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Flashcards in Mcgowen Acute Diarrhea and Small Bowel/Colon Deck (70):
1

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

2

What is lost with diarrhea

bicarb and K+

3

Medications that can cause diarrhea

-antibiotics
-Antidysrhythmics
-antihypertensives
-NSAIDS
-certain antidepressants
-Chemo
-bronchodilaters
-antacids
-laxatives

4

What is the most common/likely non-infectious etiology of diarrhea for more than 14 days

medications

5

non medicinal Non-infectious diarrhea causes

-Food sweeteners (sorbitol)
-food allergies (Anaphylaxis)
-Tube feeding
-Acute diverticulitis
-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

6

5 high risk groups for infectious diarrhea?

-travelers
-Immunodeficient
-Daycare work/attendees and family (shigella, Giardia, Cryptosporidium, Rotavirus)
-Institutionalized persons (nursing homes/assisted living/hospitals)
-Certain foods

7

-Frequent passage of small volumes of stool
-Rectal urgency, tenesmus, feeling of incomplete evacuation
-accompanies IBS or PROCTITIS

Psuedo-diarrhea

8

-involuntary discharge of rectal contents
-most often caused by neuromuscular disorders or structural anorectal problems

Fecal incontinence

9

-elderly/nursing home patients
-fecal impaction that is readily detectable by rectal exam

Overflow diarrhea

10

what do routine bacterial stool cultures include

-Salmonella
-Shigella
-E. Coli (ask for Shiga toxin detection for 0157:H7 EHEC)
-Most detect campylobacter but may need to requents

11

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)

12

What Virus is not detected with routine and study and PCR is better

Norwalk

13

Picnic, banquet, or restaurant food: Chicken

-Salmonella
-Campylobacter
-Shigella

14

Picnic, banquet, or restaurant food: Undercooked hamburger

-EHEC (0157:H7)

15

Picnic, banquet, or restaurant food: Fried rice or other reheated food

Bacillus cereus

16

Picnic, banquet, or restaurant food: potato salad, mayonnaise, or cream pastries

Staph. aureus

17

Picnic, banquet, or restaurant food: eggs

Salmonella

18

Picnic, banquet, or restaurant food: uncooked foods, LUNCH MEATS, or soft cheeses

Listeria

19

Picnic, banquet, or restaurant food: seafood, especially if raw

Vibrio species, Salmonella, acute hepatitis A
-Norwalk, Campylobacter

20

Staph Aureus: toxin?

symptoms?

type of diarrhea?

Onset?

Resolution?

Causes?

-Preformed enterotoxins

-N/V

-WATERY

-rapid . .within 6 hours of ingestion

-rapid . . 24-48 hours

-Ham, poultry, Dairy, eggs, CREAM PASTRIES, POTATO SALAD, MAYO

21

Bacillus Cereus: Toxin?

Symptoms?

Onset?

Resolution

Cause?

type of diarrhea?

-Preformed enterotoxins

-Vomiting is main symptom

-Rapid . .within 6 hours of ingestion

-Rapid . . 24-48 hours

-Fried rice

-Watery diarrhea . . happens occasionally

22

Clostridium Perfringens: toxin?

Type of diarrhea?

symptoms?

Onset?

Resolution?

Cause?

-Preformed Enterotoxins

-Watery 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

23

Shigells: Toxin?

Age?

foods?

type of diarrhea?

associated symptoms?

Stool cultures?

duration?

treatment?

complications?

-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

24

Gram-negative , non-lactose fermenting, motile rod-shaped bacteria

Salmonella typhimurium

25

Salmonella typhimurium: Diarrhea?

Ass. Symptoms?

Resolution?

Foods?

Animal exposure?

Increased risk?

Stool culture?

Antibiotics?

Complications?

Watery -->BLOODY

Fever, Abd cramping, N/v, + fecal leukocytes

Self limited . . 5-10 days

Eggs, poultry

Reptiles (turtles), ducks, birds

HIV, leukemia, and SICKLE CELL pts

Lactose -, motile

NOT indicated . . can prolong course

reactive arthritis, endocarditis, septic arthritis, oseomyelitis

26

Salmonella Typhi: Risk factors?

Prevention?

Spread?

Ass. symptoms?

Diagnosis?

Treatment?

-International travel, poor sanitation

-good food prep, hand washing, vaccine

-fecal-oral

-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

27

Campylobacter Jejuni: diarrhea?

Ass. symptoms?

Resolution?

complications?

Stool culture?

Foods?

Hosts?

Spread?

Watery -->BLOODY

-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

28

Vibrio Cholera: Diarrhea?

Ass. symto.?

Gram stain of stool?

Source?

duration?

Treatment?

Variants?

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

1 week

Rehydration/electrolyte replacement . . prevent with sanitation and vaccination

O1 and O139

29

Vibrio Parahemolyticus: Variants?

Toxin?

Ass. Sym?

Diarrhea?

duration?

Food?

NON-O1 and NON-O139

Cytotoxin production

N/V/Abd cramps, Fecal leukocyte +

Watery-->BLOODY diarrhea (colonic)

2-5 days

Sea food associated

30

Vibrio Vulnificus: stain and shape?

Found where?

Foods?

Ass. Symp.?

you get this how?

-Gram - bacillus

-Warm, shallow COASTAL SALT WATER

Raw shellfish

Vomiting, diarrhea, abdominal within 16 hrs of ingestion

Open wound in water: bullous skin lesions, life threatening in immunocompromised especially CIRRHOSIS pts

31

Aeromonas Hydrophila: describe?

Source?

get this how? location?

2 types?

Treatments?

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

Ampicillin

32

Travelers Diarrhea (TD): locations?

Onset?

Symptoms?

What is UNCOMMON?

resolution?

Risk factors?

-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

33

Travelers Diarrhea (TD): most common, Enterotoxin production, water salads meats cheese, affect small intestine?

Asia

Misc. other causes

Visitors to Russia (St. Petersburg); Campers, backpackers and swimmers in wilderness

Visitors to Nepal

Cruise ships

-ETEC

-Campylobacter Jejuni

Salmonells, shigella, Aeromonas, EAEC, Norovirus, Coronavirus

Giardia associated diarrhea

Cyclospora

Norovirus

34

E. coli; ETEC: Diarrhea?

Fecal leukocyte?

onset?

Diagnose?

source?

Treatment?

Watery

neg

sudden . . lasts 3-6 days

Clinically

contaminated food or water

Antibx may reduce infection by 1-2 days
-Trimethoprim/sulfamethoxazole, Coxycycline, ciprofloxacin,
-Bismuth may help

35

EHEC: diarrhea?

Ass. Symp?

Stool culture

Acquired

complications

Treatment

-watery-->BLOODY (can lead to ischemic colitis)

-Abd tenderness, NO FEVER, + peripheral leukocytes, + fecal leukocytes or lactoferrin

Shiga-like toxin

under cooked hamburger; raw veggies; animal contact

HUS (more often than shigella)
more likely to happen in children treated with antibiotics

Supportive, rehydration

36

Yersinia Enterocoitica: Higher risk in?

Transmission?

Diarrhea?

Ass. Sym?

location of pain?

Indistinguishable from?

duration?

complications?

Treat?

-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

10-20 days

Rash, reactive arthritis, hemochromatosis

supportive care

37

Listeria monocytogenes: Who gets it?

Sympt.

duration

confirm by?

source?

complication

anyone: predilection for PREGNANT WOMEN

Fever, NON bloody diarrhea, headache, N/V

2-3 days

BLOOD CULTURE

unpasteurized dairy, DELI MEATS, rarely cantaloupe

Menengoencephalitis

38

Clostridium Difficile: Describe?

Ass. Symt?

PCR?

other associations?

Treatment?

complications?

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

Toxic megacolon

39

Nosocomial infections

-C. diff
-Norovirus (nursing homes)

40

"wagon Wheel appearance on electon microscopy

Rotavirus

41

Rotavirus: age?

symp?

onset and duration?

detection?

spread?

Death by?

Treatment?

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

fecal oral

dehydration

Supportive care . . . vaccine available

42

Norovirus: age?

sympt?

onset and duration?

transmission and common link?

treatment?

Older children and adults

Vomiting and Watery diarrhea

in 24-48 hrs and lasts 3 days

fecal oral . . . CRUISE SHIPS

Supportive care

43

Adenovirus (serotypes 40 and 41): age?

Sympt?

course?

treatment

-Children

-Fever (103-104) chills, myalgias, sore throat, Watery diarrhea, CONJUNCTIVITIS, PHARYNGITIS,

Prolonged . . . 10 days

supportive care

44

CMV: what pts?

sympt?

duration?

diagnose how?

Immunosuppressed . . AIDS and organ transplant. CD4<200

Fever, Abd pain, bloody diarrhea

several weeks

endoscopy with biopsy of ulcerated lesions using CMV special stains

45

Most common cause of dysentery in the world

Entamoeba Histolytica

46

"Flask shaped ulcer"

Entamoeba Histolytica

47

Entamoeba histolytica: complications?

duration?

stool?

found in what situations?

treatment?

-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

48

Pear-shaped, 4 flagella, 2 nuclei protozoan

Giardia lamblia

49

Giardia Lamblia: transmission?

Diarrhea?

Ass. Sympt?

Duration?

Stool?

Acquired how?

Treatment?

fecal-oral

Watery (malodorous),

Steatorrhea, flatulence, abd pain, belching, weight loss, nasuea, malaise, cramps, anorexia, bloating

14-28 days

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

Metronidazole

50

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

51

outbreaks for cryptosporidium

Swimming pools . . can be resistant to chlorine

52

Nematode/roundworm that enters body through exposed skin such as bare feet on contaminated soil?

who is more susceptible?

Ass. Sym?

Whats in Stool?

Treatment?

Strongyloides stercoralis

those with HTLV-1 infection

Abd pain, bloating, diarrhea, cough, SOB, perianal urticaria, migratory rash

Rhabdiform larvae and eosinophils

Ivermectin

53

Cyclospora: source?

duration in immunocompetent?
suppressed?

Resistance?

Stool?

Treatment

-PRODUCE imported from endemic areas (lettuce, fresh basil, imported respberries); Travel to endemic areas

up to 21 days
indefinite

Chlorine and iodine unlikely to kill oocysts

oocysts

TMP/SMX

54

Stain for Cystoisospora belli?

What pts?

Treatment?

modified acid fast stain

Immunosuppressed

Bactrim (TMP/SMX)

55

hook worm . .bowel obstruction

Ascaris lumbricoides

56

fish tapeworm

Diphyllobothrium

57

esophageal varices . .freshwater snails . . . bladder cancer and liver cysts

Schistosoma mansoni

58

Pork tape worm; causes cysticercosis . . seizure and muscle or eye disease

Taenia solium

59

sheep and dog tapeworm
-cysts in liver or lungs
-looks like free flowing "hydatid sand" on CT

Echinococcus granulosus

60

General Nutritional advice for infectious colitis?

-BRAT diet (bananas, Rice, Applesauce, Toast)
-Easily digestible foods (boiled potatos, crackers, yogurt, soup)
-Rice water
-avoid lactose containing products as they can make diarhea worse
-Avoid high fiber roots, fats, caffeine, and alcohol

61

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

62

Alcohol gels are ineffective against what

norovirus and C. diff

63

What viral vaccines are there

-rotavirus
-S. typhi
-V. cholerae
-Hep A

64

Reactive Arthritis (Reiter's syndrome)
-Arthritis, urethritis, conjunctivitis

-Salmonella
-campylobacter
-shigella
-Yersinia

65

yersiniosis may lead to what?

-autoimmune thyroiditis
-pericarditis
-glomerulonephritis

66

Guillian-Barre syndrome

Campylobacter jejuni

67

HUS-->high mortality rate

-EHEC
-shigella

68

Pathogens that usually affect the small bowel present with what?

What is in stool?

Location of pain?

other associ?

specific organisms

-Large volume, watery stools, abd cramps weight loss

WBC absent . . NON inflammatory

Mid abdomen or diffuse

dehydration/malabsorption

-Salmonella, vibrio cholerae, ETEC, EPEC, Yersinia, Rotavirus, Norovirus, CMV, Adenovirus, Giardia, Cyrptosporidium, Cyclospora, Clostridium perfringens, staph. aureus, Bacillis cereus

69

pathogens that usually affect Large bowel present with what?

Associted with?

Locatiion?

what organisms?

-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

70

Persons with Hemochromatosis susceptible to what?

should avoid what?

-Vibrio and Yersinia infections

Avoid Raw Fish