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ICM > 2: Infectious Diarrhea > Flashcards

2: Infectious Diarrhea Flashcards

1
Q

describe normal stool volume

A

3-7 bowel movements/day

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2
Q

describe acute infectious diarrhea volume

A

20-30 bowel movements/day

up to 20L stool/day

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3
Q

diarrhea reflects increased water in stool from what two mechanisms

A
  1. increased intestinal secretion of water

2. decreased intestinal reabsorption of water

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4
Q

what three things must you differentiate diarrhea from?

A
  1. pseudodiarrhea
  2. fecal incontinence
  3. overflow incontinence
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5
Q

describe pseudodiarrhea

A
  • rectal urgency

- related to anal infection

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6
Q

describe fecal incontinence

A

-sudden discharge involuntarily

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7
Q

describe overflow incontinence

A

-obstupation or chronic constipation, then overflow of liquid stool around the solid stool -> leaks out of rectum

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8
Q

duration of each of the following:

  • acute diarrhea
  • persistent diarrhea
  • chronic diarrhea
A

acute: less than 14d
persistent: 14-30d
chronic: more than 30d

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9
Q

causes of acute diarrhea in healthy adults of developed countries

A
  1. usually viral
  2. more severe diarrhea more likely bacterial
  3. protozoa least common causes
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10
Q

is stool culture high yield?

A

nope - about 1-6% of patients showed positive stool cultures

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11
Q

S. aureus story

A
  • incubation 1-6h
  • major sx: vomit
  • prepared food - salads, dairy, meat
  • cream pie at picnic
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12
Q

B. cereus story

A
  • incubation 1-6h
  • major sx: vomit
  • rice, meat
  • leftover fried rice
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13
Q

Norwalk-like virus story

A
  • incubation 24-48h
  • major sx: vomit
  • shellfish, prepared foods, salads, sandwiches, fruit
  • cruise ships
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14
Q

non-typhoidal salmonella story

A
  • incubation 1-3d
  • major sx: inflammatory diarrhea
  • eggs, poultry, meat, unpasteurized milk or juice, fresh produce
  • hamburgers at picnic
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15
Q

shiga toxin-producing E. coli story

A
  • incubation 1-8d
  • major sx: inflammatory diarrhea
  • ground beef, unpasteurized millk and juice, raw vegetables, water
  • E. coli O157:H7 - hamburgers, spinach
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16
Q

v. parahemolyticus story

A
  • incubation 2-48h
  • major sx: inflammatory diarrhea
  • raw shellfish
  • sushi
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17
Q

v. vulnificus story

A
  • cirrhosis/ decreased immune system pt eating raw oysters in redneck riviera
  • months without an “r”
  • starts as GI issues
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18
Q

review of C. perfringens

A
  • enterotoxin produced by bacteria in small intestine
  • acute gastroenteritis sx: acute watery diarrhea
  • home-canned

-ingested bacteria can cause pig bel (necrotizing enteritis)

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19
Q

review of C botulinum

A
  • paralytic neurotoxin formed by bacteria present in anaerobic environment
  • weakness, diplopia, progresses to paralysis
  • botulism
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20
Q

review of C tetani

A
  • excitatory neurotoxin formed by bacteria present in wounds
  • lockjaw
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21
Q

review of C difficile

A
  • toxin mediated colitis caused by overgrowth of C diff in colon
  • pseudomembranous colitis
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22
Q

norovirus story

A
  • cruise ships
  • schools
  • nursing homes
  • camps
  • military barracks
  • vegetables
  • waterborne or foodborne
  • shellfish-associated outbreaks
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23
Q

rotavirus story

A
  • day care
  • nurseries
  • Australia
24
Q

Hep A story

A
  • MSM (men sex men)
  • shellfish
  • food workers
  • overcrowding
  • lack of clean water
  • patients and staff of institutions
  • day care centers
  • IV drug users
  • traverlers
  • military barracks
  • shellfish
25
Q

Giardia lamblia story

A
  • travel
  • surface water drinking
  • daycare centers
  • swimming pools
  • fruit salad
26
Q

ETEC story

A
  • traveler’s to developing world

- traveler’s diarrhea

27
Q

C. diff story

A
  • hospitalization
  • inpatient or outpatient antibiotics or chemotherapy within the last several weeks
  • daycare
  • antibiotics!!!
28
Q

V. cholerae

A
  • acute, watery diarrhea (rice water stool), large volume
  • no blood or pus in stool, no fever
  • dehydration! - treat with ORT
29
Q

history for patients complaining of diarrhea

A
  • onset of abnormal bowel movements
  • frequency in last 24h
  • presence of blood, mucus
  • do you have to get up in the night for bowel movements?(indicates more pathologic, osmotic cause)
  • associated symptoms - skin/joint, fever, pain
  • exposures - surface water drinking, camping, traveled
  • any recent antibiotic use
30
Q

bristol stool chart classifications

A

type 1: separate hard lumps, like nuts (hard to pass)
type 2: sausage-shaped but lumpy
type 3: like a sausage but with surface cracks
type 4: like a sausage or snake, smooth and soft
type 5: soft blobs with clear-cut edges
type 6: fluffy pieces with ragged edges, a mushy stool
type 7: watery, no solid pieces, entirely liquid

31
Q

physical exam for patients complaining of diarrhea

A
  • vital signs
  • general
  • abdominal exam - tenderness, evidence of surgical abdomen (need immediate surgery)
  • musculoskeletal - arthritis comes with inflam bowel disease
  • skin - associated rashes (watch for severe vasculitic rash)
  • rectal exam
32
Q

what are signs for surgical abdomen

A
  • absence of bowel sounds
  • diffuse, severely tender
  • distended
  • tympanitic
  • rebound, guarding
  • board-like rigidity
33
Q

arthritis vs. arthralgia

A

arthritis - joints red, warm, swollen, tender, evidence of synovitis

arthralgias - just joint pain, no swelling or tenderness

34
Q

what does a severe vasculitic rash look like?

A

non-blanching (like a bruise)

35
Q

what are some anal pathologies that can be in differential?

A
  • anal fissures - trauma, anal sex, constipation; usually not pathological; can cause hematochesia (bright red blood in stool), more benign
  • hemorrhoids
  • anal fistula - tend to be more severe issue, usually acquired from inflammatory bowel disease
  • anorectal HPV (sometimes pt mistakes for hemorrhoids)
36
Q

evaluation of acute diarrhea

A

study UpToDate chart in packet

37
Q

role of testing in acute diarrhea

A
  1. routine stool culture
  2. ova/parasites
  3. endoscopy
38
Q

indications for ova/parasite culture

A

-3 specimens on alternate days (3d)

  • persistent diarrhea
  • persistent diarrhea following travel to Russia, Nepal
39
Q

indications for endoscopy

A

-persistent bloody diarrhea

40
Q

treatment of acute diarrhea: 5 options

A
  • ORT
  • symptomatic therapy
  • probiotics
  • dietary alterations
  • empiric antibiotics
41
Q

describe ORT

A

-1/2 tsp salt
-1/2 tsp baking soda
-4 Tbsp sugar
per L of water

42
Q

describe symptomatic therapy of acute diarrhea

A

anti-motility agents

  • loperamide (imodium)
  • diphenoxylate (lomotil)

bismuth subsalicylate (pepto-bismol)

*don’t give anti-motility to patients w/ C diff b/c can give them toxic megacolon

43
Q

describe probiotics for acute diarrhea

A
  • align

- culturelle

44
Q

describe dietary alterations for acute diarrhea

A
  • avoid dairy (temporary loss of lactase)
  • low-residue diet (“white foods”, cooked vegetables, low fat meats)

BRAT diet

  • bananas
  • rice
  • applesauce
  • toast
45
Q

describe empiric antibiotics for acute diarrhea

A
  • fluoroquinolone (cipro 500 mg BID, levofloxacin 500 mg QD x 3-5d)
  • metronidazole 500 mg TID x 7d

directed therapy guided by culture results (Sanford Guide helpful)

46
Q

chronic diarrhea: secretory type of watery diarrhea

A
  • reduced water absorption
  • nocturnal
  • persists despite fasting
  • microscopic colitis
  • stimulant laxatives (senna)
47
Q

chronic diarrhea: osmotic type of watery diarrhea

A

-related to intake

  • osmotic laxatives (miralax)
  • Olestra (Wow!)
48
Q

chronic diarrhea: functional type of watery diarrhea

A
  • hypermotility
  • improves with fasting

-irritable bowel syndrome

49
Q

chronic diarrhea: malabsorptive/osmotic type of fatty diarrhea

A
  • bloating
  • gas
  • steatorrhea
  • giardiasis
  • celiac disease
50
Q

chronic diarrhea: maldigestive type of fatty diarrhea

A

-loss of digestive fxn (meat fibers)

  • chronic pancreatitis
  • cystic fibrosis
51
Q

chronic diarrhea: IBD type of inflammatory diarrhea

A
  • WBCs
  • pus
  • blood
  • ulcerative colitis
  • Crohn’s disease
52
Q

chronic diarrhea: invasive type of inflammatory diarrhea

A
  • infectious causes (pus)

- C diff

53
Q

chronic diarrhea: neoplasia type of inflammatory diarrhea

A
  • associated weight loss
  • abdominal pain

-Colon carcinoma

54
Q

which bugs cause diarrhea from the small bowel + what is the mechanism of each?

A
  • Salmonella (dysentery - bloody)
  • E. coli (dysentery - bloody)
  • C. perfringens (preformed toxin - large volume, watery)
  • S. aureus (preformed toxin - large volume, watery)
  • B. cereus (preformed toxin - large volume, watery)
  • V. cholerae (enterotoxin)
  • Giardia lamblia (enteroadherent)
55
Q

which bugs cause diarrhea from the colon + what is the mechanism of each?

A
  • Campylobacter (dysentery - bloody)
  • Shigella (dysentery - bloody)
  • C. diff (cytotoxin - bloody, abdominal pain)
  • E. coli O157:H7 (cytotoxin)
  • E. histolytica (dysentery - bloody)

ICM (26 decks)

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