12b Diarrhea

Question 0

Normal BMs

Answer 0

One every 3 days –> 3 every day

Question 1

Diarrhea definition

Answer 1

> 200 gm / 200ml per 24 hrs

Malabsorptive: inadequate absorption- steatorrhea- improves with fasting

Exudative: Purulent- cotinues during fasting

Question 2

Practical diarrhea definition

Answer 2

• > 3 watery stools per day

* Clear increase in frequency or decrease in consistancy over baseline

Question 3

Real diarrhea clues

Answer 3

• Truly watery- or soupy
• Urgency
• Incontinence (not leakage)
• Nocturnal urgency (waking up to poop)
• Flatuphobia

Question 4

Small bowel diarrhea

Answer 4

• Colon acts as “silencer”
• Watery diarrhea large in volume and less frequent
• Bloating, cramping, gas, weight loss
• Evvidence of malabsorption
• WBC or blood rare

Question 5

Large bowel diarrhea

Answer 5

• Frequent small regular stools
• Tenesmus “rectal dry heaves”
• Painful BM
• Fever, bloody mucoid stools
• RBC/WBCs

Question 6

Osmotic diarrhea

Answer 6

Goes away with fasting- does not have nocturnal BMs

• Mannitol- sorbitol
• Dissacharidease deficiency- i.e. lactase D

ELECTROLYTE LEVELS USUALLY LOW
Osmotic gap is very high –> >100

Question 7

Secretory diarrhea

Answer 7

• Usually infectious- enterotoxins blocking absorption, stimulating secretion
• Sometimes endocrine tumor causes
• <50 mOSM osmotic gap

Question 8

Accute vs. Persistentvs. Chronic

Answer 8

4wks

Question 9

Normal stool osmolarity

Answer 9

290 mOsm/kg

Question 10

72 hour fecal fat collection

Answer 10

eat 70-100g
7-14g in feces is abnormal
>14 is diagnostic for fat malabsorption

Question 11

Severe Community Acquired Diarrhea

Answer 11

> 4 fluid stools per day
3 days

87% of these are bacterial

Question 12

Diarrheal bacteria

Answer 12

Salmonella
Shigella
Campylobacter
E. coli 0157:H7
C.diff

Question 13

Diarrheal viruses

Answer 13

Calcivirus- Norwalk
Rota
Adeno
Astro

Question 14

Diarrheal protozoa

Answer 14

Giardia
Cryptosporidium
Entamoeba Histolytica

Question 15

Salmonella Typhi

Answer 15

(non typhoid more common in us)

• Gram neg encapsulated
• Poultry eggs, milk, pet turtles
• Colonic or dysenteric disease
• multiplies n phagosome of cell

Typhoid fever: Anorexia, abd pain, bloating , NVD (bloody), bacteremia fever

Sickle cell anemic patients succeptible to osteomyelitis

Microbiome is protective: antibiotics may worsen disease

Question 16

Shigella

Answer 16

• Gram neg facultative anaerobes
• 10% pediatric diarrheal disease
• VERY CONTAGEOUS FECAL ORAL- daycare/instituttional

usually self limited- usually left colonic involvement
Antibiotics shorten duration
antidiarrheals contraindicated (slow clearance)

RARE:HUS, seizures or arthritis

Question 17

Campylobacter Jejuni

Answer 17

Leading cause of acute bacterial diarrhea
33% of foodbourne illness,
Undercooked poultry, raw milk, contaminated water
500 organisms infective
*8 day incubation
*influenza like prodrome
*Dysenteryin 15-50% of ppatients
*Self limited
*Watery or hemorrhagic- Large or small
*Can mimic appendicitis

Assocaited with guillian barre, reactive arthritis, erythema nodosum (painful nodular bumps on shins)

Question 18

Giardia Lamlia

Answer 18

• Unfiltered fecal oral water contamination

* acute or chronic small bowel disease

Question 19

E. coli

Answer 19

Gram neg Bacill, usually commensual

Question 20

ETEC

Answer 20

Enterotoxogenic E. coli

• Travvelers diarrhea - heat labile toxin, or heat stable toxin
  
  • ^ cAMP- Cl secretion, and prevention of villous NaCl resorption

Question 21

EIEC

Answer 21

Enteroinvasive ecoli
Much like shigella
*bloody diarrhea
*invasion of gut epithelials

Question 22

EAEC

Answer 22

Enteroaggreative E.coli
Attach to enterocytes with fimbria- flagellan ^ IL8 and intestinal inflammation
*Shiga like and Labile toxin- little histologic damage

Question 23

EHEC

Answer 23

Enterohemorragic E. coli 0157:H7
Undercooked beef
4% foodbourne illness
associated with HUS- especially with antibiotics

Question 24

Vibrio Cholerae

Answer 24

* Gram neg bacteria * seafood and contaminated water * noninvasive * Choleratoxin ---> cAMP --> opens CFTR Mostly mild diarrhea 1-5 day incubation can get SEVERE DIARRHEA- treat with supportive care

Question 25

Norovirus

Answer 25

1/2 of all gastroenteritis food, water, person to person Any place people gather Self limited NVD(watery) abdominal pain

Question 26

Rotavirus

Answer 26

*Now a vaccine- previously most common cause of childhood diarrhea and diarrhea death *6 mos - 2 years NVD (watery)

Question 27

Ascaris lumbrocoides

Answer 27

Nematode- | Fecal oral ---> hepatic to pulmonary

Question 28

Strongyoloides

Answer 28

Skin infecting threadworm | Migrate to lungs cough and reswallow

Question 29

Necator and ancyclostoma

Answer 29

Hookworms that penetrate skin Cause IDA from ingesting blood in duodenum Cough and swallow

Question 30

Immunocompromised diarrhea pathoggens

Answer 30

Cryptosporidium MAC CMV

Question 31

Staph diarrhea

Answer 31

Eggs poultry and meat left at room temp- NVD shortly after eating

Question 32

Bacillius Cerus

Answer 32

Reheated fried rice | NVD within 6 hours of rice

Question 33

Clostridium perfringens

Answer 33

8-14 hours after ingestion

Question 34

When are stool studies useful

Answer 34

* >2weeks of diarrhea- otherwise is probably self limited * Severe illness * Oubreaks * requiring of hospitalization * Immunocompromised * Inflammatory bowel patients * some employees need clearance for work

Question 35

Ova and parasite studies

Answer 35

Intermittent shed Repeat 3X 24 hours apart over 3 consecutive days ``` When to order: >14 day diarrhea Travel to mountains Exposure to infants in daycare immunocompromised Community outbreaks ```

Question 36

ELSA and DFA microscopy

Answer 36

Giardia and cryptosporidium

Question 37

Infectious diarrhea treatment

Answer 37

Hydration- with some salt and glucose | gatorade has too much sugar and can worsen symptoms

Question 38

Travelers diarrhea treatment

Answer 38

Moderate to severe disease can be treated with TMP-SMZ or floroquinolone IF IT IS NOT EHEC

Question 39

Empiric diarrheal antibiotics

Answer 39

IF NOT EHEC or C.Diff * >8 stools per day, volume depletion, hospitalized, immunocompromised Fluoroquinolone or Azithromycin and Erythromycin

Question 40

C. Diff

Answer 40

Usually precipitated by clindamycin usage * Treat with metronidazole or oral Vanko. Also : diffacid * toxin A or B * Hypervirulant strains with 16X more A and 23X more B Can precipitate toxic megacolon

Question 41

C. diff illness

Answer 41

``` Bloody, watery diarrhea Fever Abdominal pain Leukocytosis Pseudomembranous colitis ``` Sometimes megacolon, sepsis, perforation and death 10-35% recurrence (risk: Continued antibiotics, age and comorbid conditions, antacids, immunnosuppression or deficiency)

Question 42

Severe Cdiff

Answer 42

Age> 65 yrs Cr > 1.5X baselinee WBC >15K complications: Shock/hypotension Ileus Megacolon

Question 43

Fidaxomicin

Answer 43

Vancomycin alternative - inhibition of RNA poly - treats gram pos anaerobes and anaerobes - does not affect gram negs- preserves intestinal flora - High fecal concentration low serum concentration Less recurrence but much more expensive