Acute & Chronic Diarrhea Flashcards
1
Q
Diarrhea is present if one of which criteria is filled?
A
One of the following:
1. frequent defecation >/= 3x a day
2. altered stool consistency (increased water content) –> increased stool volume of 200 mL/day
3. increase in stool quantity > 200-500 g/day
2
Q
Acute diarrhea is 1/3 criteria met for how many days?
A
</= 14 days
3
Q
Persistent diarrhea is 1/3 criteria met for how many days?
A
15-30 days
4
Q
Chronic diarrhea is 1/3 criteria met for how many days?
A
> 30 days
5
Q
What is tenesmus?
A
Painful rectal spasms w/ a strong urge to defecate with little passage of stool
6
Q
What is dysentery?
A
Abdominal pain, tenesmus, and passage of bloody diarrhea often associated w/ fever
7
Q
What is hematochezia?
A
Passage of bright red bloody stools
8
Q
What is acute gastroenteritis?
A
Common infectious disease syndrome causing N/V, diarrhea, abdominal pain
9
Q
Causes of acute gastroenteritis?
A
Viral, Bacterial, Parasitic
10
Q
Viral causes of acute gastroenteritis?
A
Norovirus, Rotavirus, Adenovirus, Astrovirus, Coronavirus, some picornaviruses
11
Q
Bacterial causes of acute gastroenteritis?
A
Shigella, Salmonella, Campylobacter, E. coli, Vibrio, Yersinia, C. diff
12
Q
Parasitic causes of acute gastroenteritis?
A
Giardia, Amebiasis, Cryptosporidium, Isospora, Cyclospora, Microsporidium
13
Q
Types of acute gastroenteritis?
A
Infectious (ex. foodbourne), Traveler’s, Antibiotic-related (C. diff)
14
Q
What is traveler’s diarrhea?
A
Infections which typically occur in patients with a history of recent travel to endemic areas
15
Q
Epidemiology of Traveler’s diarrhea?
A
Very common if traveling in Southeast Asia, South/Central/West Asia, sub-Saharan Africa, Latin America, Middle East
16
Q
What region is Traveler’s diarrhea referred to as “Delhi belly”?
A
South/Central/West Asia
17
Q
What region is Traveler’s diarrhea referred to as “Montezuma’s revenge”?
A
Latin America
18
Q
What is a major cause of diarrhea among children in developing countries?
A
Traveler’s diarrhea
19
Q
Transmission of traveler’s diarrhea?
A
Usually contaminated food and water (can be bacteria, viruses, parasites)
20
Q
Etiologies of traveler’s diarrhea?
A
MC: enterotoxigenic E. coli (ETEC)**
Other common pathogen causes: Campylobacter jejuni, Shigella, Salmonella, other E. coli strains (EAEC), protozoa (Giardia), viral (norovirus, rotavirus, astrovirus)
21
Q
Clinical features of traveler’s diarrhea?
A
Depends on cause/may include:
loose/watery stools, abdominal cramping, bloating, N/V, urgency to have BM, fever, headache, hematochezia, painful BMs
22
Q
Infectious causes of acute diarrhea can be further divided into what?
A
Acute non-inflammatory, Acute inflammatory
23
Q
Non-infectious causes of acute diarrhea?
A
Adverse drug effects, food allergies/intolerances (lactose, sorbitol, fructose, gluten), GI diseases (IBD, IBS, Colitis), hyperthyroid, carcinoid syndrome
24
Q
What percentage of acute diarrhea cases are mild/self limited?
A
> 90%
25
Common characteristics of acute infectious non-inflammatory diarrhea?
-Watery/non-bloody, large volume
-Viral, protozoa, non-invasive bacterial causes
-Associated w/ peri-umbilical cramps, bloating, N/V
26
Organisms disrupt normal absorption and secretory processes in which part of the GI tract in acute infectious non-inflammatory diarrhea?
Small intestine
27
Does tissue invasion occur with acute infectious non-inflammatory diarrhea?
No
28
Are fecal leukocytes present in acute infectious non-inflammatory diarrhea?
No, absent d/t no tissue invasion
29
Viral causes of acute infectious non-inflammatory diarrhea?
Noroviruses*, Rotavirus, Adenovirus, Astrovirus, Sapovirus
30
Protozoal causes of acute infectious non-inflammatory diarrhea?
Giardia lamblia, Cryptosporidium, Cyclospora
31
Bacterial causes of acute infectious non-inflammatory diarrhea with preformed enterotoxin production?
S. aureus, Bacillus cereus, Clostridium perfringens
32
Bacterial causes of acute infectious non-inflammatory diarrhea with enterotoxin production?
Enterotoxigenic E. coli (ETEC)*, Vibrio cholera, Vibrio vulnificus
33
Incubation period for S. aureus (acute non-inflammatory infectious diarrhea)?
1-6 hours
34
Symptoms of S. aureus infection (acute non-inflammatory infectious diarrhea)?
N/ V*** /D, abdominal cramping
35
Common food sources of S. aureus (acute non-inflammatory infectious diarrhea)?
Meats, poultry, potato/egg salad, mayo, cream pastries left at room temp, cookouts, potlucks
36
Incubation period for Bacillus cereus (acute non-inflammatory infectious diarrhea)?
1-6 hours
37
Symptoms of Bacillus cereus infection (acute non-inflammatory infectious diarrhea)?
N/ V*** /D, abdominal cramping
38
Common food sources of Bacillus cereus (acute non-inflammatory infectious diarrhea)?
Starchy foods such as fried rice
39
Incubation period for Clostridium perfringes (acute non-inflammatory infectious diarrhea)?
8-16 hours
40
Clostridium perfringes is also known as what (acute non-inflammatory infectious diarrhea)?
Cafeteria germ
41
Symptoms of Clostridium perfringes infection (acute non-inflammatory infectious diarrhea)?
Abdominal cramping, diarrhea, nausea
42
Common food sources of Clostridium perfringes (acute non-inflammatory infectious diarrhea)?
Meats, poultry, gravies, home canned goods
43
ETEC incubation period (acute non-inflammatory infectious diarrhea)?
1-3 days
44
MC cause of traveler's diarrhea (acute non-inflammatory infectious diarrhea)?
ETEC
45
Symptoms of ETEC infection (acute non-inflammatory infectious diarrhea)?
Watery non-bloody diarrhea, cramps, N/V, fever
46
Sources of ETEC (acute non-inflammatory infectious diarrhea)?
Salads, cheese, meats, water, fruits, travel, untreated drinking water/ice
47
Norovirus incubation period (acute non-inflammatory infectious diarrhea)?
24-48 hours
48
Common places for Norovirus outbreaks (acute non-inflammatory infectious diarrhea)?
Restaurants, healthcare facilities, schools/childcare centers, cruise ships, military populations
49
MC cause of watery diarrhea (acute non-inflammatory infectious diarrhea)?
Norovirus
50
Symptoms of Norovirus infection (acute non-inflammatory infectious diarrhea)?
N/V, vomiting predominant, non-bloody diarrhea, abdominal cramps
51
Sources of Norovirus (acute non-inflammatory infectious diarrhea)?
Shellfish, prepared foods, vegetables, fruits
52
Incubation times of other enteric viruses (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)
10-72 hours
53
Common enteric virus outbreaks (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)
Daycare centers, households, gastroenteritis in children, immunocompromised adults
54
Symptoms of enteric virus infection (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)
N/V, non-bloody diarrhea, abdominal cramping, fever
55
Sources of enteric viruses (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)
Fecally contaminated food or water
56
Vibrio cholerae incubation period (acute non-inflammatory infectious diarrhea)?
8-16 hours
57
Symptoms of Vibrio cholerae infection (acute non-inflammatory infectious diarrhea)?
Profuse watery diarrhea (Rice water stools), vomiting
58
Sources of Vibrio cholerae (acute non-inflammatory infectious diarrhea)?
Contaminated water supply, seafood from gulf coast
59
Vibrio vulnificus infection symptoms (acute non-inflammatory infectious diarrhea)?
Watery diarrhea, abdominal cramps, N/V, fever
60
Sources of Vibrio vulnificus (acute non-inflammatory infectious diarrhea)?
Raw/undercooked seafood, oysters, seawater
61
Incubation period of Giardia lamblia (acute non-inflammatory infectious diarrhea)?
7-14 days
62
Common outbreaks of Giardia lamblia (acute non-inflammatory infectious diarrhea)?
Daycare centers, swimming pools, travel, hiking, camping (contact w/ water where beavers reside)
63
What is Giardia lamblia also known as (acute non-inflammatory infectious diarrhea)?
"Backpacker's diarrhea", "Beaver fever"
64
Symptoms of Giardia lamblia infection (acute non-inflammatory infectious diarrhea)?
Frothy, greasy, foul smelling non-bloody diarrhea (steatorrhea), abdominal cramps, bloating
65
Incubation period of Cryptosporidium (acute non-inflammatory infectious diarrhea)?
2-28 days
66
Common outbreaks of Cryptosporidium (acute non-inflammatory infectious diarrhea)?
Daycare centers, swimming pools/recreational water sources, animal exposure, chronic diarrhea in advanced HIV infection
67
Symptoms of Cryptosporidium infection (acute non-inflammatory infectious diarrhea)?
Watery diarrhea, abdominal cramps, fever, vomiting
68
Sources of Cryptosporidium (acute non-inflammatory infectious diarrhea)?
Vegetables, fruit, unpasteurized milk
69
Incubation period of Cyclospora (acute non-inflammatory infectious diarrhea)?
1-11 days
70
Is Cyclospora chronic (acute non-inflammatory infectious diarrhea)?
Yes
71
Symptoms of Cyclospora infection (acute non-inflammatory infectious diarrhea)?
Watery diarrhea, abdominal cramps, bloating, nausea
72
Sources of Cyclospora (acute non-inflammatory infectious diarrhea)?
Imported berries (raspberries), herbs
73
Does colonic tissue damage occur in acute inflammatory infectious diarrhea?
Yes, d/t bacterial invasion or toxin producing bacteria
74
Common characteristics of acute inflammatory infectious diarrhea?
Commonly presents w/ fever, abdominal pain, bloody or mucoid (pus) diarrhea d/t tissue damage (dysentery), associated w/ LLQ cramps, urgency, tenesmus
75
Diarrhea characteristics in acute inflammatory infectious diarrhea?
Usually small in volume <1L/day
76
Part of digestive system affected by acute inflammatory infectious diarrhea?
Involve the colon/large intestine
77
Are fecal leukocytes or lactoferrin present in acute inflammatory infectious diarrhea?
Present in infections involving invasive organisms
78
Cytomegalovirus (Viral cause of acute inflammatory infectious diarrhea) commonly affects which populations?
Immunocompromised, HIV infected, post-transplant
79
Characteristics if Entamoeba histolytica (protozoal cause of acute inflammatory infectious diarrhea)?
Bloody diarrhea but negative fecal leukocytes
80
Cytotoxin producing bacterial causes of acute inflammatory infectious diarrhea?
EHEC, Vibrio parahaemolyticus, Clostridiodes difficile, Plesiomonas shigelloides
81
Mucosal invading bacterial causes of acute inflammatory infectious diarrhea?
Shigella*, Campylobacter jejuni*, Salmonella (nonytphoidal)*, EIEC, Yersinia enterocolitica, Chlamydia, Neisseria gonorrhoeae, Listeria monocytogenes, Aeromonas
82
Incubation period of EHEC (acute inflammatory infectious diarrhea)?
1-8 days
83
Common outbreaks of EHEC (acute inflammatory infectious diarrhea)?
Daycare centers, nursing homes, extremes of age
84
Symptoms of EHEC (acute inflammatory infectious diarrhea)?
Bloody diarrhea, abdominal cramps, vomiting, hemorrhagic colitis, HUS
85
Food sources of EHEC (acute inflammatory infectious diarrhea)?
Ground beef (contaminated meat), raw milk, raw veggies, apple juice
86
Symptoms of EIEC (acute inflammatory infectious diarrhea)?
N/V, bloody diarrhea, abdominal cramps, fever/chills
87
Food sources of EIEC (acute inflammatory infectious diarrhea)?
Raw meat, raw milk, eggs, raw veggies
88
Incubation period of Campylobacter jejuni (acute inflammatory infectious diarrhea)?
1-3 days
89
Common outbreaks of Campylobacter jejuni (acute inflammatory infectious diarrhea)?
Travel to resource-limited settings, Animal contact (young puppies, kittens, occupational)
90
Symptoms of Campylobacter jejuni (acute inflammatory infectious diarrhea)?
Diarrhea (+/- blood), abdominal cramps, pain, N/V, headache, fever
91
Campylobacter jejuni (acute inflammatory infectious diarrhea) can be a rare cause of what conditions?
Guaillain Barre, reactive arthritis
92
Food sources of Campylobacter jejuni (acute inflammatory infectious diarrhea)?
Undercooked poultry/meat, raw milk, contaminated water
93
Incubation period of Salmonella (acute inflammatory infectious diarrhea)?
6-48 hours
94
Common outbreaks of Salmonella (acute inflammatory infectious diarrhea)?
Animal contact (petting zoos, reptiles, live poultry, other pets), Travel to resource-limited settings
95
Symptoms of Salmonella (acute inflammatory infectious diarrhea)?
Diarrhea (+/-) bloody, N/V, fever, abdominal cramps, "pea soup" diarrhea
96
Sources of Salmonella (acute inflammatory infectious diarrhea)?
Beef, poultry, raw/undercooked eggs, dairy, produce, PB turtles, petting zoos
97
Common causes of Clostridiodes difficile (acute inflammatory infectious diarrhea)?
Abx use, hospitalization, cancer chemo, gastric acid suppression, IBD
98
Symptoms of C. diff (acute inflammatory infectious diarrhea)?
Watery diarrhea, fever, nausea, Pseudomembranous colitis
99
Food sources of C. diff (acute inflammatory infectious diarrhea)?
None
100
Incubation period for Listeria monocytogenes (acute inflammatory infectious diarrhea)?
1 day
101
Common outbreaks with Listeria monocytogenes (acute inflammatory infectious diarrhea)?
Pregnancy, Immunocompromised, extremes of age
102
Symptoms of Listeria monocytogenes (acute inflammatory infectious diarrhea)?
Watery diarrhea (+/- blood), N/V, fever, myalgia, fatigue, arthralgia
103
Food sources of Listeria monocytogenes (acute inflammatory infectious diarrhea)?
Processed/delicatessen meats, hot dogs, soft cheeses, pate´s, fruit
104
Incubation period for Shigella (acute inflammatory infectious diarrhea)?
24 hours
105
Common outbreaks of Shigella (acute inflammatory infectious diarrhea)?
Daycare centers, crowded living conditions, men who have sex with men, travel to resource-limited settings
106
Symptoms of Shigella infection (acute inflammatory infectious diarrhea)?
Dysentery, fever, headache, N/V
*associated w/ outbreaks
107
Food sources of Shigella (acute inflammatory infectious diarrhea)?
Potato/egg salad, lettuce, raw veggies
108
Incubation period for Yersinia (acute inflammatory infectious diarrhea)?
4-6 days
109
Common outbreaks of Yersinia (acute inflammatory infectious diarrhea)?
Abnormalities of iron metabolism (cirrhosis, hemachromatosis, thalassemia), blood transfusions
110
Symptoms of Yersinia (acute inflammatory infectious diarrhea)?
Bloody diarrhea, fever, abdominal pain (often right sided)/ may be pseudoappendicitis, pharyngitis, jaw pain
111
Food sources of Yersinia (acute inflammatory infectious diarrhea)?
Pork, pork products, untreated water, chocolate or raw milk
112
Incubation period of Vibrio parahemolyticus (acute inflammatory infectious diarrhea)?
1-3 days
113
Symptoms of Vibrio parahemolyticus (acute inflammatory infectious diarrhea)?
Dysentery, abdominal cramps, N/V, fever, headache
114
Food sources of Vibrio parahemolyticus (acute inflammatory infectious diarrhea)?
Raw seafood and shellfish
115
Incubation period for Entamoeba histolytica (acute inflammatory infectious diarrhea)?
1-3 days
116
Common outbreaks of Entamoeba histolytica (acute inflammatory infectious diarrhea)?
Travel to resource limited settings, men who have sex with men
117
Symptoms of Entamoeba histolytica (acute inflammatory infectious diarrhea)?
Bloody diarrhea, abdominal pain/cramping, fever, can invade the liver/form liver abscesses, amebic dysentery
118
Food sources of Entamoeba histolytica (acute inflammatory infectious diarrhea)?
Fecally contaminated food or water
119
Non-infectious causes of acute diarrhea?
IDB, IBS, Celiac, Lactose intolerance, Ischemic colitis (rare), Colorectal cancer, Short bowel syndrome, Malabsorption, Diverticulitis, Extra-intestinal infection, Hyperthyroidism, Medication side effects
120
Examples of drugs that may cause non-infectious acute diarrhea?
Abx, Laxative abuse/Mg antacids, Cholinesterase inhibitors, NSAIDs, Alcohol, ARBs, Chemo agents, Metformin, Allopurinol, PPIs, Orlistat
121
History for acute diarrhea?
Change in diet/exposure to tainted or raw food, daycare/senior care center exposure, sick contacts, current/recent hospitalization, untreated water consumption, food ingestion hx, hiking/camping/travel, animal/pet exposure w/diarrhea, recent/regular med use, underlying conditions, Family hx of IBD or carcinoma, sexual activity, anal intercourse/oral-anal contact, occupation (caregiver, food handler)
122
Acute diarrhea HPI?
Onset (abrupt/gradual) & duration, severity (affecting ADLs?), elderly/weakness/hydration status, stool characteristics, frequency/quantity of BMs, Dysentery sx (fever, tenesmus, blood/pus in stool), associated symptoms (abd pain/cramps, fever, N/V in gastroenteritis)
123
Vital signs for Acute diarrhea?
Temp, HR, RR, BP, Weight
124
Skin/nail characteristics to note if present in acute diarrhea?
Turgor, dry, clammy, rash, delayed cap refill
125
Characteristics of mild dehydration in acute diarrhea?
3-5% weight loss, slight inc in thirst, mucous membrane sticky to touch, normal skin turgor/cap refill, normal/slight decrease in urine output
126
Characteristics of moderate dehydration in acute diarrhea?
6-9% weight loss, mod inc in thirst, orthostatic BP changes, skin tenting/dec. turgor, mild delay in cap refill, sunken eyes/dec tear production, dry mucous membranes, dec urine output, tachycardia, tachypnea
127
Characteristics of severe dehydration in acute diarrhea?
>/= 10% weight loss, lethargy, confusion, weak pulse, hypotension, shock, large dec in skin turgor, skin tenting, delayed cap refill >3 sec, significant tachycardia & tachypnea, very dry mucous membranes, deep sunken eyes/no tear production, cool limbs, oliguria or anuria
128
Should mental status be noted with acute diarrhea?
Yes
129
Noteable characteristics of eye exam in acute diarrhea?
Pallor or yellowing, redness, pain, sunken eyes, absent tears
130
Noteable characteristics of oral exam in acute diarrhea?
Dry or moist mucous membranes, ulcers
131
Notable characteristics of cervical exam in acute diarrhea?
Adenopathy, thyromegaly
132
Notable characteristics of lung/cardiac exam in acute diarrhea?
CTA, tachycardia or bradycardia
133
Notable characteristics of abdominal exam in acute diarrhea?
Bowel sounds, tenderness or s/sx of peritonitis, borborygami
134
Notable characteristics of rectal exam in acute diarrhea?
Stool character, presence of blood (guaiac test), perineal erythema
135
Indications for lab testing in severe illness?
Profuse/watery diarrhea & signs of dehydration, passage of 6 or more unformed stools per day, severe abdominal pain, need for hospitalization
136
Indications for lab testing with inflammatory diarrhea?
WBC count >/= 15,000 mcL or anemia, Moderate to severe abd pain, Bloody diarrhea, Dysentery or + FOBT, Hx of fever >101.3 F or 38.5 C
137
Should lab testing be done for infants and young children with diarrhea?
Yes
138
When should lab testing be done with concerns for C. diff?
If diarrhea occurs during/immediately after Abx use, diarrhea onset in hospital
139
Lab testing indications for high risk patients w/ diarrhea?
Pregnancy, Age >/= 70, immunocompromised or post-transplant, nursing home patients, comorbidities (cardiac disease), IBD, persistent symptoms >7 days, public health concerns
140
Is general lab testing usually warranted in most patients with acute diarrhea?
No, often done in more severe cases
141
General lab testing for acute diarrhea?
CBC, BMP, Blood cultures, Urinalysis, CRP/ESR, Blood gasses
142
CBC for acute diarrhea may show what?
signs of anemia, leukocytosis (C. diff), thrombocytopenia (HUS - hemolytic uremic syndrome)
143
BMP for acute diarrhea used to assess for what?
low K+ levels, renal dysfunction
144
Blood cultures are taken in what cases of acute diarrhea?
If systemic illness & high fever
145
Urinalysis will show volume depletion if what characteristics are present?
Dark/concentrated urine
146
CRP/ESR for acute diarrhea are markers for what?
Inflammation
147
Blood gasses for acute diarrhea are used to assess for what?
Assessing acid-base status
148
When should abdominal imaging be done for acute diarrhea?
Patients w/ peritoneal signs or ileus
149
Imaging modality for peritoneal signs or ileus in acute diarrhea?
CT
150
When should stool be sent for analysis for viral, protozoan, and bacterial pathogens (stool microbial assessment)
If dysentery, severe illness, persistent diarrhea >7 days
151
3 most common stool cultures for microbiologic stool testing?
Salmonella, Campylobacter, Shigella
152
Microbiologic stool testing for E. coli 0157:H7?
Sorbitol MacConkey plates, antigen testing, or PCR
153
Which test are labs adopting to screen for panels of pathogens (viral, bacterial, protozoal)?
Multiplex molecular stool testing with nucleic acid amplification (PCR assays)
154
Results for multiplex molecular stool testing with nucleic acid amplification (PCR assays) take how long?
About 1-5 hours
155
Other tests for stool microbial assessment?
fecal leukocytes, lactoferrin/calprotectin (markers for IBD), Rectal swab (if unable to obtain stool culture)
156
Stool microbial work up for acute bloody diarrhea?
Immunoassay or molecular testing for STEC
157
Stool microbial work up for acute bloody diarrhea if fecal leukocytes/lactoferrin negative?
Test for intestinal amebiasis w/ ova and parasites for Entamoeba histolytica, antigen testing (Giardia, Cryptosporidium)
158
Stool microbial work up for acute diarrhea with recent hospitalization or Abx?
C. diff toxin assay
159
Stool microbial work up for persistent acute diarrhea?
Check ova/parasites for amebiasis (Giardia, Cryptosporidium, E. hystolytica)
160
Stool microbial work up for immunocompromised patients with acute diarrhea?
Stool culture and ova/parasite testing
161
Stool microbial work up for community outbreaks of acute diarrhea?
Viral testing and ova/parasite testing
162
Stool microbial work up for men who have sex with men with acute diarrhea?
Stool culture & ova and parasite testing
163
When to admit a patient with acute diarrhea?
Severe dehydration, Bloody diarrhea that is severe or worsening, Severe abdominal pain, Signs of severe infection/sepsis (Temp > 101.3-7 F, leukocytosis, rash) and organ failure, Altered mental status
164
Diet therapy for acute diarrhea?
Avoid high fiber foods, fats, milk products, caffeine, alcohol
*BRAT diet encouraged
165
Mainstay of treatment for acute diarrhea?
Oral rehydration therapy (ORT)
166
ORT for acute diarrhea consists of what?
-Solutions with water, salt, sugar for electrolyte replacement (gatorade, sports drinks, broths)
-Designed formulations or pedialyte
-IV rehydration with lactated ringers if indicated
167
Use of probiotics or prebiotics for treatment of acute diarrhea in adults is not recommended except in cases of what?
Post-antibiotic associated illness
168
Anti-diarrheal agents for treatment of mild-moderate acute diarrheal illness?
Loperamide (immodium), Bismuth subsalicylate (pepto-bismol)
**USED FOR SYMPTOMATIC RELIEF
169
What kind of agent is loperamide (immodium)?
Antimotility agent
170
What kind of agent is bismuth subsalicylate (pepto-bismol)?
Antimicrobial and antisecretory agent
171
In which cases should Loperamide be avoided?
Systemic toxicity or worsening symptoms despite therapy, dysentery (fever and/or bloody diarrhea), C. diff
172
When can Loperamide be used for symptomatic relief in acute diarrhea?
Traveler's diarrhea and in patients with severe watery diarrhea in combo with Abx
173
What is an antimotility alternative to Loperamide for symptom relief in acute diarrhea?
Diphenoxylate (Lomotil) - but not well studied
174
When can Bismuth subsalicylate be useful for symptom relief in acute diarrhea?
To control rates of passage of stool in traveler's diarrhea (safe alternative to loperamide)
175
If vomiting is present in with acute diarrhea, which medication can be given?
Antiemetics (Ondansetron)
176
In mild cases of acute diarrhea (1-3 stools/day) that does not limit any activity, what treatment is acceptable?
Symptomatic treatment with either anti-diarrheal med (Loperamide, Bismuth subsalicylate)
177
Is empiric antibiotic treatment indicated for all patients with acute diarrhea?
No
178
Which infectious acute diarrhea should NOT be treated with Abx?
Shiga toxin-producing E. coli (EHEC)
179
Empiric Abx should be tailored to what?
results of stool tests when available
180
When is empiric treatment with abx indicated for acute diarrhea?
-Severe disease (fever, >6 stools a day, dehydration requiring hospitalization, severe abd pain)
-Pts w/ moderate-severe disase (fever, tenesmus, bloody stools NOT suspicious of STEC)
-Age >70 and comorbidities, immunocompromised +/- dehydration, pregnancy, IBD
-Traveler's diarrhea (moderate-severe cases)
181
Which antibiotics can be used for therapy in acute diarrhea?
Macrolides, Fluoroquinolones, Rifaximin and Rifamycin
182
Drug of choice for Macrolide abx therapy in acute diarrhea?
Azithromycin 1g single dose or 500mg
183
Azithromycin preferred in which cases of acute diarrhea?
Fever or dysentery, Traveler's diarrhea from South/Southeast Asia (Thailand) due to fluoroquinolone resistance/ for campylobacter jejuni --> MC cause in Southeast Asia
184
Which fluoroquinolones can be given 1-3x/day for acute diarrhea?
Ciprofloxacin 500mg BID, Levofloxacin 500mg BID, Ofloxacin 400mg once daily
185
Which abx should be used as alternatives for acute diarrhea, but not for patients with fever or bloody diarrhea?
Rifaximin 200mg TID, Rifamycin two 194mg tabs BID x 3 days
186
Indications for stool parasite testing in acute non-bloody diarrhea?
Persistent diarrhea >7 days, Advanced HIV infection (CD4 <200 cells/microL), Men who have sex w men, Community waterborne outbreak
187
Initial clinical eval in approach for acute non-bloody diarrhea stool testing algorithm?
Asses duration, frequency, characteristics of sx including fever/abd pain, volume status, exposures/comorbidities
188
Initial management in approach for acute non-bloody diarrhea stool testing algorithm?
Fluids and maintenance, symptomatic therapy if desired and not C/I
189
Symptoms that determine severe illness in approach for acute non-bloody diarrhea stool testing algorithm?
Fever > 38.5 C (101.3 F), S/sx of hypovolemia, >/= 6 unformed stools in 24 hrs, Severe abdominal pain
190
Symptoms that determine high-risk host factors in approach for acute non-bloody diarrhea stool testing algorithm?
Age >/= 70, serious comorbidities (cardiac disease, immunocompromised conditions including advanced HIV)
191
If severe illness or high risk host factors are present, what testing and treatment should be initiated in approach for acute non-bloody diarrhea stool testing algorithm?
Bacterial culture, Molecular testing
Additional tests based on host/exposures: C. diff, Parasites
*Initiate empiric abx
192
If severe illness or high risk host factors are NOT present, when should testing and treatment be initiated in approach for acute non-bloody diarrhea stool testing algorithm?
If any of the following:
IBD, pregnancy, symptoms > 1 week despite conservative measures, public health concerns (public health worker, food handler)
*same testing/empiric tx initiation as severe illness and high risk pts
193
If severe illness or high risk host factors are NOT present and there are no concerning characteristics, should testing and treatment be initiated in approach for acute non-bloody diarrhea stool testing algorithm?
No indication for abx or stool testing
194
Step 1 of acute diarrhea assessment algorithm?
Are any of the following present?
1. Severe illness (fever, abd pain, bloody diarrhea, WBC >/= 15,000, >/= 6 stools in 24 hrs, dehydration)
2. Recent Abx use, new community outbreak, hospital acquired, systemic illness
3. Immunocompromised (AIDS, post-transplant)
4. Elderly >70 y/o, Nursing home pt.
195
Step 2 testing for acute diarrhea assessment algorithm if Step 1 characteristics are present?
Send stool for:
-fecal leukocytes & molecular testing (or stool culture), if positive obtain stool culture for confirmation/Abx sensitivity
-C. diff assay if recent hosp./abx
-Serotyping for STEC if bloody
-Ova and Parasite testing x3 if: >7 days, travel to endemic area, community water-borne outbreak, HIV infection, engaging in oral-anal sex
196
Step 2 treatment for acute diarrhea assessment algorithm if Step 1 characteristics are present?
Consider empiric tx while awaiting culture if:
-Fecal leukocytes positive or NAAT positive
-Bloody, fever, abd pain
-Dehydration or >6 stools in 24 hr
-Immunocompromised, >70 y/o, Cardiovascular disease
-Hospitalization required
197
Step 2 treatment for acute diarrhea assessment algorithm if Step 1 characteristics are NOT present?
Symptomatic therapy, Anti-diarrheal agents (Loperamide, Bismuth subsalicylate)
If illness resolves, no further tx
198
If illness persists after non-complicated symptomatic treatment acute diarrhea assessment algorithm for 7-10 days or worsens, what tx indicated?
Same treatment considerations as acute diarrhea with RF/svere illness
199
Prophylaxis for infectious diarrhea?
Hand hygiene, 2 tabs of Bismuth subsalicylate qid, Vaccines
Prophylactgic Abx if high risk pts
200
Prophylaxis for Traveler's infectious diarrhea?
Eat only hot, freshly cooked food, avoid raw veggies/salads/unpeeled fruit, drink only boiled/treated water and avoid ice
201
Vaccines for infectious diarrhea prophylaxis?
Rotavirus, S. typhi, V. cholorae
202
Definition of chronic diarrhea?
>/= 3 loose or watery stools daily that is present for >/= 4 weeks
203
Are most cases of chronic diarrhea infectious or non-infectious?
Non-infectious
204
Classifications of chronic diarrhea?
Secretory conditions, Osmotic conditions, Inflammatory conditions, Malabsorptive conditions, Motility disorders, Factitious (osmotic or secretory), Iatrogenic (med induced), Chronic infection
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When does secretory chronic diarrhea occur?
When a stimulating substance increases secretion or decreases absorption of water and electrolytes
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Symptoms of secretory chronic diarrhea?
Large amounts of watery diarrhea (>1L/day), painless stools, no change in sx w/ fasting, nocturnal sx
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Normal stool osmotic gap with secretory conditions?
<50 mOsm/Kg
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Examples of Secretory that can cause secretory chronic diarrhea?
-Bile salt malabsorption post surgery (bowel resection, cholecystectomy, vagotomy, gastrectomy)
-Endocrine tumors (Carcinoid, VIPoma, Zollinger Ellison Syndrome, medullary carcinoma of thyroid)
-Microscopic colitis
-Meds (Laxative abuse)
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What is osmotic chronic diarrhea?
Watery diarrhea resulting from large amounts of poorly absorbed sugars or sugar alcohols
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Triggers for osmotic chronic diarrhea?
Acquired deficiencies such as lactase and intolerances to sugar and sugar alcohols
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Stool osmotic gap in osmotic conditions?
Elevated >125 mOsm/Kg
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When does osmotic chronic diarrhea resolve and subside?
Resolves w/ fasting
Subsides when offending substance removed
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Symptoms of osmotic chronic diarrhea?
Abdominal distention, bloating & flatulence due to increased colonic gas
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Examples of osmotic chronic diarrhea?
-Carb malabsorption (lactose and fructose intolerance)
-Poorly absorbed osmotic laxatives and antacids (Mg phosphate, sulfate)
-Sugar alcohols (Mannitol, sorbitol, xylitol)
-Malabsorption d/t Celiac disease
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How to calculate fecal osmotic gap?
Fecal osmotic gap = 290-2x(stool sodium + stool potassium)
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What does fecal osmotic gap help differentiate?
Chronic secretory diarrhea (<50 mOsm/Kg) vs. Chronic osmotic diarrhea (>125 mOsm/Kg)
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When does malabsorption chronic diarrhea occur?
Impaired digestion of fat and impaired absorption of fats
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Symptoms of malabsorption chronic diarrhea?
Pale, voluminous, greasy, foul smelling stools (steatorrhea) with associated weight loss, excess gas, nutritional deficiencies, quantitative fecal fat stain and quantitative fecal fat >10g/24hr
**Stool will float
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Examples of Malabsorption conditions that can cause chronic diarrhea?
-Small bowel mucosal intestinal diseases (Celiac, Tropical sprue, Whipple disease, Eosinophilic gastroenteritis, small bowel resection, short bowel syndrome, Crohns)
-Pancreatic disease (chronic pancreatitis, pancreatic cancer)
-Lymphatic obstructions (lymphoma, carcinoid, TB/MAI infection, Sarcoidosis, Kaposi sarcoma)
-Small intestinal bacterial overgrowth (Motility disorders, DM, vagotomy, scleroderma, fistulas, SI diverticula)
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Symptoms of inflammatory chronic diarrhea?
Signs/symptoms of inflammation (abd pain, fever, weight loss, blood/pus in stool), positive fecal leukocytes/lactoferrin/elevated calprotectin level
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Examples of Inflammatory conditions that can lead to chronic diarrhea?
IBD (UC, Crohns), Diverticulitis, Microscopic colitis, Immunodeficiency, Malignancies (lymphoma, villous adenocarcinoma, colon carcinoma), invasive bacterial or ulcerative viral infections
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