The Patient with Diarrhoea Flashcards by Andrew Hay

What is Diarrhoea?

Very subjective

Decreased stool consistency from water, fat, or inflammatory discharge.

Characterised by fluidity and frequency

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What is gastro-enteritis?

3 or more loose stools/day

accompanying features

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What is dysentry?

Large bowel inflammation, bloody stools

Typically diarrhoea and visible blood

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Describe type 1 on the bristol stool chart

Separate hard lumps, like nuts (hard to pass)

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Describe type 2 on the bristol stool chart

Sausage shaped but lumpy

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Describe type 3 on the bristol stool chart

Like a sausage but with cracks on the surface

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Describe type 4 on the bristol stool chart

like a sausage or snake, smooth and soft

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Describe type 5 on the bristol stool chart

Soft blobs with clear cut edges

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Describe type 6 on the bristol stool chart

Fluffy pieces with ragged edges, a mushy stool

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Describe type 7 on the bristol stool chart

Watery, no solid pieces

Entirely liquid

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What 4 things protect against enteric infections?

Hygiene

Stomach acidity

Normal flora

Immunity

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What may decrease stomach acidity and therefore increase risk of infection?

Antacids (omeprazole and ranitidine) and infection

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What may decrease normal flora in the gut and therefore increase risk of infection?

Antibiotics (4 C’s) leading to, classically, C. difficile

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What are the 3 types of diarrhoea and give a basic example of each?

Non-inflammatory/ secretory
-e.g. Cholera

Inflammatory
-e.g. Shigella dysentery

Mixed Picture
-e.g. C. difficile

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How is non-inflammatory diarrhoea usually mediated?

Give 2 examples

Secretory toxin mediated

Cholera (increases cAMP levels and Cl secretion
Enterotoxigenic E. coli (travellers’ diarrhoea)

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What are the features of non-inflammatory diarrhoea?

Frequent watery stools with little abdominal pain

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What is the mainstay treatment for non-inflammatory diarrhoea?

Rehydration

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Give two examples of inflammatory diarrhoea

Bacterial Infection

Amoebic dysentery

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How does infection cause the symptoms seen in inflammatory diarrhoea?

What are these symptoms?

Inflammatory toxin damage and mucosal destruction -> pain and fever

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What is the basics of treatment in inflammatory diarrhoea?

Antimicrobials may be appropriate but rehydration alone is often sufficient

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What duration of symptoms are unlikely to be infective gastro-enteritis?

> 2 weeks

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How can you assess hydration in an adult?

Postural BP

Skin Turgur

Pulse

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What are some of the signs of dehydration in babies?

Sunken Fontanelle

Few or No Tears

Dry Mouth or Tongue

Sunken Eyes and Cheeks

Decreased Skin Turgur

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What investigations do you want to consider in someone presenting with diarrhoea?

Stool culture

Blood culture

Renal function

Blood count- neutrophilic, haemolysis

Abdominal X-ray if abdomen distended, tender

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What are the differential diagnosis of diarrhoea?

Inflammatory bowel disease Spurious diarrhoea- secondary constipation Carcinoma Sepsis outside the gut

Diarrhoea and fever can occur with sepsis outside the gut. What are the signs and symptoms of this?

Lack of abdo pain/tenderness No blood/ mucus in stools

How do you treat gastro-enteritis?

Rehydration - Oral rehydration with salt/sugar solution - IV saline ?Antimicrobials Treatment of complications

What do you not give routinely in gastro-enteritis?

Antidiarrhoeals

What is the incubation period for campylobacter gastroenteritis? What does this mean for finding the cause?

Up to 7 days incubation so dietary history may be unreliable

When do the stools become negative in campylobacter gastroenteritis?

Within 6 weeks

What is it about abdominal pain that can point to possible campylobacter gastroenteritis?

Abdominal pain can be severe

What post infective sequelae may occur with campylobacter gastroenteritis?

Guillain-Barre syndrome Reactive arthritis

How many days does it take to complete all tests in routine bacterial culture?

3 days

What is the commonest cause of bacterial food poisoning in UK?

Campylobacter such as C. Jejuni and C. coli

Do bacterial food poisoning cases caused by campylobacter occur in isolated cases or outbreaks?

Isolated cases

What may cause bacterial food poisoning? (campylobacter)

Chickens Historically contaminated milk Puppies

When do symptoms onset after salmonella gastroenteritis exposure?

Usually

How long does diarrhoea last in salmonella gastroenteritis?

Usually lasts

What cultures are the best way to catch salmonella gastroenteritis? (blood or stool)

Stool -20% patients still have positive stools at 20 weeks -

What post infective sequelae is common with salmonella gastroenteritis?

Post-infective irritable bowel

How is salmonella identified in routine bacterial culture?

Screened out as lactose non-fermenters | -Then antigen and biochemical tests

How does E.coli O157 spread?

Contaminated meat or person-to-person spread

How is E.coli O157 typically spotted (symptoms)?

Typical illness characterised by frequent bloody stools

What toxin does E.coli O157 produce?

Verocyto-toxin

Where does verocytotoxin go once it is released?

E.coli O157 stays in the gut but the toxin gets into the blood

What syndrome can verocytotoxin cause?

Toxin can cause hemolytic-uraemic syndrome (HUS = haemolytic anaemia and renal failure)

How does verocytotoxin cause Haemolytic-uraemic syndrome?

Toxin binds to globotriaosylceramide Platelet activation stimulated Micro-angiopathy results Attach to endothelial, glomerular, tubule and mesangial cells

What other forms of E.coli cause diarrhoea? | not O157

Enteropathogenic Enterotoxic (travellers diarrhoea) Enteroinvasive

How many species of shigella are there?

What bacteria may cause occasional food poisoning outbreaks?

Staph aureus (toxin) Bacillus cereus (re-fried rice) Clostridium perfringens (toxin)

When are antibiotics indicated in gastroenteritis?

Immunocompromised Severe sepsis or invasive infection Valvular heart disease Chronic illness Diabetes

What does the severity of Clostridium difficile diarrhoea range between?

Mild diarrhoea to severe colitis

What does C. Diff produce?

Enterotoxin (A) | Cytotoxin (B)

How do you treat C. Diff?

Stop precipitating antibiotic (if possible) Oral Metronidazole (if no severity markers) ``` Oral Vancomycin (if 2 or more severity markers) -The ONLY disease you give oral vancomycin ``` Surgery may be required

What is pathognomonic for C. Diff?

Pseudomembranous colitis

What are the 4 C's associated with C. Diff infection?

Cephalosporins Co-amoxiclav Clindamycin Clarithromycin (broad spectrum antibiotics)

Why do you need to wash hands between patients in relation to C. Diff infection?

C. Diff spores are resistant to alcohol gel

How is diagnosis usually achieved in parasitology?

Generally by microscopy Send stool with request "parasites, cysts and ova" (P, C and O)

Give 2 broad parasite types that can cause diarrhoea

Protozoa and Helminths

What does giardia lamblia infection lead to? | Signs and symptoms

Diarrhoea Malabsorption Failure to thrive

How is giardia lamblia diagnosed?

Vegetative form in duodenal biopsy or "string test" Cysts seen on stool microscopy

What is the treatment for giardia lamblia?

Metronidazole

How can people get Cryptosporidium parvum?

Contaminated water (animal faeces)

How is cryptosporidium parvum diagnosed and treated?

Cysts seen on microscopy No treatment

What is the other name for Entamoeba histolytica infection?

Amoebic dysentery

How is entamoeba histolytica infection diagnosed?

Vegetative form in symptomatic patient ("hot stool") Cysts seen in asymptomatic patient

What complication may occur with amoebic dysentery?

Amoebic liver abscess may be long term complication ("anchovy pus")

How do you treat amoebic dysentery?

Metronidazole

What is a common cause of diarrhoea in children under 5?

Rotavirus Common in winter

How do you diagnose rotavirus diarrhoea?

Antigen detection

Appart from rotavirus what other virus can cause diarrhoea?

Adenovirus Noroviruses

What is a common viral cause of diarrhoea outbreaks?

Norovirus | Winter vomiting disease

How do you diagnose norovirus?

PCR

How infectious is norovirus?

VERY Ward closures common If one person vomits on a ship the whole ship can be infected

The Patient with Diarrhoea Flashcards

(74 cards)