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ClinMed II Exam #4 GI > Acute & Chronic Diarrhea > Flashcards

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

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2
Q

Acute diarrhea is 1/3 criteria met for how many days?

A

</= 14 days

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3
Q

Persistent diarrhea is 1/3 criteria met for how many days?

A

15-30 days

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4
Q

Chronic diarrhea is 1/3 criteria met for how many days?

A

> 30 days

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5
Q

What is tenesmus?

A

Painful rectal spasms w/ a strong urge to defecate with little passage of stool

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6
Q

What is dysentery?

A

Abdominal pain, tenesmus, and passage of bloody diarrhea often associated w/ fever

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7
Q

What is hematochezia?

A

Passage of bright red bloody stools

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8
Q

What is acute gastroenteritis?

A

Common infectious disease syndrome causing N/V, diarrhea, abdominal pain

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9
Q

Causes of acute gastroenteritis?

A

Viral, Bacterial, Parasitic

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10
Q

Viral causes of acute gastroenteritis?

A

Norovirus, Rotavirus, Adenovirus, Astrovirus, Coronavirus, some picornaviruses

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11
Q

Bacterial causes of acute gastroenteritis?

A

Shigella, Salmonella, Campylobacter, E. coli, Vibrio, Yersinia, C. diff

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12
Q

Parasitic causes of acute gastroenteritis?

A

Giardia, Amebiasis, Cryptosporidium, Isospora, Cyclospora, Microsporidium

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13
Q

Types of acute gastroenteritis?

A

Infectious (ex. foodbourne), Traveler’s, Antibiotic-related (C. diff)

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14
Q

What is traveler’s diarrhea?

A

Infections which typically occur in patients with a history of recent travel to endemic areas

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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

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16
Q

What region is Traveler’s diarrhea referred to as “Delhi belly”?

A

South/Central/West Asia

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17
Q

What region is Traveler’s diarrhea referred to as “Montezuma’s revenge”?

A

Latin America

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18
Q

What is a major cause of diarrhea among children in developing countries?

A

Traveler’s diarrhea

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19
Q

Transmission of traveler’s diarrhea?

A

Usually contaminated food and water (can be bacteria, viruses, parasites)

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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)

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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

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22
Q

Infectious causes of acute diarrhea can be further divided into what?

A

Acute non-inflammatory, Acute inflammatory

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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

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24
Q

What percentage of acute diarrhea cases are mild/self limited?

A

> 90%

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25
Q

Common characteristics of acute infectious non-inflammatory diarrhea?

A

-Watery/non-bloody, large volume
-Viral, protozoa, non-invasive bacterial causes
-Associated w/ peri-umbilical cramps, bloating, N/V

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26
Q

Organisms disrupt normal absorption and secretory processes in which part of the GI tract in acute infectious non-inflammatory diarrhea?

A

Small intestine

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27
Q

Does tissue invasion occur with acute infectious non-inflammatory diarrhea?

A

No

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28
Q

Are fecal leukocytes present in acute infectious non-inflammatory diarrhea?

A

No, absent d/t no tissue invasion

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29
Q

Viral causes of acute infectious non-inflammatory diarrhea?

A

Noroviruses*, Rotavirus, Adenovirus, Astrovirus, Sapovirus

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30
Q

Protozoal causes of acute infectious non-inflammatory diarrhea?

A

Giardia lamblia, Cryptosporidium, Cyclospora

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31
Q

Bacterial causes of acute infectious non-inflammatory diarrhea with preformed enterotoxin production?

A

S. aureus, Bacillus cereus, Clostridium perfringens

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32
Q

Bacterial causes of acute infectious non-inflammatory diarrhea with enterotoxin production?

A

Enterotoxigenic E. coli (ETEC)*, Vibrio cholera, Vibrio vulnificus

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33
Q

Incubation period for S. aureus (acute non-inflammatory infectious diarrhea)?

A

1-6 hours

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34
Q

Symptoms of S. aureus infection (acute non-inflammatory infectious diarrhea)?

A

N/ V*** /D, abdominal cramping

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35
Q

Common food sources of S. aureus (acute non-inflammatory infectious diarrhea)?

A

Meats, poultry, potato/egg salad, mayo, cream pastries left at room temp, cookouts, potlucks

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36
Q

Incubation period for Bacillus cereus (acute non-inflammatory infectious diarrhea)?

A

1-6 hours

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37
Q

Symptoms of Bacillus cereus infection (acute non-inflammatory infectious diarrhea)?

A

N/ V*** /D, abdominal cramping

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38
Q

Common food sources of Bacillus cereus (acute non-inflammatory infectious diarrhea)?

A

Starchy foods such as fried rice

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39
Q

Incubation period for Clostridium perfringes (acute non-inflammatory infectious diarrhea)?

A

8-16 hours

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40
Q

Clostridium perfringes is also known as what (acute non-inflammatory infectious diarrhea)?

A

Cafeteria germ

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41
Q

Symptoms of Clostridium perfringes infection (acute non-inflammatory infectious diarrhea)?

A

Abdominal cramping, diarrhea, nausea

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42
Q

Common food sources of Clostridium perfringes (acute non-inflammatory infectious diarrhea)?

A

Meats, poultry, gravies, home canned goods

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43
Q

ETEC incubation period (acute non-inflammatory infectious diarrhea)?

A

1-3 days

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44
Q

MC cause of traveler’s diarrhea (acute non-inflammatory infectious diarrhea)?

A

ETEC

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45
Q

Symptoms of ETEC infection (acute non-inflammatory infectious diarrhea)?

A

Watery non-bloody diarrhea, cramps, N/V, fever

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46
Q

Sources of ETEC (acute non-inflammatory infectious diarrhea)?

A

Salads, cheese, meats, water, fruits, travel, untreated drinking water/ice

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47
Q

Norovirus incubation period (acute non-inflammatory infectious diarrhea)?

A

24-48 hours

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48
Q

Common places for Norovirus outbreaks (acute non-inflammatory infectious diarrhea)?

A

Restaurants, healthcare facilities, schools/childcare centers, cruise ships, military populations

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49
Q

MC cause of watery diarrhea (acute non-inflammatory infectious diarrhea)?

A

Norovirus

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50
Q

Symptoms of Norovirus infection (acute non-inflammatory infectious diarrhea)?

A

N/V, vomiting predominant, non-bloody diarrhea, abdominal cramps

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51
Q

Sources of Norovirus (acute non-inflammatory infectious diarrhea)?

A

Shellfish, prepared foods, vegetables, fruits

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52
Q

Incubation times of other enteric viruses (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)

A

10-72 hours

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53
Q

Common enteric virus outbreaks (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)

A

Daycare centers, households, gastroenteritis in children, immunocompromised adults

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54
Q

Symptoms of enteric virus infection (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)

A

N/V, non-bloody diarrhea, abdominal cramping, fever

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55
Q

Sources of enteric viruses (Rotavirus**, enteric adenovirus, astrovirus, sapovirus)?
(acute non-inflammatory infectious diarrhea)

A

Fecally contaminated food or water

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56
Q

Vibrio cholerae incubation period (acute non-inflammatory infectious diarrhea)?

A

8-16 hours

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57
Q

Symptoms of Vibrio cholerae infection (acute non-inflammatory infectious diarrhea)?

A

Profuse watery diarrhea (Rice water stools), vomiting

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58
Q

Sources of Vibrio cholerae (acute non-inflammatory infectious diarrhea)?

A

Contaminated water supply, seafood from gulf coast

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59
Q

Vibrio vulnificus infection symptoms (acute non-inflammatory infectious diarrhea)?

A

Watery diarrhea, abdominal cramps, N/V, fever

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60
Q

Sources of Vibrio vulnificus (acute non-inflammatory infectious diarrhea)?

A

Raw/undercooked seafood, oysters, seawater

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61
Q

Incubation period of Giardia lamblia (acute non-inflammatory infectious diarrhea)?

A

7-14 days

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62
Q

Common outbreaks of Giardia lamblia (acute non-inflammatory infectious diarrhea)?

A

Daycare centers, swimming pools, travel, hiking, camping (contact w/ water where beavers reside)

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63
Q

What is Giardia lamblia also known as (acute non-inflammatory infectious diarrhea)?

A

“Backpacker’s diarrhea”, “Beaver fever”

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64
Q

Symptoms of Giardia lamblia infection (acute non-inflammatory infectious diarrhea)?

A

Frothy, greasy, foul smelling non-bloody diarrhea (steatorrhea), abdominal cramps, bloating

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65
Q

Incubation period of Cryptosporidium (acute non-inflammatory infectious diarrhea)?

A

2-28 days

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66
Q

Common outbreaks of Cryptosporidium (acute non-inflammatory infectious diarrhea)?

A

Daycare centers, swimming pools/recreational water sources, animal exposure, chronic diarrhea in advanced HIV infection

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67
Q

Symptoms of Cryptosporidium infection (acute non-inflammatory infectious diarrhea)?

A

Watery diarrhea, abdominal cramps, fever, vomiting

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68
Q

Sources of Cryptosporidium (acute non-inflammatory infectious diarrhea)?

A

Vegetables, fruit, unpasteurized milk

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69
Q

Incubation period of Cyclospora (acute non-inflammatory infectious diarrhea)?

A

1-11 days

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70
Q

Is Cyclospora chronic (acute non-inflammatory infectious diarrhea)?

A

Yes

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71
Q

Symptoms of Cyclospora infection (acute non-inflammatory infectious diarrhea)?

A

Watery diarrhea, abdominal cramps, bloating, nausea

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72
Q

Sources of Cyclospora (acute non-inflammatory infectious diarrhea)?

A

Imported berries (raspberries), herbs

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73
Q

Does colonic tissue damage occur in acute inflammatory infectious diarrhea?

A

Yes, d/t bacterial invasion or toxin producing bacteria

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74
Q

Common characteristics of acute inflammatory infectious diarrhea?

A

Commonly presents w/ fever, abdominal pain, bloody or mucoid (pus) diarrhea d/t tissue damage (dysentery), associated w/ LLQ cramps, urgency, tenesmus

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75
Q

Diarrhea characteristics in acute inflammatory infectious diarrhea?

A

Usually small in volume <1L/day

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76
Q

Part of digestive system affected by acute inflammatory infectious diarrhea?

A

Involve the colon/large intestine

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77
Q

Are fecal leukocytes or lactoferrin present in acute inflammatory infectious diarrhea?

A

Present in infections involving invasive organisms

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78
Q

Cytomegalovirus (Viral cause of acute inflammatory infectious diarrhea) commonly affects which populations?

A

Immunocompromised, HIV infected, post-transplant

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79
Q

Characteristics if Entamoeba histolytica (protozoal cause of acute inflammatory infectious diarrhea)?

A

Bloody diarrhea but negative fecal leukocytes

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80
Q

Cytotoxin producing bacterial causes of acute inflammatory infectious diarrhea?

A

EHEC, Vibrio parahaemolyticus, Clostridiodes difficile, Plesiomonas shigelloides

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81
Q

Mucosal invading bacterial causes of acute inflammatory infectious diarrhea?

A

Shigella, Campylobacter jejuni, Salmonella (nonytphoidal)*, EIEC, Yersinia enterocolitica, Chlamydia, Neisseria gonorrhoeae, Listeria monocytogenes, Aeromonas

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82
Q

Incubation period of EHEC (acute inflammatory infectious diarrhea)?

A

1-8 days

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83
Q

Common outbreaks of EHEC (acute inflammatory infectious diarrhea)?

A

Daycare centers, nursing homes, extremes of age

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84
Q

Symptoms of EHEC (acute inflammatory infectious diarrhea)?

A

Bloody diarrhea, abdominal cramps, vomiting, hemorrhagic colitis, HUS

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85
Q

Food sources of EHEC (acute inflammatory infectious diarrhea)?

A

Ground beef (contaminated meat), raw milk, raw veggies, apple juice

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86
Q

Symptoms of EIEC (acute inflammatory infectious diarrhea)?

A

N/V, bloody diarrhea, abdominal cramps, fever/chills

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87
Q

Food sources of EIEC (acute inflammatory infectious diarrhea)?

A

Raw meat, raw milk, eggs, raw veggies

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88
Q

Incubation period of Campylobacter jejuni (acute inflammatory infectious diarrhea)?

A

1-3 days

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89
Q

Common outbreaks of Campylobacter jejuni (acute inflammatory infectious diarrhea)?

A

Travel to resource-limited settings, Animal contact (young puppies, kittens, occupational)

90
Q

Symptoms of Campylobacter jejuni (acute inflammatory infectious diarrhea)?

A

Diarrhea (+/- blood), abdominal cramps, pain, N/V, headache, fever

91
Q

Campylobacter jejuni (acute inflammatory infectious diarrhea) can be a rare cause of what conditions?

A

Guaillain Barre, reactive arthritis

92
Q

Food sources of Campylobacter jejuni (acute inflammatory infectious diarrhea)?

A

Undercooked poultry/meat, raw milk, contaminated water

93
Q

Incubation period of Salmonella (acute inflammatory infectious diarrhea)?

A

6-48 hours

94
Q

Common outbreaks of Salmonella (acute inflammatory infectious diarrhea)?

A

Animal contact (petting zoos, reptiles, live poultry, other pets), Travel to resource-limited settings

95
Q

Symptoms of Salmonella (acute inflammatory infectious diarrhea)?

A

Diarrhea (+/-) bloody, N/V, fever, abdominal cramps, “pea soup” diarrhea

96
Q

Sources of Salmonella (acute inflammatory infectious diarrhea)?

A

Beef, poultry, raw/undercooked eggs, dairy, produce, PB turtles, petting zoos

97
Q

Common causes of Clostridiodes difficile (acute inflammatory infectious diarrhea)?

A

Abx use, hospitalization, cancer chemo, gastric acid suppression, IBD

98
Q

Symptoms of C. diff (acute inflammatory infectious diarrhea)?

A

Watery diarrhea, fever, nausea, Pseudomembranous colitis

99
Q

Food sources of C. diff (acute inflammatory infectious diarrhea)?

A

None

100
Q

Incubation period for Listeria monocytogenes (acute inflammatory infectious diarrhea)?

A

1 day

101
Q

Common outbreaks with Listeria monocytogenes (acute inflammatory infectious diarrhea)?

A

Pregnancy, Immunocompromised, extremes of age

102
Q

Symptoms of Listeria monocytogenes (acute inflammatory infectious diarrhea)?

A

Watery diarrhea (+/- blood), N/V, fever, myalgia, fatigue, arthralgia

103
Q

Food sources of Listeria monocytogenes (acute inflammatory infectious diarrhea)?

A

Processed/delicatessen meats, hot dogs, soft cheeses, pate´s, fruit

104
Q

Incubation period for Shigella (acute inflammatory infectious diarrhea)?

A

24 hours

105
Q

Common outbreaks of Shigella (acute inflammatory infectious diarrhea)?

A

Daycare centers, crowded living conditions, men who have sex with men, travel to resource-limited settings

106
Q

Symptoms of Shigella infection (acute inflammatory infectious diarrhea)?

A

Dysentery, fever, headache, N/V
*associated w/ outbreaks

107
Q

Food sources of Shigella (acute inflammatory infectious diarrhea)?

A

Potato/egg salad, lettuce, raw veggies

108
Q

Incubation period for Yersinia (acute inflammatory infectious diarrhea)?

A

4-6 days

109
Q

Common outbreaks of Yersinia (acute inflammatory infectious diarrhea)?

A

Abnormalities of iron metabolism (cirrhosis, hemachromatosis, thalassemia), blood transfusions

110
Q

Symptoms of Yersinia (acute inflammatory infectious diarrhea)?

A

Bloody diarrhea, fever, abdominal pain (often right sided)/ may be pseudoappendicitis, pharyngitis, jaw pain

111
Q

Food sources of Yersinia (acute inflammatory infectious diarrhea)?

A

Pork, pork products, untreated water, chocolate or raw milk

112
Q

Incubation period of Vibrio parahemolyticus (acute inflammatory infectious diarrhea)?

A

1-3 days

113
Q

Symptoms of Vibrio parahemolyticus (acute inflammatory infectious diarrhea)?

A

Dysentery, abdominal cramps, N/V, fever, headache

114
Q

Food sources of Vibrio parahemolyticus (acute inflammatory infectious diarrhea)?

A

Raw seafood and shellfish

115
Q

Incubation period for Entamoeba histolytica (acute inflammatory infectious diarrhea)?

A

1-3 days

116
Q

Common outbreaks of Entamoeba histolytica (acute inflammatory infectious diarrhea)?

A

Travel to resource limited settings, men who have sex with men

117
Q

Symptoms of Entamoeba histolytica (acute inflammatory infectious diarrhea)?

A

Bloody diarrhea, abdominal pain/cramping, fever, can invade the liver/form liver abscesses, amebic dysentery

118
Q

Food sources of Entamoeba histolytica (acute inflammatory infectious diarrhea)?

A

Fecally contaminated food or water

119
Q

Non-infectious causes of acute diarrhea?

A

IDB, IBS, Celiac, Lactose intolerance, Ischemic colitis (rare), Colorectal cancer, Short bowel syndrome, Malabsorption, Diverticulitis, Extra-intestinal infection, Hyperthyroidism, Medication side effects

120
Q

Examples of drugs that may cause non-infectious acute diarrhea?

A

Abx, Laxative abuse/Mg antacids, Cholinesterase inhibitors, NSAIDs, Alcohol, ARBs, Chemo agents, Metformin, Allopurinol, PPIs, Orlistat

121
Q

History for acute diarrhea?

A

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
Q

Acute diarrhea HPI?

A

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
Q

Vital signs for Acute diarrhea?

A

Temp, HR, RR, BP, Weight

124
Q

Skin/nail characteristics to note if present in acute diarrhea?

A

Turgor, dry, clammy, rash, delayed cap refill

125
Q

Characteristics of mild dehydration in acute diarrhea?

A

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
Q

Characteristics of moderate dehydration in acute diarrhea?

A

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
Q

Characteristics of severe dehydration in acute diarrhea?

A

> /= 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
Q

Should mental status be noted with acute diarrhea?

A

Yes

129
Q

Noteable characteristics of eye exam in acute diarrhea?

A

Pallor or yellowing, redness, pain, sunken eyes, absent tears

130
Q

Noteable characteristics of oral exam in acute diarrhea?

A

Dry or moist mucous membranes, ulcers

131
Q

Notable characteristics of cervical exam in acute diarrhea?

A

Adenopathy, thyromegaly

132
Q

Notable characteristics of lung/cardiac exam in acute diarrhea?

A

CTA, tachycardia or bradycardia

133
Q

Notable characteristics of abdominal exam in acute diarrhea?

A

Bowel sounds, tenderness or s/sx of peritonitis, borborygami

134
Q

Notable characteristics of rectal exam in acute diarrhea?

A

Stool character, presence of blood (guaiac test), perineal erythema

135
Q

Indications for lab testing in severe illness?

A

Profuse/watery diarrhea & signs of dehydration, passage of 6 or more unformed stools per day, severe abdominal pain, need for hospitalization

136
Q

Indications for lab testing with inflammatory diarrhea?

A

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
Q

Should lab testing be done for infants and young children with diarrhea?

A

Yes

138
Q

When should lab testing be done with concerns for C. diff?

A

If diarrhea occurs during/immediately after Abx use, diarrhea onset in hospital

139
Q

Lab testing indications for high risk patients w/ diarrhea?

A

Pregnancy, Age >/= 70, immunocompromised or post-transplant, nursing home patients, comorbidities (cardiac disease), IBD, persistent symptoms >7 days, public health concerns

140
Q

Is general lab testing usually warranted in most patients with acute diarrhea?

A

No, often done in more severe cases

141
Q

General lab testing for acute diarrhea?

A

CBC, BMP, Blood cultures, Urinalysis, CRP/ESR, Blood gasses

142
Q

CBC for acute diarrhea may show what?

A

signs of anemia, leukocytosis (C. diff), thrombocytopenia (HUS - hemolytic uremic syndrome)

143
Q

BMP for acute diarrhea used to assess for what?

A

low K+ levels, renal dysfunction

144
Q

Blood cultures are taken in what cases of acute diarrhea?

A

If systemic illness & high fever

145
Q

Urinalysis will show volume depletion if what characteristics are present?

A

Dark/concentrated urine

146
Q

CRP/ESR for acute diarrhea are markers for what?

A

Inflammation

147
Q

Blood gasses for acute diarrhea are used to assess for what?

A

Assessing acid-base status

148
Q

When should abdominal imaging be done for acute diarrhea?

A

Patients w/ peritoneal signs or ileus

149
Q

Imaging modality for peritoneal signs or ileus in acute diarrhea?

A

CT

150
Q

When should stool be sent for analysis for viral, protozoan, and bacterial pathogens (stool microbial assessment)

A

If dysentery, severe illness, persistent diarrhea >7 days

151
Q

3 most common stool cultures for microbiologic stool testing?

A

Salmonella, Campylobacter, Shigella

152
Q

Microbiologic stool testing for E. coli 0157:H7?

A

Sorbitol MacConkey plates, antigen testing, or PCR

153
Q

Which test are labs adopting to screen for panels of pathogens (viral, bacterial, protozoal)?

A

Multiplex molecular stool testing with nucleic acid amplification (PCR assays)

154
Q

Results for multiplex molecular stool testing with nucleic acid amplification (PCR assays) take how long?

A

About 1-5 hours

155
Q

Other tests for stool microbial assessment?

A

fecal leukocytes, lactoferrin/calprotectin (markers for IBD), Rectal swab (if unable to obtain stool culture)

156
Q

Stool microbial work up for acute bloody diarrhea?

A

Immunoassay or molecular testing for STEC

157
Q

Stool microbial work up for acute bloody diarrhea if fecal leukocytes/lactoferrin negative?

A

Test for intestinal amebiasis w/ ova and parasites for Entamoeba histolytica, antigen testing (Giardia, Cryptosporidium)

158
Q

Stool microbial work up for acute diarrhea with recent hospitalization or Abx?

A

C. diff toxin assay

159
Q

Stool microbial work up for persistent acute diarrhea?

A

Check ova/parasites for amebiasis (Giardia, Cryptosporidium, E. hystolytica)

160
Q

Stool microbial work up for immunocompromised patients with acute diarrhea?

A

Stool culture and ova/parasite testing

161
Q

Stool microbial work up for community outbreaks of acute diarrhea?

A

Viral testing and ova/parasite testing

162
Q

Stool microbial work up for men who have sex with men with acute diarrhea?

A

Stool culture & ova and parasite testing

163
Q

When to admit a patient with acute diarrhea?

A

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
Q

Diet therapy for acute diarrhea?

A

Avoid high fiber foods, fats, milk products, caffeine, alcohol
*BRAT diet encouraged

165
Q

Mainstay of treatment for acute diarrhea?

A

Oral rehydration therapy (ORT)

166
Q

ORT for acute diarrhea consists of what?

A

-Solutions with water, salt, sugar for electrolyte replacement (gatorade, sports drinks, broths)
-Designed formulations or pedialyte
-IV rehydration with lactated ringers if indicated

167
Q

Use of probiotics or prebiotics for treatment of acute diarrhea in adults is not recommended except in cases of what?

A

Post-antibiotic associated illness

168
Q

Anti-diarrheal agents for treatment of mild-moderate acute diarrheal illness?

A

Loperamide (immodium), Bismuth subsalicylate (pepto-bismol)
**USED FOR SYMPTOMATIC RELIEF

169
Q

What kind of agent is loperamide (immodium)?

A

Antimotility agent

170
Q

What kind of agent is bismuth subsalicylate (pepto-bismol)?

A

Antimicrobial and antisecretory agent

171
Q

In which cases should Loperamide be avoided?

A

Systemic toxicity or worsening symptoms despite therapy, dysentery (fever and/or bloody diarrhea), C. diff

172
Q

When can Loperamide be used for symptomatic relief in acute diarrhea?

A

Traveler’s diarrhea and in patients with severe watery diarrhea in combo with Abx

173
Q

What is an antimotility alternative to Loperamide for symptom relief in acute diarrhea?

A

Diphenoxylate (Lomotil) - but not well studied

174
Q

When can Bismuth subsalicylate be useful for symptom relief in acute diarrhea?

A

To control rates of passage of stool in traveler’s diarrhea (safe alternative to loperamide)

175
Q

If vomiting is present in with acute diarrhea, which medication can be given?

A

Antiemetics (Ondansetron)

176
Q

In mild cases of acute diarrhea (1-3 stools/day) that does not limit any activity, what treatment is acceptable?

A

Symptomatic treatment with either anti-diarrheal med (Loperamide, Bismuth subsalicylate)

177
Q

Is empiric antibiotic treatment indicated for all patients with acute diarrhea?

A

No

178
Q

Which infectious acute diarrhea should NOT be treated with Abx?

A

Shiga toxin-producing E. coli (EHEC)

179
Q

Empiric Abx should be tailored to what?

A

results of stool tests when available

180
Q

When is empiric treatment with abx indicated for acute diarrhea?

A

-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
Q

Which antibiotics can be used for therapy in acute diarrhea?

A

Macrolides, Fluoroquinolones, Rifaximin and Rifamycin

182
Q

Drug of choice for Macrolide abx therapy in acute diarrhea?

A

Azithromycin 1g single dose or 500mg

183
Q

Azithromycin preferred in which cases of acute diarrhea?

A

Fever or dysentery, Traveler’s diarrhea from South/Southeast Asia (Thailand) due to fluoroquinolone resistance/ for campylobacter jejuni –> MC cause in Southeast Asia

184
Q

Which fluoroquinolones can be given 1-3x/day for acute diarrhea?

A

Ciprofloxacin 500mg BID, Levofloxacin 500mg BID, Ofloxacin 400mg once daily

185
Q

Which abx should be used as alternatives for acute diarrhea, but not for patients with fever or bloody diarrhea?

A

Rifaximin 200mg TID, Rifamycin two 194mg tabs BID x 3 days

186
Q

Indications for stool parasite testing in acute non-bloody diarrhea?

A

Persistent diarrhea >7 days, Advanced HIV infection (CD4 <200 cells/microL), Men who have sex w men, Community waterborne outbreak

187
Q

Initial clinical eval in approach for acute non-bloody diarrhea stool testing algorithm?

A

Asses duration, frequency, characteristics of sx including fever/abd pain, volume status, exposures/comorbidities

188
Q

Initial management in approach for acute non-bloody diarrhea stool testing algorithm?

A

Fluids and maintenance, symptomatic therapy if desired and not C/I

189
Q

Symptoms that determine severe illness in approach for acute non-bloody diarrhea stool testing algorithm?

A

Fever > 38.5 C (101.3 F), S/sx of hypovolemia, >/= 6 unformed stools in 24 hrs, Severe abdominal pain

190
Q

Symptoms that determine high-risk host factors in approach for acute non-bloody diarrhea stool testing algorithm?

A

Age >/= 70, serious comorbidities (cardiac disease, immunocompromised conditions including advanced HIV)

191
Q

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?

A

Bacterial culture, Molecular testing
Additional tests based on host/exposures: C. diff, Parasites
*Initiate empiric abx

192
Q

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?

A

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
Q

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?

A

No indication for abx or stool testing

194
Q

Step 1 of acute diarrhea assessment algorithm?

A

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
Q

Step 2 testing for acute diarrhea assessment algorithm if Step 1 characteristics are present?

A

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
Q

Step 2 treatment for acute diarrhea assessment algorithm if Step 1 characteristics are present?

A

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
Q

Step 2 treatment for acute diarrhea assessment algorithm if Step 1 characteristics are NOT present?

A

Symptomatic therapy, Anti-diarrheal agents (Loperamide, Bismuth subsalicylate)
If illness resolves, no further tx

198
Q

If illness persists after non-complicated symptomatic treatment acute diarrhea assessment algorithm for 7-10 days or worsens, what tx indicated?

A

Same treatment considerations as acute diarrhea with RF/svere illness

199
Q

Prophylaxis for infectious diarrhea?

A

Hand hygiene, 2 tabs of Bismuth subsalicylate qid, Vaccines

Prophylactgic Abx if high risk pts

200
Q

Prophylaxis for Traveler’s infectious diarrhea?

A

Eat only hot, freshly cooked food, avoid raw veggies/salads/unpeeled fruit, drink only boiled/treated water and avoid ice

201
Q

Vaccines for infectious diarrhea prophylaxis?

A

Rotavirus, S. typhi, V. cholorae

202
Q

Definition of chronic diarrhea?

A

> /= 3 loose or watery stools daily that is present for >/= 4 weeks

203
Q

Are most cases of chronic diarrhea infectious or non-infectious?

A

Non-infectious

204
Q

Classifications of chronic diarrhea?

A

Secretory conditions, Osmotic conditions, Inflammatory conditions, Malabsorptive conditions, Motility disorders, Factitious (osmotic or secretory), Iatrogenic (med induced), Chronic infection

205
Q

When does secretory chronic diarrhea occur?

A

When a stimulating substance increases secretion or decreases absorption of water and electrolytes

206
Q

Symptoms of secretory chronic diarrhea?

A

Large amounts of watery diarrhea (>1L/day), painless stools, no change in sx w/ fasting, nocturnal sx

207
Q

Normal stool osmotic gap with secretory conditions?

A

<50 mOsm/Kg

208
Q

Examples of Secretory that can cause secretory chronic diarrhea?

A

-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)

209
Q

What is osmotic chronic diarrhea?

A

Watery diarrhea resulting from large amounts of poorly absorbed sugars or sugar alcohols

210
Q

Triggers for osmotic chronic diarrhea?

A

Acquired deficiencies such as lactase and intolerances to sugar and sugar alcohols

211
Q

Stool osmotic gap in osmotic conditions?

A

Elevated >125 mOsm/Kg

212
Q

When does osmotic chronic diarrhea resolve and subside?

A

Resolves w/ fasting
Subsides when offending substance removed

213
Q

Symptoms of osmotic chronic diarrhea?

A

Abdominal distention, bloating & flatulence due to increased colonic gas

214
Q

Examples of osmotic chronic diarrhea?

A

-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

215
Q

How to calculate fecal osmotic gap?

A

Fecal osmotic gap = 290-2x(stool sodium + stool potassium)

216
Q

What does fecal osmotic gap help differentiate?

A

Chronic secretory diarrhea (<50 mOsm/Kg) vs. Chronic osmotic diarrhea (>125 mOsm/Kg)

217
Q

When does malabsorption chronic diarrhea occur?

A

Impaired digestion of fat and impaired absorption of fats

218
Q

Symptoms of malabsorption chronic diarrhea?

A

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

219
Q

Examples of Malabsorption conditions that can cause chronic diarrhea?

A

-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)

220
Q

Symptoms of inflammatory chronic diarrhea?

A

Signs/symptoms of inflammation (abd pain, fever, weight loss, blood/pus in stool), positive fecal leukocytes/lactoferrin/elevated calprotectin level

221
Q

Examples of Inflammatory conditions that can lead to chronic diarrhea?

A

IBD (UC, Crohns), Diverticulitis, Microscopic colitis, Immunodeficiency, Malignancies (lymphoma, villous adenocarcinoma, colon carcinoma), invasive bacterial or ulcerative viral infections

222
Q

Slide 39

A

ClinMed II Exam #4 GI (7 decks)

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