Constipation & Diarrhea Flashcards
Define Constipation
Passage of stool infrequently or with difficulty
Stool frequency of less than three per week (straining, hard stool, incomplete evacuation)
Etiology of Constipation
Inadequate fiber in diet
Inadequate hydration
Inactivity
Medications that can cause Constipation
Opiates/narcotics Antidepressants CCB Antipsychotic Antiparkinsonian agents Anticholinergics Calcium, iron supplements Antispasmodics Antacids (calcium & aluminum)
Structural Abnormalities Causing Constipation
Carcinoma Ischemia Volvulus Megacolon Anorectal Disorders (prolapse, rectocele, pelvic floor dysfunction)
What is present with ischemia of the bowel?
Usually present with pain
Rebound tenderness
Pelvic Floor Dysfunction
ANS neuropathy
Pregnancy
Males with surgeries near the perineum
Metabolic Issues Causing Constipation
Hypokalemia Hypomagnesemia Hypothyroidism Hyperparathyroidism Porphyria- genetic hemoglobin disorder Addison's disease Hypercalcemia
Neurological Issues Causing Constipation
Parkinson's MS Automonic neuropathy Hirschsprung disease Chugs disease Spinal cord lesions Cerebrovascular disease
Hirschprung Disease
Myenteric plexus affected
Lack of cells at birth
Systemic Issues Causing Constipation
Amyloidosis
Scleroderma
Polymyositis
Pregnancy
Define Amyloidosis
Sclerotic fibers embedded in tissues
Define Scleroderma
Tightening of all outside tissue
Surgical Issues Causing Constipation
Abdominal
Pelvic
Colonic
Anorectal
Psychiatric Issues Causing Constipation
Depression
Eating disorders
Treatment of constipation in patients less than 50 years old with no alarm symptoms
Empiric treatment
Further treatment should be performed on patients with any of the following:
Over age 50 Severe constipation Signs of an organic disorder Hematochezia Weight loss Positive FOBT
Evaluation of Constipation
KUB
Barium enema
Colonoscopy
Blood Tests
Blood Tests for Constipation
Glucose CBC Thyroid Calcium Magnesium Phosphorous
Define Colonic Transit Study
Observe transit time in patients with refractory constipation not responding to conservative measures
Management of Constipation
Prevention
Patient Education
Patient Education for Constipation
Exercise
Fluid intake
Fiber intake
What does exercise do for bowel movements?
Stimulus to colon peristalsis and defecation
Encourage and enable patient to be mobile
Fluid intake
Constipated stools are low in water content
Fiber intake
Acute constipation low on fiber diet
Chronic constipation responds poorly to fiber
Classes of Medications for Constipation
Stool softeners Laxatives stimulant laxatives Opioid-receptor antagonist Digital disimpaction
Types of Stool Softeners
Colace
Docusate calcium
Types of Laxatives
Bulk laxatives
Osmotics
Types of Bulk Laxatives
Psyllium
Methylcellulose
Fibercon (polycarbonophil)
Benefiber (wheat dextran)
Types of Osmotics
Lactulose Sorbitol Polyethylene glycol Magnesium citrate Magnesium sulfate
Types of Stimulant Laxatives
Bisacodyl
Senna
Type of Opioid-receptor Antagonist
Methylnaltrexone
What is methylnaltrexone approved for?
Palliative care patients
Patients on chronic opioid treatment
Define Diarrhea
Increase in stool liquidity and/or frequency
How many stools a day is considered abnormal?
3 times a day
Osmotic Diarrhea Pathophysiology
Non-absorbable substance draws out excess water into the intestines & increases stool weight and volume
Secretory Diarrhea Pathophysiology
Mucosal secretion of fluid and electrolytes secondary to bacterial enterotoxins, neoplasms, or exotoxins
Motility Diarrhea Pathophysiology
Food is not mixed properly, digestion is impaired and motility is increased
Secondary to resection of the small intestine, surgical bypass of an area of intestine or diabetic neuropathy
Acute Diarrhea Length
Persistent Diarrhea Length
More than 14 days in duration
Chronic Diarrhea Length
More than 30 days in duration
Clinical Manifestations of Acute Diarrhea
Self-limited
Fever
Cramping pain
Clinical Manifestations of Chronic Diarrhea
Secondary to IBS
IBD
Malabsorption syndromes
Clinical Manifestation of Inflammatory Diarrhea
Blood Fever Peritoneal signs Weight loss Pus
Clinical Manifestation of Non-inflammatory Diarrhea
Diarrhea
Self-limited
Most common cause of diarrhea in pregnant women
Listeria
Most common cause of diarrhea in daycares
Adenovirus
Norovirus
Most common cause of diarrhea in drinking water
Giardia
Most common cause of traveling diarrhea
E. coli
Treatment for Diarrhea
Cipro (go to)
Flagyl (weird bugs)
Leukocytes in the stool would be a sign of what type of bugs?
Invasive bugs
Viral Agents for Acute Infectious Diarrhea
Norovirus
Rotavirus
Adenoviruses
Astrovirus
Bacterial Culprits for Acute Infectious Diarrhea
Salmonella Campylobacter (Guillan Barre) Shigella (blood, fever) Enterotoxigenic E. coli C. difficile
Protozoa Culprits for Acute Infectious Diarrhea
Cryptosporidium
Giardia
Cyclospora
Entamoeba
Sources for Salmonella Diarrhea
Beef Pork Poultry Eggs Raw milk Ice cream Vegetables Unpasteurized Orange juice Pet ducklings Lizards Rattlesnake meat
Sources for Campylobacter Diarrhea
Poultry
Raw milk
Raw cheeses
Sources for Shigella Diarrhea
Daycare centers
Vegetables
Sources for Vibrio Cholerae Diarrhea
Shellfish from the Gulf of Mexico
Inadequately cooked seafood from South America
Coconut milk from Thailand
Airline outbreaks
Sources for C. Difficile Diarrhea
Hospitalization
Inpatient or outpatient antibiotics or chemo within last several weeks
Daycare centers
Sources for Listeria Diarrhea
Beef Pork Poultry Milk cheese Coleslaw Hot dogs Potato salad Pregnancy Neonates Immunocompromised patients
Sources for Rotavirus Diarrhea
Daycare centers
Nurseries
Australia
Sources for Norovirus Diarrhea
Schools Nursing homes Cruise ships Camps Military barracks Vegetables waterborne Foodborne Shellfish-associated outbreaks
Sources for Hepatitis A Diarrhea
Overcrowding Lack of clean water Patient & staff of institutions Daycare centers Men who have sex with men IV drug users Travelers Military barracks Shellfish
Sources for Adenovirus Diarrhea
Infantile diarrhea
AIDS
Sources for CMV Diarrhea
HIV-infected homosexual men with AIDS
Organ transplantation
Sources for Giardia Diarrhea
Daycare centers
Swimming pools
Travel
Fruit salad
Sources for Cryptosporidium Diarrhea
Daycare centers Swimming pools AIDS Farm animal exposure City water supply contamination
Sources for Cyclospora Diarrhea
Raspberries from Guatemala
Non-infectious Agents Acute Diarrhea
Drugs
Food allergies
Thyrotoxicosis
Carcinoid syndrome
Indications for Diagnostic Evaluation of Acute Diarrhea
Profuse watery diarrhea with signs of hypovolemia
Passage of small volume stools containine blood and mucus
Bloody diarrhea
Temperature > 101.3
Passage of >6 unformed stools in 24 hours or a duration of illness >48 hours
Severe abdominal pain
Hospitalized patients or recent use of antibiotics
Diarrhea in the elderly or immunocompromised
Systemic illness with diarrhea
Etiology of Chronic Diarrhea
Medications Osmotic Secretory Inflammatory Malabsorptive Motility disorders Chronic infections
Examples of Medications in Chronic Diarrhea
Cholinesterase inhibitors Metformin SSRI's Flexors ARB's PPI NSAIDs
Examples of Osmotic Issues in Cause Chronic Diarrhea
Malabsorption
Lactose, fructose, sucrose
Laxative abuse
Examples of Secretory Issues in Chronic Diarrhea
Endocrine tumors
Bile salt absorption
Examples of Inflammatory Issues in Chronic Diarrhea
Crohn’s
Ulcerative colitis
Examples of Malabsorptive Disorders in Chronic Diarrhea
Steatorrhea
Vitamin deficiences
Example of Motility Disorders in Chronic Diarrhea
IBS
Examples of Chronic Infections in Chronic Diarrhea
DM
Carcinoid syndromes
Collagen/vascular disorders
Thyroid issues
Causes of Osmotic Diarrhea
Antacids, lactulose, sorbitol
Lactose Intolerance
Magnesium: antacids, laxitives
Clues for Osmotic Diarrhea
Stool volume decreases with fasting
Increased stool osmotic gap
Clues for Secretory Diarrhea
Large volume (>1L/day) Little change with fasting Normal stool osmotic gap
Causes of Secretory Diarrhea
Hormonally: carcinoid, medullary CA of thyroid, Zollinger-Ellison syndrome
Factitious: phenolphthalein, cascara, senna
Villous adenoma
Bile salt malabsorption
Medications
Clues for Inflammatory Diarrhea
Fever
Hematochezia
Abdominal pain
Causes of Inflammatory Diarrhea
IBD
Lymphoma
Adenocarcinoma
Radiation enteritis
Clues for Malabsorption Syndrome Diarrhea
Weight loss
Abnormal laboratory values
Fecal fat
Causes of Malabsorption Syndrome Diarrhea
Small bowel mucosal disorders: celiac, tropical sprue, Whipple disease, eosinophilic, gastroenteritis, resection, Crohn's Lymphoma Carcinoid Infectious Kaposisarcoma Sarcoidosis Retroperitoneal fibrosis Pancreatic disease Bacterial overgrowth: motility disorders, scleroderma, fistulas, small intestinal diverticula
Clues of Motility Disorder Diarrhea
Systemic disease
Prior abdominal surgery
Causes of Motility Disorder Diarrhea
Post surgical: vagotomy, partial gastrectomy, blind loop with bacterial overgrowth Scleroderma DM Hyperthyroidism IBS
Causes of Chronic Infection Diarrhea
AIDS related: CMV, HIV C. difficile Mycobacterium avid complex Giardia, Entamoeba histolytica Microsporida Cryptosporidium Isospora
Diarrhea Work-Up
History: travel, longevity of symptoms, family hx, food intake and relationship to onset CBC TSH CMP ESR CRP Wet mount of stool Guiac
What are you looking for in a fecal analysis?
Fecal leukocytets Fecal occult blood Fecal fats Enteric pathogen cultures C. difficile toxin Ova & parasites
What are you looking for on a CMP for diarrhea?
Hypoalbumin- malabsorption
Hyponatremia- secretory
What are you looking for on an ESR/CRP?
Crohn’s ulcerative colitits
What are you looking for on a CBC for diarrhea?
Anemia
What does the presence of fecal leukocytes indicate?
Bowel mucosal inflammation
Invasive bacterial enteritis
Ulcerative colitis
What bugs are you looking for in a stool for culture & sensitivity?
Enterococcus
E. coli
Clostridium
What do you treat enterococcus, e. coli, clostridium with?
Cipro
What bugs are you looking for in a stool ova & parasite study?
Salmonella
Shigella
Giardia
How does a C. diff toxin assay work?
C. diff multiplies and releases toxin that causes necrosis of the colonic epithelium which causes the diarrhea
Yellow, mucus stools
Which diseases have fecal fat?
Steatorrhea
Sprue
Crohn’s
Whipples disease
Colonoscopy with Mucosal Biopsy Excludes
IBD
Microscopic colitis
Colonic neoplasia
What is an upper endoscopy looking for?
Celiac sprue
Whipple disease
Further Stool Studies
24 hour stool collection
Other imaging
What is the most common reason for a 24 hour stool collection?
Patient with IBS who wants a definitive answer
Treatment of Diarrhea
Fluid replacement Antibiotic therapy Bismuth subsalicylate Opiate antidiarrheal agents Cholestyramine (Questran)
What is the best way to replace fluids in children?
Pedialyte
What is the best way to replace fluids in adults?
1/2 tsp. salt
1 tsp. baking soda
8 tsp sugar
8 oz. orange juice in 1 L of water
Most common antibiotic therapy for diarrhea
Cipro
Flagyl
Bactrim
