CPS: Diarrhea and C. Difficile Flashcards
define diarhea
stool measuring over 300 grams per day sometimes decreased consistency
if you have diarrhea for longer than 3 weeks, then its considered to be:
chronic diarrhea
most common functional disorder for diarrhea
IBS
does C Dif produce bloody or non bloody diarrhea
usually non bloody
important aspects of physical exam for diarrhea
temperature, signs of dehydration, abdominal exam for signs of peritonitis and tenderness–> some bacteria can cause toxic megacolon, rectal exam
investigative tests for acute diarrhea
CBC with urea, bytes, creatinine stool test- parasites, cultures, CDiff 3 views of abdomen sigmoidoscopy if available
6 bacteria tested during stool test
- campylobacter 2. e coli 3. salmonella 4. shigella 5. yersinia 6. C diff.
alternative dx for bloody diarrhea if there’s no bacteria in culture
ischemic colitis
how to diagnose cdif
liquid stool only. done through PCR and toxin A and B testing (Elsa) stool cultures are not specific for CDI
hypervirulent Cdiff
a hardcore Cdif strain that has a deletion of tcdC- which usually down regulates toxin production. Causes greater toxin A and B production
preventing CDI
- wash with soap and water - avoid empiric BSA antibiotic use 3. probiotics is controversial 4. avoid/discontinue PPI 5. use disinfection with chlorine-based disinfectants
treatment for mild CDI
1st line: vancomycin PO QID alternatives: fidaxomicin, metronidazole
treatment for severe CDI but uncomplicated
both vancomycin QID and fidaxomicin BID
treatment for severe and complicated CDI
vancomycin NG, enema, metronidazole IV
treatment for 1st, 2nd and 3rd reoccurrence od Cdif
1st. vancomycin QID OR fidaxomicin BID 2nd. vancomycin 3xdaily for 7 days, BID for 7x, then OD x 7days, and then every second /third day for 2-8 weeks 3. fecal microbiota transplant.
why is vancomycin better than metronidazole better for treating CDif?
because vancomycin stays in the lumen of the intestine and kills the Cdif in the gut. metronidazole gets absorbed fast into the bile and then blood and gets excreted. good for UTI or systemic infection or for toxic mega colon.
4 ways to have fecal transplant
- capsules 2. NG tube 3. colonoscope and shoot it into colon. 4. enema
what must you do prior to fecal translant
must test for hepatitis C and other fecal-oral diseases.
which antibiotics for toxic megacolon
IV metronadazole, oral vancomycin
positive Cdif
vancomycin
positive culture but negative Cdif, non bloody diarrhea
oral hydration
stable signs, but bloody diarrhea
oral rehydration. you can’t give antibiotics all the time– you can contract Cdiff if you give antibiotics. Therefore, only give Vancomycin if there is Cdif, or metronidazole if toxic megacolon
difference in amount of diarrhea in someone will small bowel vs large bowel disease
small bowel– LOTS of diarrhea large bowel – not as much
if someone has chronic diarrhea with high frequency bms, disease of ____ bowel should be sustpected
LARGE bowel
if someone has chronic diarrhea with bleeding symptoms, disease of ___ bowel should be suspected
LARGE bowel
if someone has chronic diarrhea with periumbilical pain, disease of ___ bowel should be usspected
SMALL bowel. large bowel presents with lower quandrant pain
if someone has chronic diarrhea with steatorrhea, disease of ____ bowel should be suspected
SMALL bowel. also would affect some nutrition because you’re not absorbing the fat, hence fat in the poop
if someone has chronic diarrhea with weightless, disease of ___ bowel should be suspected
SMALL bowel. if nutrition and absorption is compromised, you’d lose weight
if someone has chronic diarrhea with rectal symptoms and tenesmus, disease of ___ bowels mould be suspected
LARGE bowel.
if someone has chronic diarrhea with has decreased diarrhea if they fast, disease of the ___ bowels should be suspected
SMALL bowel. if fasting doesn’t help with diarrhea symptoms, consider large bowel disease
if if someone has chronic diarrhea with nutritional deficiencies, disease of the ___ bowels should be suspected.
small bowel. this is the site of absorbing. if there is disease and small bowel integrity is compromised, there would be nutritional defieicneis like B12 def, folate def etc.
in chronic diarrhea, what tests to run in ALL Cases (small and large bowel diseases)
- CBC + Cdiff, urea, lytes, creatinine 2. stool for O and P (leukocytes)–ova and parasites 3. 72 hour stool collection– if comes back at 500 grams of stool, there’s no diarrhea. because diarrhea is defined as 300 grams per day. If you have steattorhea without profuse diarrhea, then it might be PANCREAS related
in chronic diarrhea what tests to run in SMALL BOWEL suspect
small bowel biopsies CT/MR enterography 72 hour stool for fat- if steatorrhea, consider pancreatic investigations. - blood work: ferritin, B12, RBC folate, albumin, calcium, INR
in chronic diarrhea what tests to run in LARGE BOWEL suspect
- colonoscopy 2. if non-bloody, do random biopsies (right colon, for microscopic or collagenous colitis)
2 types of watery chronic diarrhea
- secretory: secretory toxins and excess bile acids enter the colon. LARGE VOLUME EVEN WHEN FASTING 2. osmotic: maldigestion/malabsorption. Tons of poorly absorbed ions (ex/ from lactulose or PEG) draws water out from body into lumen of colon.
what type of diet can increase osmotic diarrhea
FODMAPS. Can cause IBS-D. gotta have a low-FODMAP diet.
causes of fatty diarrhea
maldigestion or malabsorption causes
maldigestion: pancreatic insufficency– not enough lipase. OR chronic pancreatitis – decrease lipase
malabsorption: mucosa integrity decrease – crohns, ulcerative colitis. OR a hepatobiliary problem – can’t absorb because no bile or cholestasis
causes of dysmotility
Functional – most common, IBS/D
Diabetes – autonomic nervous system dysfunction
Hyperthyroidism
Carcinoid tumor
if there’s rapid motility: then theres malabsorption
if there’s too slow motility: bacterial overgrowth or fat malabsorption.
colitis vs enteritis
colitis: inflammation and ulceration disrupt mucosal integrety of large bowel. Would see bleeding mucus and pus
enteritis: deranged mucosa usually in small bowel. Impaired carb and electrolyte absorption.
common causes of inflammatory chronic diarrhea
epidemiology and etiology of chronic diarrhea in developed and developing countries
developed: major (IBS), IBD, malabsorption (lactose intolerance)
developing countries: BUGS
A person previously on ciprofloxacin for a UTI comes in with abdominal cramping and diarrhea (non-bloody). they feel urgency and no one else in their family has it. They tested positive for Cdif culture.
CT was done and thumbprinting was seen– waht does this indicate?
biospy of colon was done and this was seen:– what does this indicate? Dx?
Mucopurulent exudate forming a layer (pseudomembrane) on the surface of the mucosa.
this is pseudomembranous colitis
thurmbprinting indicates an inflammation–ischemic, UC, pseudomembranous, micropscopic colitis etc.
how woudl you treat C dif
vancomycin, if it’s second time consider also using metronidazole
