Flashcards in Mcgowen Acute Diarrhea and Small Bowel/Colon Deck (70):
Definition of Diarrhea
-Adult: >200 grams/day
-Child >20 g/Kg/day
-Clinically: 3 or more loose or watery stools/day or decreased consistency and increase in frequency of BM
What is lost with diarrhea
bicarb and K+
Medications that can cause diarrhea
What is the most common/likely non-infectious etiology of diarrhea for more than 14 days
non medicinal Non-infectious diarrhea causes
-Food sweeteners (sorbitol)
-food allergies (Anaphylaxis)
-Graft vs. Host disease
-ingestion of toxins (insecticides, amanita and mushrooms, arsenic, preformed environmental toxins in seafood, like ciguatera and scombroid
-Chronic illness early in course (IBD and microscopic colitis, endocrine diseases, tumors: VIPoma, carcinoid, colorectal
-Occlusive or nonocclusive ischemic colitis (over 50, acute lower abdominal pain preceding watery-->bloody diarrhea, . . acute inflammatory changes in sigmoid or left colon while sparing rectum
5 high risk groups for infectious diarrhea?
-Daycare work/attendees and family (shigella, Giardia, Cryptosporidium, Rotavirus)
-Institutionalized persons (nursing homes/assisted living/hospitals)
-Frequent passage of small volumes of stool
-Rectal urgency, tenesmus, feeling of incomplete evacuation
-accompanies IBS or PROCTITIS
-involuntary discharge of rectal contents
-most often caused by neuromuscular disorders or structural anorectal problems
-elderly/nursing home patients
-fecal impaction that is readily detectable by rectal exam
what do routine bacterial stool cultures include
-E. Coli (ask for Shiga toxin detection for 0157:H7 EHEC)
-Most detect campylobacter but may need to requents
What cultures do you specifically need to ask for
-C. diff PCR/toxin
-Ova parasites (increase yield by obtaining 3 samples sequentially)
-Stool antigen (parasites - giardia and cryptosporidium)
What Virus is not detected with routine and study and PCR is better
Picnic, banquet, or restaurant food: Chicken
Picnic, banquet, or restaurant food: Undercooked hamburger
Picnic, banquet, or restaurant food: Fried rice or other reheated food
Picnic, banquet, or restaurant food: potato salad, mayonnaise, or cream pastries
Picnic, banquet, or restaurant food: eggs
Picnic, banquet, or restaurant food: uncooked foods, LUNCH MEATS, or soft cheeses
Picnic, banquet, or restaurant food: seafood, especially if raw
Vibrio species, Salmonella, acute hepatitis A
Staph Aureus: toxin?
type of diarrhea?
-rapid . .within 6 hours of ingestion
-rapid . . 24-48 hours
-Ham, poultry, Dairy, eggs, CREAM PASTRIES, POTATO SALAD, MAYO
Bacillus Cereus: Toxin?
type of diarrhea?
-Vomiting is main symptom
-Rapid . .within 6 hours of ingestion
-Rapid . . 24-48 hours
-Watery diarrhea . . happens occasionally
Clostridium Perfringens: toxin?
Type of diarrhea?
-Crampy abd pain
-Rapid . . within 8-16 hours of ingestion . . Need to ingest large quantity of organisms
- Rapid . .within 24-48 hours
-Beef, ham, poultry, legumes, gravy (heat resistant spores inadequately cooked
type of diarrhea?
-enterotoxin Shiga Toxin
-any age, but primarily children (daycare and families)
-Potato or egg salad, lettuce, raw veggies
-BLOODY, small volume
-Abdominal cramps, FEVER for 3-4 days, FECAL LEUKOCYTES
-distinguish from IBD . . . lactose neg.
-1-2 weeks duration
-Bismuth, Amp., Fluoro., or Trimethorpim/sulfamethoxazole
-Respiratory complaints and seizures in children and Post infectious reactive arthritis and HUS
Gram-negative , non-lactose fermenting, motile rod-shaped bacteria
Salmonella typhimurium: Diarrhea?
Fever, Abd cramping, N/v, + fecal leukocytes
Self limited . . 5-10 days
Reptiles (turtles), ducks, birds
HIV, leukemia, and SICKLE CELL pts
Lactose -, motile
NOT indicated . . can prolong course
reactive arthritis, endocarditis, septic arthritis, oseomyelitis
Salmonella Typhi: Risk factors?
-International travel, poor sanitation
-good food prep, hand washing, vaccine
-Typhoid Fever: systemic SUSTAINED FEBRILE illness, 103 to 104, sometimes accompanied by weakness, headache, anorexia, RLQ pain, rash of flat rose-colored spots, and diarrhea
-Stool and blood samples, fecal leukocyte +
-Fluoroquinolones, ceftriaxone, and azithromycin
Campylobacter Jejuni: diarrhea?
-Fever, crampy abd pain, fecal leukocytes +
-Self limited 7 days, supportive treatment
-Late onset, 1-8 weeks after diarrhea resolved, reactive arthritis, GUILLAN-BARRE syndrome
-gram- curved rod, Campy blood agar, Spiral (S shaped), Oxidase +, motile with flagellum
-raw undercooked meats (POULTRY), dairy (raw milk)
-Wild birds including ducks
-cross contamination during food prep, contaminated water
Vibrio Cholera: Diarrhea?
Gram stain of stool?
RICE WATER , profulse up to 1 L/hour
vomiting and dehydration: hypotension, renal failure, death
Curved/comma shaped, anaerobic gram- bacilli with flagellum, Darting, motile
waterborn, salt water, raw oysters, underdeveloped nations
Rehydration/electrolyte replacement . . prevent with sanitation and vaccination
O1 and O139
Vibrio Parahemolyticus: Variants?
NON-O1 and NON-O139
N/V/Abd cramps, Fecal leukocyte +
Watery-->BLOODY diarrhea (colonic)
Sea food associated
Vibrio Vulnificus: stain and shape?
you get this how?
-Gram - bacillus
-Warm, shallow COASTAL SALT WATER
Vomiting, diarrhea, abdominal within 16 hrs of ingestion
Open wound in water: bullous skin lesions, life threatening in immunocompromised especially CIRRHOSIS pts
Aeromonas Hydrophila: describe?
get this how? location?
Gram -, non spore forming, rod shaped, facultative anaerobeic bacteria, motile with flaggelum
Fresh water or brackish water (more salt than fresh but less than salt)
Wounded in water; foot and ankle most common; necrotizing fasciitis aka flesh eating bacteria
Eating rish or shellfish
Scuba divers that swallow small amounts of fresh water
cholera-like: Non bloody watery rice water stools
Boody mucoid stools
Travelers Diarrhea (TD): locations?
What is UNCOMMON?
-Asia, South and Central America, Mexico
3 days - 2 weeks after travel
N/V, WATERY diarrhea, bloating, Abd cramps, fatigue/malaise, loss of appetite and LOW grade fever
Bloody diarrhea and fever
Self limited; 1-5 days
H2blocker/PPI use . . . lowers pH
Travelers Diarrhea (TD): most common, Enterotoxin production, water salads meats cheese, affect small intestine?
Misc. other causes
Visitors to Russia (St. Petersburg); Campers, backpackers and swimmers in wilderness
Visitors to Nepal
Salmonells, shigella, Aeromonas, EAEC, Norovirus, Coronavirus
Giardia associated diarrhea
E. coli; ETEC: Diarrhea?
sudden . . lasts 3-6 days
contaminated food or water
Antibx may reduce infection by 1-2 days
-Trimethoprim/sulfamethoxazole, Coxycycline, ciprofloxacin,
-Bismuth may help
-watery-->BLOODY (can lead to ischemic colitis)
-Abd tenderness, NO FEVER, + peripheral leukocytes, + fecal leukocytes or lactoferrin
under cooked hamburger; raw veggies; animal contact
HUS (more often than shigella)
more likely to happen in children treated with antibiotics
Yersinia Enterocoitica: Higher risk in?
location of pain?
-IRON OVERLOAD SYNDROMEs, diabetes and preexisting GI disorders
Contaminated food/water; dairy, contaminated domestic animal feces (maybe a puppy?)
Bloody (and non bloody) . . + fecal leukocytes
Abd pain + PHARYNGITIS
Terminal ileum: right sided abd pain . . mimic APPENDICITIS or Crohns
Salmonella or shigella
Rash, reactive arthritis, hemochromatosis
Listeria monocytogenes: Who gets it?
anyone: predilection for PREGNANT WOMEN
Fever, NON bloody diarrhea, headache, N/V
unpasteurized dairy, DELI MEATS, rarely cantaloupe
Clostridium Difficile: Describe?
Anaerobic, Gram +, spore forming baciliius
Watery diarrhea, Abd pain and fever, Pseudomembranes
Toxins A and B
-recent hospitalization; antibiotics (PPIs, Clindamycin, cephalosporins, fluroquinolones) . . WASH hands with soap and water
PO/IV metronidazole, ORAL vancomycin
-Norovirus (nursing homes)
"wagon Wheel appearance on electon microscopy
onset and duration?
Most common cause of acute diarrhea in INFANTS (under 2) . . in winter months
Vomiting and watery diarrhea --> severe dehydration
in 72 hr . . . last 2-3 days up to 5
viral culture or PCR
Supportive care . . . vaccine available
onset and duration?
transmission and common link?
Older children and adults
Vomiting and Watery diarrhea
in 24-48 hrs and lasts 3 days
fecal oral . . . CRUISE SHIPS
Adenovirus (serotypes 40 and 41): age?
-Fever (103-104) chills, myalgias, sore throat, Watery diarrhea, CONJUNCTIVITIS, PHARYNGITIS,
Prolonged . . . 10 days
CMV: what pts?
Immunosuppressed . . AIDS and organ transplant. CD4<200
Fever, Abd pain, bloody diarrhea
endoscopy with biopsy of ulcerated lesions using CMV special stains
Most common cause of dysentery in the world
"Flask shaped ulcer"
Entamoeba histolytica: complications?
found in what situations?
-can penetrate bowel and into portal circulation: liver abscesses or lung or brain. Toxic megacolon or pneumatosis coli
days to weeks
Stool for ova and parasites or Stool antigen (PCR or DNA)
Crowded living conditions (fecal oral); mental health institutions, poor sanitation, endemic areas, Asia, Africa, Central and south american
Metronidazole and Paromomycin
Pear-shaped, 4 flagella, 2 nuclei protozoan
Giardia Lamblia: transmission?
Steatorrhea, flatulence, abd pain, belching, weight loss, nasuea, malaise, cramps, anorexia, bloating
ova parasites (3 samples sequentially); STOOL ANTIGEN DETECTION
Water (lakes, streams) from hiking camping; Zoonosis, beaver, cattle, dogs, rodents, big horn sheep, person-person. conatminated water in russia . . IgA deficiency more susceptible
What are the 2 main clinical syndromes from cryptosporidium?
Self limited diarrhea in immunoCOMPETENT . .. 7-14 days no treatment other than rehydration
Life-threatening intractable in immunoSUPPRESSED pts . . . AIDS . .CD4 <200 . . biliary dx RUQ pain and fever
outbreaks for cryptosporidium
Swimming pools . . can be resistant to chlorine
Nematode/roundworm that enters body through exposed skin such as bare feet on contaminated soil?
who is more susceptible?
Whats in Stool?
those with HTLV-1 infection
Abd pain, bloating, diarrhea, cough, SOB, perianal urticaria, migratory rash
Rhabdiform larvae and eosinophils
duration in immunocompetent?
-PRODUCE imported from endemic areas (lettuce, fresh basil, imported respberries); Travel to endemic areas
up to 21 days
Chlorine and iodine unlikely to kill oocysts
Stain for Cystoisospora belli?
modified acid fast stain
hook worm . .bowel obstruction
esophageal varices . .freshwater snails . . . bladder cancer and liver cysts
Pork tape worm; causes cysticercosis . . seizure and muscle or eye disease
sheep and dog tapeworm
-cysts in liver or lungs
-looks like free flowing "hydatid sand" on CT
General Nutritional advice for infectious colitis?
-BRAT diet (bananas, Rice, Applesauce, Toast)
-Easily digestible foods (boiled potatos, crackers, yogurt, soup)
-avoid lactose containing products as they can make diarhea worse
-Avoid high fiber roots, fats, caffeine, and alcohol
General advice to make you feel better
-drink 8-10 glasses of clear fluids/day
-drink at least 1 cup of liquid every time you have a loose BM
-Eat small meals throughout the day instead of 3 big meals
-Eat some salty foods such as pretzels, soups, and sports drinks
-Eat some high K+ foods such as bananas, potatoes without the skin
Alcohol gels are ineffective against what
norovirus and C. diff
What viral vaccines are there
Reactive Arthritis (Reiter's syndrome)
-Arthritis, urethritis, conjunctivitis
yersiniosis may lead to what?
HUS-->high mortality rate
Pathogens that usually affect the small bowel present with what?
What is in stool?
Location of pain?
-Large volume, watery stools, abd cramps weight loss
WBC absent . . NON inflammatory
Mid abdomen or diffuse
-Salmonella, vibrio cholerae, ETEC, EPEC, Yersinia, Rotavirus, Norovirus, CMV, Adenovirus, Giardia, Cyrptosporidium, Cyclospora, Clostridium perfringens, staph. aureus, Bacillis cereus
pathogens that usually affect Large bowel present with what?
-Frequent small volume stools
Fever, Blood or WBC in stool (inflammatory), fecal leukocytes common
lower abd or rectum . . (tenesmus)
-Campylobacter, Salmonella, Shigella, yersinia, EIEC, EHEC, C. diff, vibrio parahaemolyticus, E. histolytica, CMV, Adenovirus, Herpes simplex