Chapter 43 - Diarrhea Flashcards
one of the most common causes of mortality in developing
countries, particularly among impoverished infants, accounting for
1.8 million deaths per year.
Acute infectious diarrhea
results in environmental enteropathy with long-term
impacts on physical and intellectual development.
Recurrent, acute diarrhea in children in
tropical countries
primary function of the small intestine
digestion and
assimilation of nutrients from food
function of small intestine and colon
regulate the secretion and
absorption of water and electrolytes, the storage and subsequent
transport of intraluminal contents aborally, and the salvage of some
nutrients
Alterations in motor and sensory functions of the colon result in highly
prevalent syndromes such as _______, _______, and _________
irritable bowel syndrome (IBS), chronic
diarrhea, and chronic constipation
also called the enteric nervous system, comprises
myenteric, submucosal, and mucosal neuronal layers
intrinsic innervation
regulates smooth-muscle function through intermediary pacemaker-
like cells called the interstitial cells of Cajal
myenteric
plexus
affects secretion, absorption, and mucosal blood flow
submucosal
plexus
receives input from the extrinsic nerves, but it
is capable of independent control of these functions.
enteric nervous system
innervations of the small intestine and colon are part of
the autonomic nervous system and also modulate motor and secretory
functions.
extrinsic innervations
convey visceral sensory pathways
from and excitatory pathways to the small intestine and colon
parasympathetic nerves
Parasympathetic fibers via the vagus nerve reach the small intestine
and proximal colon along the branches of the
superior mesenteric
artery
distal colon is supplied
sacral parasympathetic nerves
(S2–4) via the pelvic plexus
chief excitatory neurotransmitters
controlling motor function
acetylcholine and the tachykinins,
such as substance P
modulates motor
functions and reaches the small intestine and colon
sympathetic nerve supply
Sympathetic input to the gut is generally __________ to
sphincters and ________ to non-sphincteric muscle
excitatory
inhibitory
___ of fluid enter the GI tract, ___ of residual fluid
reaches the colon, and the stool excretion of fluid constitutes about
_____.
9L
~1 L
0.2 L/d
During the fasting period, the motility of the small intestine is characterized
by a cyclical event called the ___________),
which serves to clear nondigestible residue from the small intestine
(the intestinal “housekeeper”).
migrating motor complex (MMC)
MMC lasts for how long and occurs every???
lasts for 4min and occurs every 60-90min
acts as a reservoir, emptying intermittently by bolus
movements. This action allows time for salvage of fluids, electrolytes,
and nutrients.
distal ileum
Segmentation by ______
compartmentalizes the colon and
facilitates mixing, retention of residue,
and formation of solid stools
haustra
The resident microorganisms, predominantly \_\_\_\_\_\_\_\_\_\_, in the colon are necessary for the digestion of unabsorbed carbohydrates that reach the colon even in health, thereby providing a vital source of nutrients to the mucosa.
anaerobic bacteria
regions
of colon function as reservoirs (average
transit time,____)
ascending and transverse regions
15h
region of the colon that acts as a conduit (average transit time, ____).
descending colon
3h
efficient
at conserving sodium and water, a function that is particularly important
in sodium-depleted patients in whom the small intestine alone
is unable to maintain sodium balance
colon
result from alteration in the reservoir function of the proximal colon
or the propulsive function of the left colon.
Diarrhea or constipation
result from disturbances of the rectal or sigmoid reservoir, typically
as a result of dysfunction of the pelvic floor, the anal sphincters, the
coordination of defecation, or dehydration.
constipation
associated with mass movements through the colon and
normally occur approximately five times per day, usually on awakening
in the morning and postprandially
short duration or phasic contractions
high-amplitude (>75 mmHg) propagated contractions (HAPCs)
refers to the background contractility upon which
phasic contractile activity (typically contractions lasting <15 s) is superimposed
Colonic tone
After meal ingestion, colonic phasic and tonic contractility increases for
a period of ____
~2 h
The initial phase (~10 min) is mediated by the ______ in response to mechanical distention of the stomach
vagus nerve
Tonic contraction of the ____________, which forms a sling
around the rectoanal junction, is important to maintain continence
puborectalis muscle
during defecation, ______________ relax this muscle,
facilitating the straightening of the rectoanal angle
sacral parasympathetic nerves
Distention
of the rectum results in transient relaxation of the internal anal
sphincter via _______________.
intrinsic and reflex sympathetic innervation
loosely defined as passage of abnormally liquid or
unformed stools at an increased frequency
Diarrhea
diarrhea in adults
typical
Western diet, stool weight >200 g/d
acute diarrhea
<2 weeks
persistent diarrhea
2-4 weeks
chronic diarrhea
> 4 weeks
frequent
passage of small volumes of stool, is often associated with rectal
urgency, tenesmus, or a feeling of incomplete evacuation, and accompanies
IBS or proctitis
Pseudodiarrhea
involuntary discharge of
rectal contents and is most often caused by neuromuscular disorders
or structural anorectal problems
Fecal incontinence
may occur in nursing
home patients due to fecal impaction that is readily detectable by rectal
examination.
Overflow diarrhea
More than 90% of cases of acute diarrhea are caused by ______________
infectious
agents
acute diarrhea is accompanied by_________
vomiting, fever, and
abdominal pain
Disturbances of flora by antibiotics can lead to diarrhea
by reducing the digestive function or by allowing the overgrowth of
pathogens, such as ____________
Clostridium difficile
five high-risk groups in US
- Travelers
- Consumers of certain foods
- Immunodeficient persons
- Daycare attendees and their family members
- Institutionalized persons
Nearly 40% of tourists to endemic regions of Latin America,
Africa, and Asia develop so-called traveler’s diarrhea, most commonly
due to __________
enterotoxigenic or enteroaggregative Escherichia coli as
well as to Campylobacter, Shigella, Aeromonas, norovirus, Coronavirus,
and Salmonella
Visitors to Russia (especially St. Petersburg) may
have increased risk of _________
Giardia-associated diarrhea
Campers, backpackers, and swimmers in
wilderness areas may become infected with __________
Giardia
Cruise ships
may be affected by outbreaks of gastroenteritis caused by agents
such as ______
norovirus
chicken
Salmonella, Campylobacter, or Shigella
undercooked hamburger
enterohemorrhagic
E. coli (O157:H7)
fried rice or other reheated food
Bacillus cereus
mayonnaise or creams
Staphylococcus aureus or
Salmonella
eggs
Salmonella
fresh or frozen uncooked foods or soft cheeses
Listeria
seafood
Vibrio species,
Salmonella, or acute hepatitis A
primary immunodeficiency
IgA deficiency,
common variable hypogammaglobulinemia, chronic granulomatous
disease
secondary immunodeficiency
states
AIDS, senescence, pharmacologic suppression
In patients with AIDS, agents
transmitted venereally per rectum or by extension from vaginal
infection (e.g., Neisseria gonorrhoeae, Treponema pallidum, Chlamydia)
may contribute to ________
proctocolitis
most common microorganism in institutionalized persons
C. difficile
Profuse, watery diarrhea secondary to small-bowel hypersecretion
occurs with _____________, _______________, ____________
ingestion of preformed bacterial toxins
enterotoxin-
producing bacteria
enteroadherent pathogens
Diarrhea
associated with marked vomiting and minimal or no fever may occur
abruptly within a few hours
ingestion of preformed bacterial toxins
enterotoxin-
producing bacteria
vomiting is usually less, abdominal cramping or bloating is greater,
and fever is higher
enteroadherent pathogens
cause high fever and abdominal pain
Cytotoxin-producing and invasive
microorganisms
cause bloody diarrhea
Invasive
bacteria and Entamoeba histolytica
bloody diarrhea
dysentery
invades the terminal ileal and proximal colon
mucosa and may cause especially severe abdominal pain with tenderness
mimicking acute appendicitis
Yersinia
Reactive arthritis (formerly known as Reiter’s syndrome),
arthritis, urethritis, and conjunctivitis may accompany or follow infections
by _______, ____________, ________, _______.
Salmonella, Campylobacter, Shigella, and Yersinia
may
also lead to an autoimmune-type thyroiditis, pericarditis, and glomerulonephritis.
Yersiniosis
can
lead to the hemolytic-uremic syndrome with an attendant high mortality
rate
enterohemorrhagic E. coli (O157:H7) and Shigella
recognized as
a complication of infectious diarrhea
postinfectious IBS
may precede the diagnosis of celiac disease or Crohn’s disease
acute gastroenteritis
most
common noninfectious causes of acute diarrhea, and etiology may be
suggested by a temporal association between use and symptom onset
Side effects from medications
frequently incriminated medications that may produce diarrhea
antibiotics, cardiac antidysrhythmics,
antihypertensives, nonsteroidal anti-inflammatory drugs
(NSAIDs), certain antidepressants, chemotherapeutic agents, bronchodilators,
antacids, and laxatives
typically occurs in persons aged >50 years; often presents as
acute lower abdominal pain preceding watery, then bloody diarrhea;
and generally results in acute inflammatory changes in the sigmoid or
left colon while sparing the rectum
Occlusive or nonocclusive ischemic
colitis
Indications for evaluation in acute diarrhea
profuse diarrhea with
dehydration,
grossly bloody stools,
fever ≥38.5°C (≥101°F)
duration
>48 h without improvement, recent antibiotic use, new community
outbreaks, associated severe abdominal pain in patients aged
>50 years, and elderly (≥70 years) or immunocompromised patients
cornerstone of diagnosis in those suspected of severe acute
infectious diarrhea
microbiologic analysis of the stool
Workup
included in microbiologic analysis of the stool
cultures for bacterial and viral pathogens; direct inspection
for ova and parasites; and immunoassays for certain bacterial toxins
(C. difficile), viral antigens (rotavirus), and protozoal antigens (Giardia,
E. histolytica)
Persistent diarrhea is commonly due to _____ (Chap. 218),
but additional causative organisms that should be considered
include _____ (especially if antibiotics had been administered),
E. histolytica, Cryptosporidium, Campylobacter
Giardia
C. difficile
If stool
studies are unrevealing, _________ with biopsies and
________ with duodenal aspirates and biopsies may be
indicated
flexible sigmoidoscopy
upper endoscopy
abrupt-onset diarrhea that persists for at least
4 weeks, but may last 1–3 years, and is thought to be of infectious
origin
Brainerd diarrhea
appropriate in patients with uncharacterized
persistent diarrhea to exclude IBD or as an initial approach in patients
with suspected noninfectious acute diarrhea such as might be caused
by ischemic colitis, diverticulitis, or partial bowel obstruction
Structural examination by sigmoidoscopy, colonoscopy, or
abdominal computed tomography (CT) scanning
central importance to
all forms of acute diarrhea
Fluid and electrolyte replacement
should be instituted promptly
with severe diarrhea to limit dehydration, which is the major cause
of death
Oral sugar-electrolyte solutions (iso-osmolar sport
drinks or designed formulations)
group of people that needs IV rehydration during acute diarrhea
Profoundly dehydrated patients, especially infants and the
elderly
In moderately severe nonfebrile and nonbloody diarrhea,
antimotility and antisecretory agents such as _______ can be
useful adjuncts to control symptoms
loperamide
loperamide should be avoided with _______, which may be exacerbated or prolonged by
them.
febrile dysentery
may reduce symptoms of vomiting
and diarrhea but should not be used to treat immunocompromised
patients or those with renal impairment because of the risk of
bismuth encephalopathy.
Bismuth subsalicylate
Many physicians treat moderately to severely ill patients with
febrile dysentery empirically without diagnostic evaluation using a
quinolone, such as _______________
ciprofloxacin (500 mg bid for 3–5 d).
Empirical
treatment can also be considered for suspected giardiasis with ______________.
metronidazole
250 mg qid for 7 d
Because of resistance to first-line treatments, newer agents
such as ________ may be required for Giardia and Cryptosporidium
infections.
nitazoxanide
may reduce the frequency of traveler’s
diarrhea
Bismuth subsalicylate
Antibiotic prophylaxis is only indicated for certain patients
traveling to high-risk countries in whom the likelihood or seriousness
of acquired diarrhea would be especially high, including those with
_____________
immunocompromise, IBD, hemochromatosis, or gastric achlorhydria
may reduce bacterial
diarrhea in such travelers by 90%
ciprofloxacin, azithromycin, or rifaximin
is not suitable for
invasive disease but rather as treatment for uncomplicated traveler’s
diarrhea.
rifaximin
most of the causes
of chronic diarrhea are ________.
noninfectious
are due to derangements
in fluid and electrolyte transport across the enterocolonic mucosa
Secretory diarrheas
They are characterized clinically by watery, large-volume fecal outputs
that are typically painless and persist with fasting
Secretory diarrheas
are the most common secretory causes of chronic diarrhea
Side effects from regular ingestion of drugs and toxins
may cause a secretory-type diarrhea due to enterocyte
injury with impaired sodium and water absorption as well as rapid
transit and other alterations
Chronic ethanol
consumption
is associated with diarrhea due to sprue-like
enteropathy
oral angiotensin-receptor
blocker, olmesartan
These
conditions may result in a secretory-type diarrhea because of inadequate
surface for reabsorption of secreted fluids and electrolytes
BOWEL RESECTION, MUCOSAL DISEASE, OR ENTEROCOLIC FISTULA
this subset of conditions tends to
worsen with eating
BOWEL RESECTION, MUCOSAL DISEASE, OR ENTEROCOLIC FISTULA
bile acids are functionally malabsorbed from a
normal-appearing terminal ileum
idiopathic secretory diarrhea or bile acid diarrhea
BAD
diseases that are present with bile acid diarrhea
Crohn’s ileitis or resection of
<100 cm of terminal ileum
may
paradoxically lead to increased fecal output due to fluid hypersecretion
Partial bowel obstruction, ostomy stricture, or fecal impaction
may produce
watery diarrhea alone or as part of the carcinoid syndrome that comprises
episodic flushing, wheezing, dyspnea, and right-sided valvular
heart disease.
Metastatic gastrointestinal
carcinoid tumors or, rarely, primary bronchial carcinoids
Diarrhea is due to the release into the circulation of
potent intestinal secretagogues including ____________
serotonin, histamine, prostaglandins,
and various kinins
SHPK
one of the most common neuroendocrine tumors, most typically
presents with refractory peptic ulcers, but diarrhea occurs in up
to one-third of cases and may be the only clinical manifestation in 10%
Gastrinoma
While other secretagogues released with gastrin may play a role, the
diarrhea most often results from ___________ by low intraduodenal pH
fat maldigestion owing to pancreatic
enzyme inactivation
watery diarrhea
hypokalemia achlorhydria syndrome
pancreatic cholera
non-β cell pancreatic adenoma
VIPoma
secretory diarrhea in pancreatic cholera is often massive
with stool volumes ____; daily volumes as high as ____ have been
reported.
> 3 L/d
20 L
may present with watery diarrhea caused by
calcitonin, other secretory peptides, or prostaglandins
Medullary
carcinoma of the thyroid
may be associated with the skin lesion urticaria pigmentosa, may cause diarrhea that is either secretory and
mediated by histamine or inflammatory due to intestinal infiltration
by mast cells
Systemic mastocytosis
may rarely be associated
with a secretory diarrhea that may cause hypokalemia, can be inhibited
by NSAIDs, and are apparently mediated by prostaglandins
colorectal villous adenomas
defective Cl−/HCO3
− exchange with alkalosis
congenital
chloridorrhea
defective Na+/H+ exchange
congenital sodium diarrhea
Some hormone deficiencies may be associated with watery diarrhea,
such as occurs with _________
that may be accompanied by skin hyperpigmentation
adrenocortical insufficiency (Addison’s disease)
occurs when ingested, poorly
absorbable, osmotically active solutes draw enough fluid into the
lumen to exceed the reabsorptive capacity of the colon
ceases with fasting or with discontinuation of the
causative agent
Osmotic diarrhea
Ingestion of ________ may induce osmotic diarrhea typified
by a stool osmotic gap
magnesium-containing antacids,
health supplements, or laxatives
One of the
most common causes of chronic diarrhea in adults is _________,
which affects three-fourths of nonwhites worldwide and 5–30% of
persons in the United States; the total lactose load at any one time
influences the symptoms experienced.
lactase deficiency
are frequently malabsorbed,
and diarrhea ensues with ingestion of medications, gum, or
candies sweetened with these poorly or incompletely absorbed sugars
sorbitol, lactulose, or fructose
osmotic diarrhea with a low pH
Carbohydrate malabsorption
recognized as symptoms of non-celiac gluten intolerance
(which is associated with impaired intestinal or colonic barrier
function) and intolerance of fermentable oligosaccharides, disaccharides,
monosaccharides, and polyols (FODMAPs).
Chronic diarrhea, bloating, and
abdominal pain
may lead to greasy,
foul-smelling, difficult-to-flush diarrhea often associated with weight
loss and nutritional deficiencies due to concomitant malabsorption
of amino acids and vitamins.
Fat malabsorption
steatorrhea
stool fat exceeding the normal 7 g/d
rapid-transit diarrhea
fecal fat up to 14 g/d
average daily fecal fat of small-intestinal diseases
15–25 g
average daily fecal fat of pancreatic exocrine
insufficiency
> 32 g
these diseases may produce steatorrhea
Intraluminal maldigestion, mucosal malabsorption, or
lymphatic obstruction
This condition most commonly results
from pancreatic exocrine insufficiency, which occurs when >90% of
pancreatic secretory function is lost
INTRALUMINAL MALDIGESTION
usually a
sequel of ethanol abuse, most frequently causes pancreatic insufficiency.
Chronic pancreatitis
this may deconjugate bile acids and alter micelle formation, impairing fat
digestion
Bacterial overgrowth
Bacterial overgrowth in the small intestine occurs with _____
blind-loop, small-bowel diverticulum
or dysmotility and is especially likely in the elderly
mucosal malabsorption most commonly occurs from ______
celiac disease
gluten-sensitive enteropathy affects all ages and is characterized by
villous atrophy and crypt hyperplasia in the proximal small bowel and
can present with fatty diarrhea associated with multiple nutritional deficiencies
of varying severity
celiac disease
frequently presents
without steatorrhea, can mimic IBS, and has many other GI and extraintestinal
manifestations
celiac disease
may produce a similar histologic
and clinical syndrome with celiac disease but occurs in residents of or travelers to tropical
climates;
abrupt onset and response to antibiotics suggest an infectious
etiology
Tropical sprue
due to the bacillus Tropheryma whipplei and
histiocytic infiltration of the small-bowel mucosa, is a less common
cause of steatorrhea that most typically occurs in young or middle-aged
men;
it is frequently associated with arthralgias, fever, lymphadenopathy,
and extreme fatigue, and it may affect the CNS and endocardium
Whipple’s disease
a rare defect of chylomicron formation and fat malabsorption in
children, associated with acanthocytic erythrocytes, ataxia, and retinitis
pigmentosa.
Abetalipoproteinemia
unique constellation of fat malabsorption
with enteric losses of protein (often causing edema) and lymphocytopenia.
Carbohydrate and amino acid absorption are preserved
POSTMUCOSAL LYMPHATIC OBSTRUCTION
POSTMUCOSAL LYMPHATIC OBSTRUCTION is due to ________
rare congenital intestinal lymphangiectasia
or to acquired lymphatic obstruction secondary to trauma, tumor, cardiac
disease or infection
generally
accompanied by pain, fever, bleeding, or other manifestations of
inflammation.
Inflammatory diarrheas
unifying feature on stool analysis of inflammatory diarrhea
presence of leukocytes or
leukocyte-derived proteins such as calprotectin
generalized edema
anasarca
among the most common organic causes of chronic diarrhea in adults
and range in severity from mild to fulminant and life-threatening under idiopathic inflammatory bowel disease
Crohn’s disease and chronic ulcerative colitis
They may be associated with uveitis, polyarthralgias, cholestatic liver
disease (primary sclerosing cholangitis), and skin lesions (erythema
nodosum, pyoderma gangrenosum)
Crohn’s disease and chronic ulcerative colitis
cholestatic liver
disease
primary sclerosing cholangitis
skin lesions in Crohn’s disease and chronic ulcerative colitis
erythema
nodosum, pyoderma gangrenosum
an increasingly recognized cause
of chronic watery diarrhea, especially in middle-aged women and
those on NSAIDs, statins, proton pump inhibitors (PPIs), and selective
serotonin reuptake inhibitors (SSRIs
biopsy of a normal-appearing
colon is required for histologic diagnosis.
typically responds well to anti-inflammatory drugs (e.g., bismuth),
the opioid agonist loperamide, or to budesonide
Microscopic colitis, including both
lymphocytic and collagenous colitis
diarrhea that is
particularly prevalent and often the result of giardiasis, bacterial overgrowth,
or sprue
selective IgA
deficiency or common variable hypogammaglobulinemia
disease that presents diarrhea, pain, vomitting, or ascites
EOSINOPHILIC GASTROENTERITIS
hx of atopy, charcot-leyden crystals
may accompany many diarrheas
as a secondary or contributing phenomenon, but primary dysmotility
is an unusual etiology of true diarrhea
Rapid transit
stool features of rapid transit
secretory diarrhea
may produce hypermotility with resultant
diarrhea
Hyperthyroidism, carcinoid syndrome, and certain drugs (e.g., prostaglandins,
prokinetic agents)
may lead to stasis with secondary bacterial
overgrowth causing diarrhea
Primary visceral neuromyopathies or idiopathic acquired
intestinal pseudoobstruction
often accompanied
by peripheral and generalized autonomic neuropathies, may occur in
part because of intestinal dysmotility.
Diabetic diarrhea
characterized by disturbed intestinal and colonic motor
and sensory responses to various stimuli.
Symptoms of stool frequency
typically cease at night, alternate with periods of constipation, are
accompanied by abdominal pain relieved with defecation, and rarely
result in weight loss.
IBS
accounts for up to 15% of unexplained
diarrheas referred to tertiary care centers.
Factitial diarrhea
deception or self-injury for secondary gain
Munchausen syndrome
causes of factitial diarrhea
Munchausen syndrome
eating disorders, some patients covertly self-administer laxatives alone
or in combination with other medications (e.g., diuretics) or surreptitiously
add water or urine to stool sent for analysis
_______ and ________
are common co-presenting features in factitial diarrhea
hypotension and hypokalemia
Measuring IgA
tissue transglutaminase antibodies may help detect _______
celiac disease
confirmed by a scintigraphic radiolabeled bile
acid retention test
Bile acid diarrhea
chronic watery diarrhea, which
ceases with fasting in an otherwise healthy young adult, may justify a trial of a ___________
lactose-restricted diet
bloating and diarrhea persisting
since a mountain backpacking trip may warrant a trial of ________
for likely giardiasis
metronidazole
postprandial diarrhea persisting
following resection of terminal ileum might be due to bile acid
malabsorption and be treated with __________
before further evaluation.
cholestyramine or colesevelam
Patients suspected of
having IBS should be initially evaluated with __________
with colorectal biopsies to exclude IBD, or particularly microscopic
colitis
flexible sigmoidoscopy
Any patient
who presents with chronic diarrhea and hematochezia should be
evaluated with _______________
stool microbiologic studies and colonoscopy.
If stool weight is _______, additional stool analyses
should be performed that might include electrolyte concentration,
pH, occult blood testing, leukocyte inspection (or leukocyte protein
assay), fat quantitation, and laxative screens
> 200 g/d
the most sensitive test for giardiasis
Giardia antigen
assay
two most common
causes of osmotic diarrhea
lactose intolerance and magnesium ingestion
Low fecal pH suggests _______
carbohydrate malabsorption
can be confirmed by lactose breath testing or by a
therapeutic trial with lactose exclusion and observation of the effect
of lactose challenge (e.g., a liter of milk).
lactose
malabsorption
should be suspected by the
presence of blood or leukocytes in the stool
Chronic inflammatory-type diarrheas
Whipple’s disease or tropical sprue treatment
antibiotic administration
trmt for lactase deficiency
elimination of dietary lactose
trmt for celiac sprue
elimination of gluten
trmt for idiopathic IBDs
use of glucocorticoids or other anti-inflammatory agents
trmt for bile acid malabsorption
use of bile acid sequestrants
trmt for gastric hypersecretion of gastrinomas
PPIs
trmt for malignant carcinoid
syndrome
somatostatin analogues such as octreotide
trmt for medullary
carcinoma of the thyroid
prostaglandin inhibitors such as indomethacin
trmt for pancreatic insufficiency
pancreatic enzyme replacement
often
helpful in mild or moderate watery diarrhea
Mild opiates, such as diphenoxylate or loperamide
trmt for those with more
severe diarrhea, _______ may be beneficial
codeine or tincture of opium
should be avoided with severe IBD, because toxic
megacolon may be precipitated
antimotility agents
may allow control of diabetic diarrhea, although the medication
may be poorly tolerated because it causes postural hypotension
Clonidine, an α2-adrenergic agonist
may relieve
diarrhea and urgency in patients with IBS diarrhea
5-HT3 receptor antagonists (e.g., alosetron, ondansetron
may induce sphincter of Oddi spasm and subsequent
acute pancreatitis, usually in patients with prior cholecystectomy
eluxadoline
For all patients with chronic diarrhea, ___________
is an important component of management
fluid and electrolyte repletion
___________ may also be necessary
in patients with chronic steatorrhea
Replacement of fat-soluble vitamins
