Diarrhea Flashcards

Question

WHO CDC PROTOCOL ON REHYDRATION

Answer 1

PLAN A Fluids: Give ORS after every loose stool <2yrs: 50-100 ml per loose stool 2-10yrs: 100-200 ml per loose stool >10 yrs: as much as tolerated Plan B Fluids: give 75cc/kg ORS per orem over 4 hours *Re-assess hydration status after 4 hours and adjust tx as needed *May be repeated if some signs of dehydration are still present after 4 hours The following may be used to approximate amount of ORS: *see table p119 *After 4 hrs, evaluate and continue treatment using plan A, B or C Feeding: continue feeding as in plan A follow up as plan A PLAN C *give a total of 100cc/kg (PLR or PNSS) IV as follows -first 30cc/kg over 1hour for infants (<12mos) or 30mins for children -Next 20cc/kg over 5 hours for infants (<12mos) or 2.5hrs for children *fluid of choice: PLR aternative is PNSS *30mL/kg may be repeated once if the patient is still in shock *re-assess and adjust fluids accordingly *Give ORS 5ml/kg as soon as the patient can drink *After 6hrs for infants or 3 hrs for children, evaluate and continue treatment using plan A, B or C

Answer 2

IVF - Indications: o Acute volume expansion o Correction of fluid and electrolyte imbalances o Maintenance tx for those who cannot be fed enterally to prevent dehydration, electrolyte disorders, ketoacidosis, protein degradation A. Maintenance Tx - Compensate for ongoing losses (UO + fecal fluid) - Insensible losses (respiration, perspiration) - If NPO: adolesents >12-18h Infants and child >8h - Usual max = 2400mL/d (equiv to 100ml/h) 1. Holiday-Segar Method (weight based): - Most commonly used worldwide - May overestimate energy expenditure in hospitalized children -May cause overestimation of water requirement as body weight inc - For obese, overweight: use 50th percentile of body weight based on height - Not used in neonates Weight M tx (for 24h) 0-10 kg---> 100 mL/kg 11-20 kg ---> 1000mL + 50mL/kg >20kg --->1500mL + 20ml/kg 2. Ludan Method (basal caloric expenditure based) - Widely used in PH, not int’l - Closer to basal caloric expenditure Weight M tx for 24h 0-10kg ---> 100ml/kg 10-20kg --->75 ml/kg 20-30kg --->50-60 ml/kg 30-60kg ---> 40-50 ml/kg For volume resuscitation, best: isotonic fluids (PNSS, pLR, IES). In local practice, some use(??): D5IMB for <20kg D5NM for >20kg B. Deficit Tx - Based on degree of dehydration - Deficit fluids: fluids lost prior to medical care (GI losses from vomiting/diarrhea, inadequate OFI) C. Replacement tx - Given to meet ongoing losses while on medical tx (vomiting/diarrhea) - Replace losses v/v q1-4h - For IVF: infuse over 30min-1h - For diarrhea: reduced osmolarity ORS is fluid of choice - If cannot tolerate ORS: pLR or D5LR (prevent hypoglycemia) 2. Feeding – reintroduce food once rehydration is complete - Continued enteral feeding in diarrhea aids recovery - Zn: reduces duration and severity of diarrhea and prevents recurrence - Vitamin A: <6mos 50,000 IU; 6-12 mos 100,000 IU; >12mos 200,000 IU SD - Folic acid 5mg on D1 then 1mg/d for 2w - Elemental copper 0.1mkd - MgSO4 2mL of 50% sol’n IM - Fe supplementation 3mkd for anemic pxs starting on week 2 Adjuncts: 3. Anti-diarrheals (loperamide) – not recommended 4. Abx – only for some infectious causes to reduce fluid requirements and limit excretion of organism: a. Shigella: Ciprofloxacin 20-40 mkd q6 b. Cholera: Doxycycline/Tetracycline/Cotrimoxazole 8-12 mkd q12 po/Macrolides/Chloramphenicol c. Ameobiasis: Metronidazole 30mkd q6 po 5. Probiotics – saccharomyces boulardii 250-750 mg/dx5- 7d> lactobacillus rhamnosus GG 1x109-10 CFU/d x5-7d > lactobacillus reuteri DSM 17968 1-2 x108/d x 5d; multistrain preferable 6. Racecadotril – anti-secretory agent. Potent eliminator of enkaphalinase à less fluid and e’ loss. Reduce stool output. Most useful for hypersecretory type diarrhea, 72% cured within 72h. Given during the 1st 3d of watery, nonbloody diarrhea 7. Smectite – natural absorbent clay of aluminoMg sulfate. Adsorb virus, bacteria and toxins protecting intestinal mucosa. Promising, moderate effects. 8. Bovine colostrum – not effective. 9. Anti-emetic – Ondansentron

Answer 3

WATERY DIARRHEA Rotavirus: supportive S. aureus: supportive Salmonella:Chloramphenicol/Ceftriaxone V. cholera: Tetracycline OR erythromycin OR azithromycin OR doxycycline Giardia: metronidazole Campylobacter jejuni: supportive; if severe: azithromycin, erythromycin Clostridium deficile: metronidazole or vancomycin BLOODY DIARRHEA Shigella: Ciprofloxacin Entamoeba histolytica: Metronidazole WATERY OR BLOODY E.coli: Cotrimoxazole

Answer 4

Prevention 1. Drinking water should be clean and safe. 2. Wash raw foods. Cook foods well. Store food properly. 3. Diligent hand washing, esp after the toilet. Hand sanitizer >60% alcohol. 4. Safe stool disposal and hand hygiene.

Answer 5

CH 305: TODDLER’S DIARRHEA - “Functional diarrhea” or “chronic nonspecific diarrhea of childhood” - Between 1-3yo - Otherwise healthy child who drink excessive CHOcontaining beverages - Excessive fluid intake - Osmotic diarrhea CM: 1. Intermittent loose stools 2. Stools occur during the day (>4) and not overnight 3. No FTT Mgt 1. Limit sugar and complex CHO, increase fat in diet 2. Self-limiting. Resolves in grade school

Answer 6

CH 212: PSEUDOMEMBRANOUS COLITIS - Clostridium difficile infection (CDI) - “C.difficile-associted diarrhea” Etiology - Clostridium difficile, gram (+) - Risk factors: o Broad spectrum ABX o Hospitalization, GI sx, IBD, chemotx, enteral feeding, PPI, chronic illness Patho - Toxin A and B --> cell inflammation and death - CD toxin --> disrupt normal GI flora, impair acid barrier, alter GI immune response, inhibits intestinal motility CM 1. Mild, self-limited 2. explosive, watery diarrhea with occult blood or mucus 3. pseudomembranous colitis – bloody diarrhea with fever, abd pain/cramps, nausea, vomiting 4. develop during or weeks after abx 5. death Dx 1. stool C/S 2. colonoscopy/sigmoidoscopy – pseudomembranous nodules and characteristic plaques Mgt 1. d/c nonvital abx tx 2. rehydration – ORS/IVF 3. Metronidazole 20-40mkd q6-8 x 7-10d 4. Vancomycin 40mkd q6h x7-10d Prevention 1. Appropriate abx and PPI use 2. Proper handwashing 3. Probiotics

Answer 7

CH 338: MALABSORPTION - Chronic diarrhea CELIAC DISEASE (GLUTEN-SENSITIVE ENTEROPATHY) - Immune-mediated systemic disorder elicited by gluten in genetically susceptible individuals - Triggered by ingestion of wheat gluten, rye and barley. - Concomitant iron, ca, vit.D malabsorption - Usually diagnosed within 1st 2 yrs Patho - Inappropriate adaptive immune response to glutenderived peptides --> Small intestinal mucosal injury and nutrient malabsorption CM 1. FTT, muscle wasting, anorexia 2. Chronic diarrhea 3. Vomiting, abdominal distention 4. Occ. constipation, rectal prolapse, intussusception 5. IDA – most common extraintestinal fx - Unresponsive to iron tx 6. Osteoporosis, arthritis, arthralgia, epilepsy with bilateral occipital calcifications, 7. CNS: peripheral neuropathy, epilepsy, irritability, cerebellar ataxia 8. Endo: short stature, pubertas tarda, sec. hyperparathyroidism 9. cardiomyopathy, dental enamel hypoplasia 10. derma: aphthous stomatitis, alopecia, dermatitis, herpetiformis, erythema nodosum 11. Non-Hodgkin lymphoma – main cause of death Dx 1. Anti-TG2 IgA Ab/Tissue transglutaminase IgA Ab – DxOC 2. Total IgA – exclude IgA deficiency 3. DQ2, DQ8 HLA testing – confirms celiac 4. Sudan black stain – standard lipid stain Mgt 1. Lifelong strict Gluten-free diet: wheat, barley and rye free diet

Answer 8

LACTASE DEFICIENCY/ LACTOSE INTOLERANCE Etiology - Progressive, age-related, beginning at 7yo, usually nonwhite population Patho - Brush border enzyme defect in lactase, intestinal mucosal damage - Osmotic diarrhea CM 1. Chronic diarrhea 2. Nausea, vomiting 3. Abd cramps 4. Bloating/gas Dx 1. Lactose tolerance test 2. Hydrogen breath test 3. Stool acidity test Mgt 1. IVF/ORS – fluid replacement tx, e’s 2. Lactose-free diet 3. Elimination diet 4. Zn 5. Lactase enzyme tab/drops 6. probiotics

Answer 9

CH ?: IRRITABLE BOWEL SYNDROME - chronic functional GI d/o in the absence of organic pathology Patho - 3-part complex of altered GI motility, visceral hyperalgesia and psychopathology CM 1. episodic lower abd.pain, cramping/aching, relieved by defecation 2. bloating, flatulence 3. altered bowel function – alternating diarrhea and constipation - diarrhea: frequent, watery, (+)mucoid, (+)pain, (+) feeling of incomplete emptying 4. no evidence of inflammation, anatomic, metabolic/neoplastic process Mgt - self-limiting 1. probiotics, fibers 2. avoidance of caffeine, legumes, lactose/fructose 3. psychological therapy

Answer 10

CH 336: INFLAMMATORY BOWEL DISEASE (IBD) - Chronic intestinal inflammation - Usually onset at preadolescent/adolescent/young adulthood. Bimodal 10-20 yo, 50-80 yo - 0-2yo: neonatal onset, infant/toddler onset - <6 yo: very early onset - <10yo: early onset - <17 yo: pediatric onset Patho - FHx: CD>UC -dysregulated/inappropriate immune response + env’tl factors --> abn intestinal immunoregulation (elev proinflamm cytokine activation) - alteration in gut microbiome: “western diet”, inc abx use, less exposure to microbes while young (Germ theory)

Answer 11

- Localized to the colon and spares UGIT - Begins in the rectum and extends proximally CM 1. Diarrhea – bloody, mucus, pus 2. Constipation (some) 3. Tenesmus – cramping rectal pain 4. Cramping abd pain – worse w/ BM 5. Urgency 6. Nocturnal BM 7. Anorexia, weight loss, growth failure 8. Fulminant colitis – fever, severe anemia, hypoalbuminemia, leukocytosis, >5 bloody stools/d 9. Colon CA risk after 10 yrs - Colonoscopy + biopsy q1-2 yrs Dx 1. CBC – anemia of chronic ds 2. Hypoalbuminemia 3. Elev ESR, CRP 4. Inc focal calprotectin 5. Endoscopy (flexible sigmoidoscopy) + colon biopsy – gold standard. Edematous mucosa, erythema, loss of vascular markings, mucosal friability, erosions, ulcers, and bleeding sites Mgt 1. Sulfasalazine 50-75 mkd 2. Mesalamine 50 mkd q8-12 po 3. Probiotics 4. Prednisone 1-2 mkd for flares 5. Immunomodulators – azathioprine, 6-Mercaptopurine 6. Surgery – colectomy for fulminant ds

Answer 12

CHRON DISEASE - Involves entire region of GIT (mouth to anus) o Eccentric, segmental with skip areas CM 1. UGI – obstructive sx: RLQ cramping abd pain esp with meals, abd distention, borborygmus 2. Colon – diarrhea, bleeding, cramping 3. Fever, malaise, easy fatigability 4. Growth failure, delayed bone and sexual devt 5. Perianal tag, fistula, fissure, abscess 6. Gastric – vomiting, epigastric pain 7. Extrainstestinal – aphthous ulcer, arthritis, erythema nodosum, clubbing, episcleritis, renal stones, gall stone 8. TRIAD: diarrhea, weight loss, abdominal pain 9. (+)colon CA risk Dx 1.Esophagogastroduodenoscopy+ileocolonoscopy – discontinuous distribution of longitudinal ulcers (>4 to 5cm ulcers), cobblestone appearance, and/or aphthous ulcerations arranged longitudinally 2. Whole abd XR – to r/o penetrating ds 3. CT & MR enterography 4. Video capture endoscopy Mgt 1. Mesalamine, probiotics, CS, Azathioprine, 6- Mercaptopurine 2. Abx: metronidazole 30 mkd q6 – perianal ds 3. Biologics: infliximab, adalimumab 4. Enteral nutrition tx 5. Surg: bowel resection for refractory localized ds