Diarrhea

Question 1

5 year-old male from Makati, consulted for diarrhea

HISTORY
1 year prior to admission, noted bouts of foul-smelling, watery diarrhea with associated abdominal pain. Was treated by family physician with oral rehydrating solution.

6 months prior, again complained of abdominal pain and watery stools occurring twice a day. Said doctor gave ORS, zinc and probiotics with some relief.

In the interim, patient would have occasional bouts of watery stooling without blood, usually with associated abdominal pain

PAST MEDICAL HISTORY
Previously admitted for a few days vomiting and diarrhea at 7 mos, no known allergies

FAMILY MEDICAL HISTORY
Unremarkable

BIRTH AND MATERNAL HISTORY
Born full term to a 29-year-old G1P0 mother with unremarkable birth and maternal history.

IMMUNIZATIONS
Completed EPI and given one dose of MMR, influenza 4 mos. ago

NUTRITION
Exclusively breastfed until 3 months then mother started working, given age-appropriate milk formula, shifted to Nido at 3 years until 1 month ago
Started complementary feeding at 5 mos
Eats 3 meals consisting of meat or chicken, vegetables and rice, has 1-2 snacks/day consisting of fruits and/or yogurt, only drinks fruit juices

DEVELOPMENTAL
At par with age

PHYSICAL EXAM
Alert, converses with examiner, not in distress
BP 90/60, HR 116, RR 24, Afebrile
Wt 17 kg (z -1), Ht 110 cm (z 0)
Pink conjunctivae, anicteric sclerae, no cervical lymphadenopathy, no tonsillopharyngeal congestion
Equal chest expansion, clear breath sounds, no retractions
Adynamic precordium, loud S1 S2, PMI not displaced, regular rhythm, no murmurs
Flat abdomen, soft, liver not enlarged, non-tender
Pink nail beds, full pulses, no edema, good CRT

LABORATORY EXAMS
CBC: Hgb 115, Hct 0.31, MCV 52, MCH 27, MCHC 34, WBC 12, N 60%, L 34%, M 4%

Stool exam: Brown, soft, no ova/parasites seen

FOBT: negative

Stool pH: acidic
Reducing sugars: 3+

Question 2

What are the salient features of this case?

Answer 2

recurrent diarrhea and abdominal pain after 3yrs of age
normal physical exam

Question 3

Systematic approach to diagnosis, discussed differentials

Answer 3

Malabsorption disorders and Intestinal mucosal defects

Carbohydrates (lactase, sucrase-isomaltase deficiency)

Fat (cystic fibrosis, bile acid malabsorption)
Celiac Disease
Congenital microvillus atrophy

Infection
Acute gastroenteritis
Parasitic infection (amebiasis, ascariasis)
Post-infectious diarrhea (Clostridium difficile, Campylobacter, Shigella, Salmonella,
rotavirus)

Immunologic, non-infectious causes
Inflammatory bowel disease
Crohn’s Disease

Others (encopresis, excessive sorbitol intake, laxative abuse/manchausen by proxy)

Question 4

What are the diagnostic test for diarrhea?

Answer 4

CBC
Stool exam with occult blood, reducing sugars, pH

Question 5

INTERPRET THE LABORATORY EXAMS

CBC: Hgb 115, Hct 0.31, MCV 52, MCH 27, MCHC 34, WBC 12, N 60%, L 34%, M 4%

Stool exam: Brown, soft, no ova/parasites seen

FOBT: negative

Stool pH: acidic

Reducing sugars: 3+

Answer 5

*acidic stool pH
*presence of reducing substance in stool

Question 6

What is the management for this case?

Answer 6

*Avoid milk products
*may give lactase tablets with dairy yogurt which has lactase

Question 7

Preventive pediatrics

Answer 7

*Developmental surveillance
*Atopy screen
[ ] Monitor weight, height
[ ] Blood pressure
[ ] Eye exam
[ ] Immunizations
[ ] Iron (30mg/5ml, 1 tsp OD for 3 mos) , Vitamin A supplementation (200T IU q6mos)
[ ] Deworming (albendazole 400 mg q6mos, mebendazole 500 mg q6mos)
[ ] Dental care
[ ] Nutrition counseling
[ ] Physical activity
[ ] Injury and poisoning prevention
[ ] Child maltreatment prevention
[ ] Counseling on lead and toxicant exposure

Question 8

Case:
5 year-old male from Makati, consulted for diarrhea
HISTORY
1 year prior to admission, noted bouts of foul-smelling, watery
diarrhea with associated abdominal pain. Was treated by family
physician with oral rehydrating solution.
6 months prior, again complained of abdominal pain and watery
stools occurring twice a day. Said doctor gave ORS, zinc and
probiotics with some relief.
In the interim, patient would have occasional bouts of watery
stooling without blood, usually with associated abdominal pain
PAST MEDICAL HISTORY
Previously admitted for a few days vomiting and diarrhea at 7
mos, no known allergies
FAMILY MEDICAL HISTORY
Unremarkable
BIRTH AND MATERNAL HISTORY
Born full term to a 29-year-old G1P0 mother with unremarkable
birth and maternal history.
IMMUNIZATIONS
Completed EPI and given one dose of MMR, influenza 4 mos. ago
NUTRITION
Exclusively breastfed until 3 months then mother started working,
given age-appropriate milk formula, shifted to Nido at 3 years
until 1 month ago
Started complementary feeding at 5 mos
Eats 3 meals consisting of meat or chicken, vegetables and rice,
has 1-2 snacks/day consisting of fruits and/or yogurt, only drinks
fruit juices
DEVELOPMENTAL
At par with age
PHYSICAL EXAM
Alert, converses with examiner, not in distress
BP 90/60, HR 116, RR 24, Afebrile
Wt 17 kg (z -1), Ht 110 cm (z 0)
Pink conjunctivae, anicteric sclerae, no cervical lymphadenopathy,
no tonsillopharyngeal congestion
Equal chest expansion, clear breath sounds, no retractions
Adynamic precordium, loud S1 S2, PMI not displaced, regular
rhythm, no murmurs
Flat abdomen, soft, liver not enlarged, non-tender
Pink nail beds, full pulses, no edema, good CRT
LABORATORY EXAMS
CBC: Hgb 115, Hct 0.31, MCV 52, MCH 27, MCHC 34, WBC 12, N
60%, L 34%, M 4%
Stool exam: Brown, soft, no ova/parasites seen
FOBT: negative
Stool pH: acidic
Reducing sugars: 3+

Question 9

1.List down salient features of case

Answer 9

[ ] Recurrent diarrhea and abdominal pain after 3 years of age
[ ] Stopped drinking milk, no milk in diet
[ ] Normal physical exam

Question 10

2. Systematic approach to diagnosis, discussed differentials

Answer 10

[ ] Malabsorption disorders and Intestinal mucosal defects
Carbohydrates (lactase, sucrase-isomaltase deficiency)
Fat (cystic fibrosis, bile acid malabsorption)
Celiac Disease
Congenital microvillus atrophy
[ ] Infection
Acute gastroenteritis
Parasitic infection (amebiasis, ascariasis)
Post-infectious diarrhea (Clostridium difficile,
Campylobacter, Shigella, Salmonella,
rotavirus)
[ ] Immunologic, non-infectious causes
Inflammatory bowel disease
Crohn’s Disease
[ ] Others (encopresis, excessive sorbitol intake, laxative abuse/manchausen by proxy)

Question 11

3. Order diagnostic tests

Answer 11

[ ] CBC
[ ] Stool exam with occult blood, reducing sugars, pH

Question 12

Interpret lab results

Answer 12

[ ] Acidic stool pH
[ ] Presence or reducing substance in stool

Question 13

Management

Answer 13

[ ] Avoid milk, products
[ ] May give lactase tablets with dairy, yogurt which has lactase

Question 14

Preventive pediatrics

Answer 14

[ ] Developmental surveillance
[ ] Atopy screen
[ ] Monitor weight, height
[ ] Blood pressure
[ ] Eye exam
[ ] Immunizations
[ ] Iron (30mg/5ml, 1 tsp OD for 3 mos) , Vitamin A
supplementation (200T IU q6mos)
[ ] Deworming (albendazole 400 mg q6mos, mebendazole 500
mg q6mos)
[ ] Dental care
[ ] Nutrition counseling
[ ] Physical activity
[ ] Injury and poisoning prevention
[ ] Child maltreatment prevention
[ ] Counseling on lead and toxicant exposure

Question 15

Differentials for diarrhea

Answer 15

DDx: Viral and bacterial gastroenteritis
o Rotavirus (p.61)
o Adenovirus (p.68)
o Norwalk agent (p.62)
o Enterovirus (p.63)
o Salmonella (p.80)
o Shigellosis (p.74)
o E.coli (p.74)
o Campylobacter jejuni (p.77)
o Yersinia enterocolitis (p.77)
Protozoan infections/Parasitic infections
o Giardia lambia (p.79)
o E.hystolitica (p.81)

Question 16

What is acute gastroenteritis and give the etiology?

Answer 16

Diarrhea – loose or watery, excessively frequent, large volume
stools (>10ml/k/d in infants, >200 g/d in older child)
Dysentery – bloody diarrhea + fever. Bacterial enteritis.
Etiology
1. Inflammatory – C.jejuni, C.difficile, EIEC, Salmonella,
Shigella, Yersinia
2. Non-inflammatory – EPEC, ETEC, V.cholera
3. Viral – rotavirus, adenovirus, astrovirus, Norwalk,
calicivirus
4. Parasitic – G.lamblia, E.histolytica, B.coli,
Strongyloides, spore-forming protozoa
5. Others – Malabsorption, endocrinopathies, food
poisoning, neoplasms
- Milk allergy, immunodeficiency states, laxative abuse,
ulcerative colitis, motility disorders

Question 17

What is the pathophysiology of acute gastroenteritis?

Answer 17

• Acute diarrhea: <2w. most common viral
• Chronic diarrhea: >2w.
• Majority are foodborne illnesses
• Viruses are one of the most common causes of acute
  diarrhea in children

Question 18

Two types of acute infectious diarrhea

Answer 18

1. Inflammatory – bacteria invade intestine directly or
   produce cytokines
2. Non-inflammatory – enterotoxin production by
   bacteria, destruction of villus by viruses, adherence by
   parasites

Question 19

Mechanisms of diarrhea

Answer 19

OSMOTIC DIARRHEA
patho: presence of nonabsorbable solutes in the GIT as a result of:
Intestinal damage
reduced absorptive surface area
defective digestive enzyme (eg. lactose intolerance)
causes: lactose intolerance due to lactase enzyme deficiency
volume of stool:moderately increased
response to fasting: diarrhea stops
Stool Na: <70mEq/L
Stool pH:>5.5
Ion gap: >100mOsm/kg

SECRETORY DIARRHEA
patho: activation of intracellular mediators (cAMP, cGMP) that stimulate active chloride secretion & inhibit the neutral coupled NaCl absorption
toxin-mediated injury to the tight junctions

causes: cholera &e.coli
Clostridium deficile
Vasoactive peptides
Volume: very large volume
response to fasting: diarrhea continues
Stool Na: >70mEq/L
stool pH: usually >5.6
Ion Gap: <50 mOsm/kg

Stool output in infants/children contains approximately per (ave
composition of diarrhea):
- 55 mEq Na
- 25 mEq K
- 15 mEq HCO

Question 20

What are the clinical manifestations of diarrhea?

Answer 20

1. Diarrhea
2. Abdominal cramps/tenesmus – LGI
3. Vomiting - UGI
4. fever – sec. infection/dehydration

Question 21

Clinical manifestations of diarrhea with dehydration

Answer 21

Hx/PE:
- Oral intake
- Frequency and volume of stool output
- General appearance and activity
- Freq of urination, last UO
- Recent travel
- Use of abx
- Intake of seafood, contaminated water, uncooked
meat, unwashed vegetables
- Duration of diarrhea
- Presence of blood
- Fever, tenesmus, vomiting

Question 22

*review the differences between mild, moderate and severe dehydration

Answer 22

NONE TO MILD DEHYDRATION
Sensorium: Alert
Thirst: drinks normally
skin turgor:goes back quickly
eyaballs: normal
respiratory: normal
capillary refill time: normal
heart rate: normal tachycardic
peripheral pulses: normal or increased
BP: Normal
UO: decreased
extremities: warm to touch
mucous membrane: normal
tears: normal
Fluid deficit: <5% (50mL/kg)
older children: <3% (30mL/kg)
commonly used values for fluid computation:
Infants: 50ml/kg
older children: 30 ml/kg

MODERATE DEHYDRATION
Sensorium: irritable
Thirst: thirsty, drinks eagerly
skin turgor:goes back slowly
eyaballs: sunken
respiratory: tachypneic
capillary refill time: >1.5 secs
heart rate: tachycardic
peripheral pulses: rapid
BP: normal
UO: little or absent
extremities: cool and pale
mucous membrane: dry
tears: decreased
Fluid deficit: 5-10% (50-100mL/kg)
older children: 3-6% (30-60mL/kg)
commonly used values for fluid computation:
Infants: 100ml/kg
older children: 60 ml/kg

SEVERE DEHYDRATION
Sensorium: lethargic
Thirst: notable to drink
skin turgor:goes back very slowly
eyaballs: sunken
respiratory: deep and labored
capillary refill time: >3 secs
heart rate: tachycardic
peripheral pulses: rapid and weak or absent
BP: low
UO: no urine output
extremities: cold and pale
mucous membrane: parched
tears: no tears
Fluid deficit: >10% (>100mL/kg)
older children: >6% (>60mL/kg)
commonly used values for fluid computation:
Infants: 150ml/kg
older children: 90 ml/kg

Thirst, sensorium, extremities, pulses, and UO remain accurate
determinant of degree of dehydration
Only 2 signs needed to classify in a category

Question 23

Diagnostics

Answer 23

Dx
1. Based on clinical recognition, evaluating the severity by
rapid assessment
2. Stool exam – examine mucus, blood, leukocytes
- Fecal leukocytes = bacterial invasion of colonic mucosa
or early infection: Shigella, Shiga-toxin producing E.coli
E.hystolitica
3. Stool C/S – indications:
a. Hemolytic uremic syndrome (HUS) suspect
b. Bloody diarrhea
c. Stool with fecal leukocytes
d. Outbreaks
e. Immunocompromised pxs

Question 24

Management

Answer 24

Triad of mgt: ORS, Znx2wks, continued feeding
1. Rehydration – cornerstone. management of
dehydration
- Rehydration + Replacement of losses during 1st 4-6h
- Assess the degree of dehydration and provide fluid and
electrolyte replacement
Oral rehydrating solution (ORS)
- Reduces stool output, vomiting, need for IV tx
- Reduced osmolarity ORS contains 1:1 Na to glu ratio to
maximize sodium-glucose co-transport (Hydrite)
o Glu 75 mEq/L
o Na 75
o Cl 65
o K 20
o Citrate 10
o Osmolarity 245
- For severe malnutrition: use ½ strength ORS + refer to
GI and nutritionist
- Safest and preferred method to correct fluid deficit

Question 25

WHO CDC PROTOCOL ON REHYDRATION

Answer 25

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

Question 26

IVF

Answer 26

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

Question 27

Determine etiologic agent and provide treatment

Answer 27

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

Question 28

Prevention

Answer 28

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.

Question 29

What is Toddler’s diarrhea?

Answer 29

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

Question 30

What is Pseudomembranous colitis?

Answer 30

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

Question 31

Malabsorption

Answer 31

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

Question 32

Lactose intolerance/Lactase deficiency

Answer 32

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

Question 33

IRRITABLE BOWEL SYNDROME

Answer 33

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

Question 34

INFLAMMATORY BOWEL DISEASE

Answer 34

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)

Question 35

What is Chronic Ulcerative Colitis?

Answer 35

• 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

Question 36

What is Chron Disease?

Answer 36

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