogenic disorders of the colon 5. Spinal cord disorders
59
How does fecal impaction usually present clinically?
1. Decreased appetite 2. N/V 3. Abd pain and distension 4. Paradoxical diarrhea
60
What is the initial management for a fecal impaction?
* Enemas * Digital disimpaction

GI (17 decks)

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