Acute and Chronic Diarrhea Flashcards
acute diarrhea
-Diarrhea: persisting < 2 weeks
-Infectious agents, bacterial toxins or meds
-Most cases are likely viral- self limiting
-non-inflammatory and inflammatory
Diarrhea
-Increased stool frequency:
-> 3BM/day
OR
-Liquidity of feces*
OR
-Stool weight >200–300g/24 h
-get pts baseline/normal
-note which problem it is
bacteria, virus, protozoa: acute diarrhea
-take away- many causes, can be small bowel or colon affected, different symptoms
-bacteria- salmonella, e coli, clostridium perfringens, staph aureus (VOMITING, old food, coming out both ends), aeromonas hydrophilia, bacillus cereus, vibrio cholerae
-virus- rotavirus, norovirus, astrovirus
-protozoa- cryptosporidium, microsporidium, cystoisospora, cyclospora, giardia lamblia
where and how diarrhea contracted
-Community outbreaks (nursing homes, schools, cruise ships)- Viral or food source
-Exposure to unpurified water- Giardia (not immune compromised) or Cryptosporidium (immune compromised)
-Contaminated produce- Cyclospora outbreaks
-Antibiotic administration- Clostridium difficile colitis
-Contaminated meat- E. coli, salmonella
-anal intercourse- e. coli
vomiting microbes (chart)
-s aureus***- food left out, picnic
-b cereus
-norwalk like viruses
-old food
watery diarrhea microbes
-c perfringens
-enterotoxigenic e coli** - fecal oral
-enteric viruses** norovirus - fecal oral
-c parvum
-c cayetanensis
-food or water contaminated
inflammatory diarrhea
-often involves bleeding
-campylobacter spp
-nontyphoidal salmonella
-shiga toxin producing e coli*
-shigella spp*
-v parahemolyticus
-vibrio- shellfish
-food and water
-can have more than one strain -> shiga toxin producing e. coli and entertoxigenic e coli (watery diarrhea) - common
non-inflammatory acute diarrhea
-SMALL BOWEL
-Secretory* process in small intestine-
-Stimulates secretion into bowel or decrease absorption
-Periumbilical cramps, bloating, nausea, or vomiting
-Watery, non-bloody diarrhea- Usually mild but can be voluminous -> Tissue invasion does not occur -> fecal leukocytes are not present in stool**
-voluminous- hypokalemia, metabolic acidosis, dehydration
causes of non-inflammatory diarrhea
-viral- noroviruses, rotovirus
-protozal- giardia lamblia, crytosporidum, cyclospora
-bacterial:
-preformed enterotoxin production (consume toxin)- s. aureus, bacillus cereus, clostridium perfringens
-enterotoxin production (produced inside body) - enterotoxigenic e. coli, vibrio cholerae
-e coli- travelers diarrhea- drinking unpure water
-SMALL BOWEL
inflammatory acute diarrhea
-COLON
-Colonic* tissue damage caused by INVASION or TOXIN production:
-Invasion: Shigellosis, Salmonellosis, Campylobacter or Yersinia infection, Amebiasis
-Toxin: C difficile, E coli O157:H7
-Fever, bloody diarrhea - Diarrhea is small volume (< 1 L/d)
-LLQ cramps, urgency, and tenesmus (need to go to bathroom)
- + Fecal leukocytes (usually)
-smaller volume of diarrhea than non inflammatory
most common cause of bloody diarrhea
-e. coli O157:H7 is a toxin producing noninvasive** organism
-organism not invading but the toxin!!
-inflammatory- colon
-MC- contaminated meat
-acute, often severe hemorrhagic coliotis
-less common are shigella, campylobacter, and salmonella species
evaluation of acute diarrhea
-90% with acute non-inflammatory diarrhea:
-mild and self limited*
-bland diet, limit dairy
-approx 5 days
-dx investigation unnecessary - by the time you have results the disease is typically gone…
-goal of initial eval- determine mild disease vs more serious illness
physical exam- assess
-Hydration
-Mental status
-Abdominal tenderness
-Hospitalize: Marked dehydration, toxicity, or marked abdominal pain
when to obtain stool specimens
-Severe illness (fever ≥101.3°F), hypovolemia, ≥6 unformed stools per 24 hours, severe abdominal pain, or hospitalization, hypotensive, high pulse
-Features of inflammatory diarrhea (bloody diarrhea, small volume mucous stools, fever) -> get sample if blood
-High-risk host features (age ≥70 years, cardiac disease, immunosuppression, inflammatory bowel disease, pregnancy)
-Symptoms persisting >1 week
-Public health concerns that are persisting (eg, diarrheal illness in food handlers, health care workers, and individuals in day care centers)
-* consider empiric therapy if sick enough
stool w/u for acute diarrhea
-Fecal leukocytes (chronic diarrhea)- IBD
-Ovum and parasite
-Bacterial culture
-C diff - sterile cup
-Giardia antigen
-viruses
-all in one vial now :)
-***Newer tests are all in one
Order GI pathogen panel PCR if available
treatment for acute diarrhea
-diet- no caffeine
-fluids
-probiotics- most helpful in c diff
-carbs
-small frequent meals
-antidiarrheal agents - NOT RECOMMENDED can bottle up the infection in acute diarrhea like Imodium (pepto bismol is ok bc its antimicrobial)
-antibiotic therapy- empiric antibiotic -> not usually needed -> if severe/bloody etc. -> MC cipro, levofloxacin or azithromycin
specific treatments of acute diarrhea
-Shigellosis: Fluoroquinolone
-Cholera: Doxycycline or Azithromycin
-Traveler’s diarrhea: Fluoroquinolone
-C. difficile infection- Vancomycin
-Giardiasis, and amebiasis: Metronidazole or Tindazole (one day) *
chronic diarrhea
-Decrease in fecal consistency lasting ≥4 wks
-Types:
-Osmotic
-Secretory
-Inflammatory
-Malabsorption
-Motility Disorders
-Chronic Infections
chronic: osmotic diarrhea
-lactose intolerance
-Retention of solute molecules within the bowel lumen generates osmotic forces that retard the normal absorption of water or draw water from the circulation into the intestinal lumen
-influx of fluid into lumen
-causes:
-Disaccharidase deficiency- lactose intolerance
-Lactulose- causes diarrhea (poop out ammonia with encephalopathy)
-Sorbitol- artificial sweetener, not absorbable -> fluid pulling small bowel
-Olestra- fat substitute, not absorbable
-Magnesium containing medications and laxatives- draws water into bowel -> also magnesium supplements
secretory diarrhea: chronic
-Increased intestinal secretion (fluid into lumen) or decreased absorption
-watery diarrhea
-High-volume watery diarrhea and diarrhea with fasting
-not food mediated- can occur with fasting**
-Dehydration/electrolyte imbalance may develop
-Causes:
-Endocrine tumors
-Bile salt malabsorption
-Laxative abuse
inflammatory diarrhea: chronic
-Diarrhea is present in most patients with IBD- Ulcerative colitis, Crohn’s disease
-Other symptoms present: Abdominal pain, fever, weight loss, and hematochezia
malabsorption syndromes: chronic
-The major causes are:
-Small intestinal mucosal diseases - MC celiac (malabsorption of gluten)
-Intestinal resections- malabsorption of fat
-Lymphatic obstruction- malabsorption of fat
-Small intestinal bacterial overgrowth
-Pancreatic insufficiency- cant digest and absorb
-Weight loss, osmotic diarrhea, steatorrhea, and nutritional deficiencies
motility disorders: chronic
-Abnormal intestinal motility causes:
-Rapid transit- dumping syndrome
-Stasis of intestinal contents with bacterial overgrowth
-IBS
-bowel resection
-dumping syndrome
chronic infections
-Chronic parasitic infections:
-Immune competent parasite: Giardia, E. histolytica, and Cyclospora
-Immunocomproised: Microsporida, Cryptosporidium, CMV, Isospora belli, Cyclospora, and Mycobacterium avium complex (HIV, chemo)
-C. Diff- immune competent bacterial -> toxin -> long term
-Post infectious IBS- had infection and its gone -> leaves you with irritable bowel
