DIARRHEA

Question 1

Definition of a patient with Diarrhea.

Answer 1

(1) Increased stool frequency
(a) (more than 3 BM’s QD)
(b) Liquidity of feces
(c) May vary from one individual to another

Question 2

Diarrhea can be classified as

Answer 2

acute or chronic

Question 3

Describe acute diarrhea

Answer 3

acute in onset and persisting for less than 2 weeks is most commonly caused by
infectious agents, bacterial toxins (either preformed or produced in the gut)

Question 4

Infectious sources can be transmitted by

Answer 4

fecal- oral contact, food and water and usually

have incubation periods between 12 and 72 hours

Question 5

Pertinent Anatomy of diarrhea

Answer 5

(1) Small intestine
(2) Large intestine (colon)
(a) Cecum
(b) Rectosigmoid Colon

Question 6

Pertinent Physiology of diarrhea

Answer 6

(1) The small intestine is the prime absorptive surface of the gastrointestinal tract.
(2) The colon then absorbs additional fluid, transforming a relatively liquid fecal stream in the cecum to well-formed solid stool in the rectosigmoid.
(3) Disorders of the small intestine result in increased amounts of diarrheal fluid with a concomitantly greater loss of water, electrolytes, and nutrients

Question 7

usual cause of acute gastroenteritis

Answer 7

Infectious agents

Question 8

These agents cause diarrhea by several mechanisms

Answer 8

adherence, mucosal

invasion, enterotoxin production, and/or cytotoxin production

Question 9

These mechanisms (adherence, mucosal
invasion, enterotoxin production, and/or cytotoxin production)  result in

Answer 9

increased fluid secretion and/or decreased absorption. This
produces an increased luminal fluid content that cannot be adequately reabsorbed,
leading to dehydration and the loss of electrolytes and nutrients

Question 10

Chronic Diarrheal illnesses may be classified as

Answer 10

(a) Osmotic, due to an increase in the osmotic load presented to the intestinal lumen, either through excessive intake or diminished absorption:
1) Medications
2) Zollinger- Ellison Syndrome
(b) Inflammatory (or mucosal), when the mucosal lining of the intestine is inflamed (inflammatory bowel disease, malignancy)
(c) Secretory, when increased secretory activity occurs
(d) Chronic Infections: Parasites: Giardia Lamblia
(e) Malabsorption syndromes: Celiac disease, Whipple, Crohn disease, Lactose Intolerance
(f) Motility disorders: Irritable bowel syndrome

Question 11

Causes of Acute Infectious Diarrhea

Answer 11

(a) From a diagnostic and therapeutic standpoint, it is helpful to classify infectiousdiarrhea into syndromes that produce inflammatory or bloody diarrhea and those that are non- inflammatory, non-bloody, or water

Question 12

A common protozoal cause is

Answer 12

Entamoeba histolytica

Question 13

Common causes of this inflammatory diarrhea include

Answer 13

Shigella, Salmonella, Escherichia coli,

E coli O157:H7.

Question 14

What kind of diarrhea suggests colonic involvement by invasive bacteria or parasites or by toxin production

Answer 14

inflammatory diarrhea

Question 15

Patients complain of frequent bloody, small-volume stools, often associated with
fever, abdominal cramps, tenesmus, and fecal urgency.

Answer 15

inflammatory diarrhea

Question 16

What kind of diarrhea suggests suggest a

viral etiology or a common food source.

Answer 16

Community outbreaks (including nursing homes, schools, cruise ships)

Question 17

Similar recent illnesses in family members suggest

Answer 17

an infectious origin.

Question 18

Ingestion of improperly stored or prepared food implicates

Answer 18

food poisoning.

Question 19

generally milder and is caused by viruses or toxins

that affect the small intestine

Answer 19

Acute Non-inflammatory diarrhea

Question 20

Acute Non-inflammatory diarrhea interfere with

Answer 20

salt and water balance, resulting in large-volume watery diarrhea,
often with nausea, vomiting, and cramps.

Question 21

Common causes of Acute Non-inflammatory diarrhea

Answer 21

viruses (eg, rotavirus, Norwalk virus,
vibriones (Vibrio cholerae, Vibrio parahaemolyticus), enterotoxin- producing E coli,
and agents that can cause food-borne gastroenteritis.

Question 22

Common Protozoal causes of acute Non- inflammatory diarrhea include

Answer 22

Giardia

Lamblia, cryptosporidium and cyclospora

Question 23

diseases caused by toxins present in consumed foods

Answer 23

food poisoning

Question 24

incubation period is short (1-6 hours after consumption)

Answer 24

the toxin is usually

preformed

Question 25

Vomiting is usually a major complaint, and fever is usually absent

Answer 25

“food poisoning

Question 26

e incubation period is longer (between 8 hours and 16 hours)

Answer 26

the organism is
present in the food and produces toxin after being ingested. Vomiting is less prominent,
abdominal cramping is frequent, and fever is often absent.

Question 27

the illness is mild and
self-limited, responding within 5 days to simple rehydration therapy or antidiarrheal
agents; diagnostic investigation is unnecessary

Answer 27

In over 90% of patients with acute non- inflammatory diarrhea

Question 28

) If diarrhea worsens or persists for more than 7 days

Answer 28

stool should be sent for fecal

leukocyte, ovum and parasite evaluation, and bacterial culture.

Question 29

Prompt medical evaluation is indicated in the following situations

Answer 29

(a) Signs of inflammatory diarrhea manifested by any of the following: fever (> 38.5
degree Celcius), bloody diarrhea, or abdominal pain.
(b) The passage of six or more unformed stools in 24 hours.
(c) Profuse watery diarrhea and signs or symptoms of dehydration.

Question 30

pay specific attention to the patient’s level of

Answer 30

hydration, mental

status, and the presence of abdominal tenderness or peritonitis

Question 31

Peritoneal findings may be present in infection with

Answer 31

C difficile or enterohemorrhagic

E coli.

Question 32

Hospitalization is required in patients with

Answer 32

severe dehydration, toxicity, or marked
abdominal pain. Stool specimens should be sent for examination for bacterial
cultures.

Question 33

Symptoms depend on causative agent but may include:

Sudden onset

Answer 33

(a) sudden onset
1) Nausea, vomiting, and decreased appetite
2) Crampy abdominal pain
3) Loose stool
4) Malaise
5) Fatigue
(b) Diffuse abdominal tenderness
(c) Distention
(d) Increased bowel sounds
(e) Usually afebrile
(f) May see + tilts, depending on fluid loss

Question 34

Lab

Answer 34

(1) CBC/DIFF
(2) Fecal leukocyte
(3) Fecal O/P
(4) Stool culture
(5) C difficile assay, if recent hospitalization or antibiotics
(6) Stool examination for Giardia Lamblia if Giardiasis suspected, which is an important
cause of waterborne and

Question 35

Treatment

(1) Initial Care

Answer 35

(a) Assess vital signs for stability, treat symptomatically.
(b) The goal of treatment is to allow for symptoms to subside. Stopping the diarrhea
abruptly with antidiarrheal could prolong symptom relief if causes are ingested
bacteria, parasites, etc.
(c) Most mild diarrhea will not lead to dehydration provided the patient takes adequate
oral fluids containing carbohydrates and electrolytes.
(d) Rehydration-Oral rehydration with fluids containing glucose, Na+, K+, Cl-, and
bicarbonate or citrate is preferred when feasible.
1) A convenient mixture is 1/2 tsp salt (3.5 g), 1 tsp baking soda (2.5 g NaHCO3), 8
tsp sugar (40 g), and 8 oz orange juice (1.5 g KCl), diluted to 1 L with water.
Avoid high- fiber foods, fats, milk products, caffeine, and alcohol.
(e) Alternatively, oral electrolyte solutions (e.g., Pedialyte, Gatorade) are readily
available. Fluids should be given at rates of 50-200 mL/kg/24 h depending on the
hydration status.
(f) Intravenous fluids (lactated Ringer injection) are preferred in patients with severe
dehydration or those that cannot drink enough orally.
(g) Frequent feedings of tea, “flat” carbonated beverages, and soft, easily digested foods
(e.g., soups, crackers, bananas, applesauce, rice, toast) are encouraged.
(h) BRAT diet; avoid irritating foods

Question 36

Antidiarrheal Agents

Answer 36

Loperamide (Imodium) - anti- diarrheal
a) Dose: 4mg initially, then followed by 2mg after each loose stool with
a maximum dose of 16mg/day
Bismuth subsalicylate (Pepto- Bismol) - anti-diarrheal
a) Dose: 2 tablets or 30 mL PO q 30-60 min as needed, Max 16 tablets
or 240 mL/24 hours

Question 37

1) Normally not indicated in patients with acute, community-acquired diarrhea
2) The infectious bacterial diarrheas for which for which antibiotic treatment is
recommended are shigellosis, cholera, salmonellosis, listeriosis and C. difficile.
3) The parasitic infection treatment is required are amebiasis, giardiasis,
cryptosporidiosis

Answer 37

Empiric Antibiotic therapy

Question 38

Chronic Non-Infectious Diarrheal illnesses

Answer 38

1) Treat the underlying causes