Diarrhea Flashcards
increased stool frequency, liquidity, or volume
Diarrhea
before interpreting diarrhea, It is mandatory to know the individual’s ……….
normal bowel habits
normal bowel habits frequency
3 times/day – once/3 days
Frequency <2 weeks
Acute diarrhea
usually infectious but occasionally is due to drugs or a first presentation of inflammatory bowel disease
Acute diarrhea
Frequency >4 weeks
Chronic/relapsing diarrhea
may reflect colorectal cancer or inflammatory bowel disease, but the most frequent cause is irritable bowel syndrome
Chronic/relapsing diarrhea
Large stool volume is a sing of ………
Small intestine disease
Rare mucus in feces
Small intestine disease
Blood in feces is unusual
Small intestine disease
Sometimes there is fat in feces this is a sing of ………
Small intestine disease
Variable feces color is a sing of ………
Small intestine disease
Undigested food is occasionally in
Small intestine disease
Tenesmus defecation is rare in
Small intestine disease
Frequency of defection is 2-3 times per day is in
Small intestine disease
Urgency defecation is uncommon in
Small intestine disease
Sometimes there is vomiting in patients with
Small intestine disease
Weight loss is a common sing of ………
Small intestine disease
Small stool volume is a sing of ………
Large intestine disease
Mucus in feces is a common sing of ………
Large intestine disease
Fat in feces is absent in
Large intestine disease
Feces color is normal in
Large intestine disease
Undigested food in feces is absent in
Large intestine disease
Defecation Tenesmus is common a sing of ………
Large intestine disease
Frequency of defecation is >3 times per day is a sing of ………
Large intestine disease
Defecation urgency is common in
Large intestine disease
Vomiting is uncommon in
Large intestine disease
Weight loss is rare in
Large intestine disease
an abnormality in absorption of food nutrients across the gastrointestinal (GI) tract
Malabsorption
Impairment can be of …….. nutrients depending on the abnormality
single or multiple
Diarrhea and weight loss in patients with a normal diet is likely to be caused by …….
malabsorption
Bulky, pale and offensive stools which float in the toilet
It signify fat malabsorption
Steatorrhea
Steatorrhea signify ………
fat malabsorption
Pallor in anemic patient
Sign of malabsorption of iron
Angular stomatitis
Sign of malabsorption of vitamin B2 (riboflavin) + other vitamins B + iron
Glossitis
Sign of malabsorption of vitamin B2 (riboflavin) + other vitamins B + iron
Bleeding gum
Sign of malabsorption of vitamin C
follicular hyperkeratosis
Sign of malabsorption of vitamin A
Koilonychias
Sign of malabsorption of iron
Muscle wasting
Sign of malabsorption of protein
Leg edema
Sign of malabsorption of protein
Clubbing
Sign of malabsorption
pathophysiologic mechanisms of diarrhea include (4)
• Osmotic
• Secretory
• Inflammatory
•Altered motility
Osmotic
pathophysiologic mechanism of diarrhea
Secretory
pathophysiologic mechanism of diarrhea
Inflammatory
pathophysiologic mechanism of diarrhea
Altered motility
pathophysiologic mechanism of diarrhea
in most of the cases the pathophysiologic mechanism of diarrhea is
multifactorial
involves an unabsorbed substance that draws water from the plasma into the intestinal lumen along osmotic gradients
Osmotic diarrhea
results from disordered electrolyte transport
Secretory diarrhea
diarrhea with exudative, secretory, or osmotic components
Diarrhea caused by Inflammatory diseases
may alter fluid absorption by increasing or decreasing the exposure of luminal content to intestinal absorptive surface
Altered motility of the intestine or colon
Bloody Diarrhea
Either ……… or ………
INFECTIVE
NON-INFECTIVE
INFECTIVE diarrhea
Invasive organisms
Cytotoxic organisms
Cytotoxic organisms
INFECTIVE Diarrhea
Invasive organisms
INFECTIVE Diarrhea
Campylobacter
Invasive organisms
Shigella
Invasive organisms
Amoeba
Invasive organisms
C. difficile
Cytotoxic organisms
E. coli O157
Cytotoxic organisms
When patients with infective diarrhea
What to do
Send CBC, CRP
Take three stool samples in all patients
blood cultures if fever is present.
Test stool for ………. if the patient has risk factors
(lives nursing home, recently hospitalized, received antibiotics within the last 3 months or is >65 years. In high-risk patients send ≥3 samples before ruling out the diagnosis.)
C. difficile toxin (CDT)
Test stool for ………. if the patient has severe systemic upset
C. difficile toxin (CDT)
Test stool for ………. if the patient has ↑↑WBC
C. difficile toxin (CDT)
Request analysis of stool for ova, cysts and parasites in patients with ……. Or when …….
history of recent foreign travel
suspect immune compromised state
Ischemic colitis
NON-INFECTIVE
inflammatory diarrhea
NON-INFECTIVE
NON-INFECTIVE
Ischemic colitis
or inflammatory diarrhea
bloody diarrhea is preceded by sudden onset of LLQ abdominal pain or in any patient >50 years with known atherosclerotic disease or a source of systemic embolism e.g. atrial fibrillation
ischemic colitis
In ischemic colitis Check for ….. (3)
ECG, CT Angio, Colonoscopy
Patient without risk factors of ischemic colitis may has
inflammatory cause
e.g. Inflammatory Bowel Disease (IBD)
In inflammatory cause diarrhea
e.g. Inflammatory Bowel Disease (IBD)
Check …… (2)
Refer to …….
Stool for leukocytes and leukocyte proteins
inflammatory markers: CRP and ESR
colonoscopy for histological confirmation and assess the disease severity
calprotectin or lactoferrin
Check Stool for leukocytes and leukocyte proteins
Non bloody diarrhea (3)
Protozoal infection
Gastroenteritis
Drug-related diarrhea
Protozoal infection
Non bloody diarrhea
Gastroenteritis
Non bloody diarrhea
Most cases are self-limiting viral or toxin mediated infections and do not require further investigation or antimicrobial treatment
Gastroenteritis
Gastroenteritis
If symptoms persist ……….. , seek specialist advice and consider further assessment as for
> 14 days
chronic/relapsing diarrhea
Drug-related diarrhea
Non bloody diarrhea
*Laxatives (including occult laxative abuse)
cause Drug-related diarrhea
- Antibiotics (especially macrolides)
Can cause Drug-related diarrhea
- Alcohol (especially chronic/excess)
Can cause Drug-related diarrhea
- NSAIDs
Can cause Drug-related diarrhea
*Proton pump inhibitors
Can cause Drug-related diarrhea
- Cytotoxic agents
Can cause Drug-related diarrhea
Metformin
Can cause Drug-related diarrhea
Colchicine
Can cause Drug-related diarrhea
Orlistat
Can cause Drug-related diarrhea
SSRIs
Can cause Drug-related diarrhea
Nicorandil
Can cause Drug-related diarrhea
high index of suspicion for overflow diarrhea in frail, immobile or confused elderly patients
Always do ……..
PR examination
Hard or impacted stool in rectum
Always do ………
PR examination
If hard or impacted stool found, treat with …….. , then ………
fecal softeners and laxatives
reassess
If the PR is normal, ………..
but consider an ………. if there is strong clinical suspicion
overflow diarrhea is unlikely
abdominal X-ray
If steatorrhea is present
Ensure that the patient is not taking ………..
Check ………. and ………
orlistat
celiac serology (AntiTTG) and faecal elastase
↓in pancreatic insufficiency
faecal elastase
steatorrhea is present
If ↓fecal elastase or a strong suspicion of pancreatic disease, consider ………
pancreatic imaging (CT/MRCP)
steatorrhea is present
If AntiTTG is +ve
Duodenal biopsy to confirm celiac disease
to confirm celiac disease
Duodenal biopsy
steatorrhea is present
If all other possibility were excluded do (2)
small bowel investigation
Screen for nutritional deficiencies
e.g. duodenal biopsy, video capsule, MRI
small bowel investigation
Consider colonoscopy, to exclude
colorectal cancer/inflammatory bowel disease
if the patient has persistent diarrhea with any of the following:
•PR bleeding
•palpable rectal/abdominal mass •weight loss
•iron deficiency anemia
•new presentation in a patient >45 years.
Do …..
colonoscopy
to exclude colorectal cancer/inflammatory bowel disease
With Alarm features (5)
•PR bleeding
•palpable rectal/abdominal mass •weight loss
•iron deficiency anemia
•new presentation in a patient >45 years.
Clinical or laboratory features suggesting organic disease
Screen for hyperthyroidism, hypercalcemia and celiac disease
Refer to GI for further small bowel investigation
if large volume, non-bloody stool, previous gastric/small bowel surgery or evidence of nutritional deficiencies
Refer to GI for further small bowel investigation
if there is a positive family history, mouth ulcers, fever, ↑CRP/ESR or extra-intestinal manifestations
Exclude inflammatory bowel disease
If no Hard or impacted stool in rectum, Steatorrhea, Alarm features, and Clinical or laboratory features suggesting organic disease
So it’s…….
functional cause
irritable bowel syndrome, particularly when typical symptoms are present
Is example of …..
functional cause
If patient is with functional cause diarrhea provide ……..
If symptoms progressive distressing or disabling, ………
reassurance and explanation +/- symptomatic Rx
Refer to GI
