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Clin Med 3 > Diarrhea > Flashcards

Diarrhea Flashcards

1
Q

Do most patients with diarrhea present for care?

A

No

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2
Q

Do most cases of diarrhea need tx?

A

No

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3
Q

What are most cases of diarrhea?

A

Infectious

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4
Q

Most cases of infectious diarrhea are what?

A

Viral

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5
Q

Most cases of viral diarrhea are what?

A

Norovirus

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6
Q

Most cases of severe diarrhea are what?

A

Bacterial

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7
Q

Most cases of bacterial diarrhea are what?

A

Campylobacter

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8
Q

Diarrheal diseases represent what?

A

One of 5 leading causes of death world wide

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9
Q

Approach to patients with diarrhea focuses on what?

A

Distinguishing infectious etiologies from non infectious etiologies

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10
Q

Definition of diarrhea

A

Decreased absorption or increased secretion (or both) causing >200 grams of stool a day - in dry weight

3x in a 24hr period

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11
Q

Diarrhea reflects what?

A

Impaired water absorption or increased water secretion by the bowel

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12
Q

What is acute diarrhea? Likely what?

A

Acute is 14 days or less, likely infectious

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13
Q

What is persistent/subacute diarrhea? Could be what?

A

More than 14 days but <30 days

Could be inflammatory or infectious

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14
Q

What is chronic diarrhea? What are the 3 types?

A

> 30 days

3 types: osmotic, secretory and inflammatory vs non-inflammatory

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15
Q

Small bowel vs large bowel functions

A

Small bowel - functions as a fluid and enzyme secreting/regulating organ
-ABSORBS NUTRIENTS

Large bowel - absorbs fluid and salt
-EXCRETES K

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16
Q

Dysregulation of what 2 processes leads to watery diarrhea?

A

Dysregulation of small bowel and large bowel processes leads to watery diarrhea

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17
Q

What are the major causes of acute infectious diarrhea?

A

Viruses - norovirus, rotavirus, adenovirus, astrovirus

Bacteria - Salmonella, Campylobacter, Shigella, entertoxigenic, E. Coli, C. Dif

Protozoa - cryptosporidium, guardia, cyclospora

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18
Q

When do non-infectious etiologies of diarrhea become more likely?

A

As the course of diarrhea becomes more persistent and chronic

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19
Q

When is Acute Evaluation of diarrhea warranted?

A
  • persistent fever
  • bloody diarrhea
  • severe abdominal pain (they look like toxic megacolon)
  • sx’s of volume depletion (hypotension, scant urine)
  • hx of inflammatory bowel disease
  • possible widespread food-borne outbreak
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20
Q

What is the most common etiology of diarrhea?

A

Viruses

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21
Q

Evaluation of diarrhea

A
  • good hx
  • character of sx’s, duration
  • food hx
  • exposure, pets
  • travel
  • meds/medical hx
  • volume status
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22
Q

What determines whether diarrhea originates from small or large bowel?

A

Frequency and nature of stool

Different pathogens depending on if small or large bowel diarrhea

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23
Q

Diarrhea of small bowel sx’s

A
  • watery
  • large volume
  • abd cramping
  • bloating
  • gas
  • weight loss w/ persistent diarrhea
  • rarely occurs with fever, occult blood or inflammatory cells in stool
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24
Q

Diarrhea of large bowel sx’s

A
  • frequent, regular
  • small volume
  • painful bowel movements
  • fever
  • bloody or mucoid stools common
  • inflammatory and red blood cells seen on microscopy
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25
Q

Diarrhea of large bowel suggests what?

A

Invasive bacteria (salmonella, shigella, or campylobacter)

Enteric virus (cytomegalovirus or adenovirus)

Cytotoxic organism (C. Diff)

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26
Q

Enterotoxic cause of diarrhea - what’s the diarrhea look like? Fever, WBC, Fecal leukocytes?

A

Infectious agent creates a toxin floating in gut causing large amount of WATERY DIARRHEA

NO FEVER, NO ELEVATED WBC, NO FECAL LEUKOCYTES

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27
Q

Invasive diarrhea - what’s the diarrhea like? Fever? WBCs? Fecal leukocytes?

A

The infectious agent breaks thru the blood/gut barrier - BLOODY DIARRHEA

FEVERS, LEUKOCYTOSIS, + FECAL LEUKOCYTES

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28
Q

Difference b/w diarrhea in enterotoxic causes and invasive causes?

A

Enterotoxic diarrhea is WATERY DIARRHEA

Invasive diarrhea is BLOODY DIARRHEA

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29
Q

Food hx timing and diarrhea

A

Within 6 hrs - ingestion of a preformed toxin (staph aureus or Bacillius cereus) esp if N/V

8-16 hrs - infection with C. Perfringens

> 16 hrs - other bacterial or viral infection

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30
Q

If get diarrhea within 6 hrs of eating, what is the cause?

A

Ingestion of a preformed toxin

(Staph aureus or B. Cereus) esp if N/V

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31
Q

If get diarrhea within 8-16 hrs after eating, what is it?

A

Infection with C. Perfringens

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32
Q

If get diarrhea >16 hrs after eating, what is it?

A

Other bacterial or viral infection

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33
Q

If have vomiting and diarrhea, what’s the most likely cause?

A

Viral

Bacterial doesn’t have as much vomiting

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34
Q

Other exposures that cause diarrhea

A

Animals - Salmonella

Travel - bacterial diarrhea and parasitic infections

Daycare centers - Shigella, Cryptosporidium and Giardia

Recent Abx use - C. Diff

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35
Q

When do you do stool cultures for diarrhea?

A

Severe illness - profuse watery diarrhea with signs of hypovolemia

Signs and sx concerning for inflammatory diarrhea

High-risk host features (age >70, etc)

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36
Q

What classifies severe illness for stool cultures?

A

Profuse watery diarrhea w/signs of hypovolemia

Passage of >6 unformed stools in 24 hrs

Severe abd pain

Need for hospitalization

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37
Q

Signs and sx’s concerning for inflammatory diarrhea

A

Bloody diarrhea

Passage of many small volume stools containing blood or mucous

Temp >101.3

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38
Q

High-risk host features that you should do stool cultures for diarrhea

A

Age >70

Comorbidities, CV disease, DM

Immunocompromised

IBD

Pregnancy

Sx’s >1 week

Public health concern

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39
Q

How to dx campylobacter, salmonella, shigella

A

Culture and sensitivity

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40
Q

Dx evaluations of diarrhea O&P stool study

A

Parasites such as Giardia and Strongylodies and entero-adherent bacteria can be difficult to detect but may be dx by intestinal bx

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41
Q

Fecal Leukocytes and dx evaluation of diarrhea

A

May also support the dx of inflammatory diarrhea, more sensitive is Fecal Lactoferrin (but not widely used)

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42
Q

What is fecal lactoferrin?

A

Used for diarrhea dx

Used to detect inflammation in the intestines, most sensitive than fecal leukocytes

Can be used to detect bacterial infections that cause inflammatory diarrhea

Sensitive and specific, but limited use

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43
Q

What is the first thing to assess when pt presents with diarrhea?

A

Hydration status and electrolytes b/c death from diarrhea is caused by DEHYDRATION

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44
Q

Severe diarrhea tx needs what?

A

IV with added K+ or NaHCO3-

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45
Q

Oral Rehydration Solution (ORS) tx for diarrhea

A

Given to infants and children at rate of 50-100ml/kg in 4 hrs

Adults should drink 1L/hr

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46
Q

Is NOT eating recommended as tx for diarrhea?

A

NO!!! Not necessary and not recommended

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47
Q

What should you avoid when have diarrhea?

A

Dairy

Caffeinated beverages - will enhance intestinal motility

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48
Q

Pharmacologic management of diarrhea

A

Anti-motility Rx (Bismuth subsalicylate)

Anxiolytics and antiemetics
-decr sensation of having to go (may make sx’s more tolerable, but don’t treat diarrhea)

Food derived substances (zinc and pectin)

Probiotics (keep good bacteria balanced in gut)

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49
Q

what meds make diarrhea sx’s more tolerable?

A

anxiolytics and antiemetics

-decr sensation of having to go (may make sx’s more tolerable, but don’t treat diarrhea)

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50
Q

Norovirus common where?

A

cruise ships, dorms

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51
Q

when do norovirus sx’s develop and how long do they last?

A

within 12-48 hrs after being exposed and last 24-72hrs

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52
Q

acute onset sx’s of Norovirus

A

N/V

watery, NON-BLOODY diarrhea

abd cramps

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53
Q

how is Norovirus transmitted?

A

close contact with infected person

fecal-oral route with contaminated food

touching contaminated surfaces

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54
Q

who can norovirus be serious for?

A

children and elderly

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55
Q

what is the most common complication of norovirus?

A

dehydration

-just hydrate, don’t usually need to go to ER

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56
Q

types of bacterial diarrhea

A

C. Diff, campylobacter, salmonella, Enterohemorrhagic E. coli, shigella, cholera

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57
Q

what can the toxins of C. diff cause?

A
  • Severe watery diarrhea
  • Pseudomembranous colitis
  • Toxic megacolon
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58
Q

when do sx’s for c. diff develop?

A

Symptoms may develop while still on ABX or 5-10 days after completion
-timing of when you started abx is important

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59
Q

what abx are most frequently associated with C. diff?

A
  • fluoroquinolones
  • Cephalosporins
  • PCNs
60
Q

when should C. diff be suspected?

A

in patients with diarrhea (>3 watery stools in 24 hours) or ileus in the setting of relevant risk factors:

  • ABX use
  • Recent hospitalization
  • Advanced age
61
Q

what culture should you do for dx of C. diff?

A

stool culture

62
Q

C. diff treatment

A

Metronidazole (Flagyl) - FIRST LINE

Vancomycin PO - 2nd line

Fecal transplant - if meds fail

63
Q

what is the first line treatment for C. diff?

A

Metronidazole

64
Q

what 2 species of campylobacter cause most of human disease-enteritis?

A

C. jejune and C. coli

65
Q

what does campylobacter inhabit?

A

intestinal tracts of animals -> POULTRY

66
Q

campylobacter sx’s

A

Abrupt onset of:

  • Abdominal pain (can mimic appendicitis - RLQ pain)
  • Diarrhea (bloody or mucoid)
  • INVASIVE diarrhea

Prodrome of fever, chills, aches in 30%

67
Q

campylobacter dx

A

stool culture

68
Q

campylobacter tx in healthy pts

A

IV fluids and antiemetics

69
Q

campylobacter tx in immunocompromised and severe disease

A

Cipro/Levo or Azithromycin

70
Q

what is the leading cause of foodborne disease in the US?

A

non-typhoidal salmonellosis

71
Q

most common salmonella species?

A

Salmonella enteritidis and Salmonella typhimurium

72
Q

what food is salmonella associated with?

A

ingestion of poultry, milk products, eggs

73
Q

when does salmonella gastroenteritis occur?

A

8-72hrs post exposure to ingestion of contaminated food or water

74
Q

sx’s of salmonella gastroenteritis? resolves when?

A

INVASIVE!!!

  • N/V
  • Diarrhea (pea soup) - not grossly bloody, but may have blood
  • abd cramping
  • fever with chills

resolves in 48-72 hrs

75
Q

salmonella dx

A

stool culture

76
Q

salmonella tx

A
  • Self-limiting 4-10 days
  • Supportive
  • IV fluid replacement and electrolyte repletion
  • ABX not indicated in healthy patients
  • Cipro or Levo for severe disease or immuncompromised
77
Q

what is short-term vs long-term carriage of salmonella?

A

Short term carriage - normal shedding of bacteria after infection

Long term carriage - shedding of bacteria for more than 1 year after infection

78
Q

sx’s of enterohemorrhagic e.coli diarrhea

A

Invasive

  • abd pain
  • BAD BLOODY DIARRHEA
  • no fever
79
Q

tx for enterohemorrhagic e.coli diarrhea

A

ABX NOT RECOMMENDED  may increase incidence of hemolytic uremic syndrome (HUS)

-HUS = acute renal failure, hemolytic anemia, thrombocytopenia

Shigella also has high risk of HUS

80
Q

what bacteria have a high risk of hemolytic uremic syndrome (HUS) when treated with abx?

A

e.coli and shigella

81
Q

what is HUS?

A

hemolytic uremic syndrome

acute renal failure, hemolytic anemia, thrombocytopenia

82
Q

why aren’t abx recommended to treat enterohemorrhagic E. coli?

A

b/c of hemolytic uremic syndrome (HUS)

83
Q

what type of bacteria is Shigella?

A

Gram negative facultative anaerobe -> non spore forming bacteria

84
Q

what is Shigella less susceptible to vs other bacteria?

A

stomach acid

-multiplies in small bowel

85
Q

transmission of shigella

A
  • Direct person to person contact
  • Contaminated food and water
  • Humans are the only natural reservoir
  • Spread by fecal-oral route
  • Predominantly institutions like day-care centers
  • MSM
86
Q

shigella sx’s

A

Invasive

  • high fever
  • diarrhea (small volume, bloody and mucoid, but may initially be watery)
  • abd cramping
  • tenesmus
87
Q

shigella dx

A

stool culture

88
Q

shigella tx

A
  • Supportive
  • IV fluids and electrolyte repletion
  • Self limiting -> averages 7 days
  • ABX not indicated in healthy patients because of risk of HUS

-Cipro, azithromycin, and Bactrim for severe disease and immunocompromised

89
Q

what abx do you use for shigella and when?

A

Cipro, azithromycin, and Bactrim for severe disease and immunocompromised

90
Q

what is cholera?

A

Acute secretory diarrheal illness cause by toxin producing strains of vibrio cholera

Secretory -> TONS of fluid

91
Q

cholera sx’s

A

Massive diarrhea

  • Non bloody
  • Liquid
  • Gray, RICE WATER STOOL***
  • No odor

Profound fluid and electrolyte loss in stool and rapid progression to hypovolemic shock within 24 hours of symptom onset d/t nothing being absorbed

92
Q

what can occur when have cholera?

A

Profound fluid and electrolyte loss in stool and rapid progression to hypovolemic shock within 24 hours of symptom onset d/t nothing being absorbed

93
Q

cholera tx

A

HYDRATION!!!

Abx:

  • tetracyclines
  • ampicillin
  • azithromycin
  • bactrim
  • FQs
94
Q

where does cholera primarily affect in the world?

A

places with inadequate access to clean water

95
Q

when does cholera peak?

A

before and after rainy seasons

96
Q

types of protozoan induced diarrhea?

A

intestinal entamoeba

cryptosporidium

giardia

97
Q

what is intestinal entamoeba?

A

type of protozoan induced diarrhea

caused by entamoeba hystolytica

poor sanitation

98
Q

who is at increased risk of infection of intestinal entamoeba?

A

Institutional patients (prisons, nursing facilities) and MSM are at increased risk of infection

99
Q

transmission of intestinal entamoeba?

A

Parasite exists in two forms
-Cyst stage -> infective form -> what gets passed on

-Trophozoite -> invasive disease form -> turns into this after cyst is ingested -> this is what does the damage -> causes BLOODY DIARRHEA

Can be associated with fecal-oral route

100
Q

infection of intestinal entamoeba caused by?

A

ingestion of amebic cysts via contaminated food or water

101
Q

sx’s of intestinal entamoeba

A
  • Majority are asymptomatic
  • Onset is 1-3 weeks
  • Ranges from mild diarrhea -> severe dysentery, abdominal pain, weight loss, fever
  • INVASIVE
102
Q

intestinal entamoeba dx

A

O&P (ovum and parasite) culture

serum antigen

103
Q

complications of intestinal entamoeba

A

Fulminant colitis with bowel necrosis leading to perforation and peritonitis

104
Q

tx of intestinal entamoeba

A
  • Metronidazole
  • Tinidazole
  • Ornidazole
105
Q

what is giardia?

A

type of protozoan diarrhea cause

one of 2 common intestinal parasites found in US (with cryptosporidium)

106
Q

giardia sx’s

A
  • Watery, YELLOW, foul smelling diarrhea
  • Alternating between soft and greasy stools
  • Associated fatigue and bloating
  • Weight loss = as much as 10% of body weight
107
Q

giardia transmission

A

Can be both epidemic and sporadic

Common cause of waterborne and foodborne diarrhea in daycare center outbreaks

HISTORY OF CAMPING -> fresh water

108
Q

common hx with giardia infection?

A

HISTORY OF CAMPING

109
Q

giardia tx

A
  • Metronidazole
  • Tinidazole
  • Nitzoxinide

Even after treatment may have recurrent episodes up to 6 weeks
-Takes a while to get back to baseline

110
Q

what is the most common parasitic cause of acute food borne diarrhea in US?

A

cryptosporidium

111
Q

how does cryptosporidium infect?

A

Digest the cyst and excrete the cyst - no trophozoite like in intestinal entamoeba

112
Q

Cryptosporidium transmission

A

Spread from an infected person or animal

Fecally contaminated food or water

113
Q

Cryptosporidium tx

A

Antiparasitic med: Nitazoxanide

-Good for children because liquid form

114
Q

what defines traveler’s diarrhea?

A

Diarrhea that develops during or within 10 days of returning from travel

115
Q

what is the most common cause of traveler’s diarrhea? how long does it last?

A

e. coli non-hemorrhagic

- lasts 1-5 days

116
Q

highest risk of traveler’s diarrhea where?

A

india, nepal, western/central africa

117
Q

campylobacter as cause of traveler’s diarrhea most common where?

A

SE Asia

118
Q

rotavirus as cause of traveler’s diarrhea most common where?

A

Jamaica and in kids

119
Q

prevention of traveler’s diarrhea

A
  • Prudent selection of food and drink (bottle only)
  • Food that is thoroughly cooked
  • Pasteurized dairy products
120
Q

traveler’s diarrhea sx’s

A
  • Depend on microbial etiology
  • Malaise
  • Anorexia
  • Abdominal cramps
  • Watery diarrhea
121
Q

traveler’s diarrhea tx

A
  • Cipro or Levo

- Can consider loperamide

122
Q

when do you consider food borne illness?

A

Consider foodborne illness when patients present with diarrhea, N/V

123
Q

Non-infectious causes of diarrhea

A
  • Inflammatory bowel disease
  • Irritable bowel disease
  • Partial SBO
  • Pelvic abscess in rectosigmoid region
  • Fecal impaction
  • Ingestion of poorly absorbable sugars -> lactulose
  • Acute alcohol ingestion
124
Q

what is irritable bowel syndrome?

A

chronic abdominal pain and altered bowel habits in absence of any organic cause

125
Q

what is the most commonly diagnosed GI disorder?

A

irritable bowel syndrome

126
Q

pathophysiology of IBS?

A
  • GI motility
  • Visceral hypersensitivity- nerves in gut are flared in response to something
  • Inflammation
  • Good sensitivity
  • Bacterial overgrowth
127
Q

definition of IBS

A

recurrent abdominal pain or discomfort on average at least 1 day per week in last 3 months with 2 or more of the following:

  • Improvement with defecation
  • Abdominal pain gets better with shitting
  • Change in frequency of stool
  • Change in form of stool
128
Q

definition of IBS with constipation

A

abnormal bowel movements are usually constipation

129
Q

definition of IBS with diarrhea?

A

abnormal bowel movements are usually diarrhea

130
Q

definition of mixed IBS

A

abnormal bowel movements are both constipation and diarrhea

131
Q

indications for endoscopic evolution for IBS

A
  • More than minimal rectal bleeding
  • Weight loss
  • Unexplained iron deficiency anemia
  • Nocturnal symptoms
  • Ask if it wakes them up at night (usually means inflammatory diarrhea)
  • Family history of colorectal cancer, inflammatory bowel disease, or celiac sprue
132
Q

IBS tx

A

Dietary modification

  • Eat low gas producing foods
  • Avoid beans, onions, celery, bananas, apricots, bagels, pretzels
  • Avoid alcohol and caffeine
  • Avoid lactose
  • Low FODMAP diet: fementable foods (Honey, corn syrup, apples, pears, mangoes, cherries)
  • Avoid gluten

Physical activity

133
Q

pharmacologic therapy for IBS-C

A

Mirilax (polyethylene glycol)

Lubiprostone - chloride channel activator that enhances chloride rich intestinal fluid secretion

Linaclotide - guanylate cyclase agonist that stimulates intestinal fluid secretion and transit

134
Q

what is malabsorption caused by?

A

Caused by many different diseases, drugs, or nutritional products that impair:

  • Intraluminal digestion
  • Mucosal absorption
  • Nutrient delivery to systemic circulation
135
Q

what is the HALLMARK of malabsorption?

A

steatorrhea - excess fat in stool

  • Bulky fat laden stool: >30g of fat per day
  • Yellow, smelly, floating poop
136
Q

what is the goal of tx for malabsorption?

A

Goal is to treat or correct underlying cause

  • Celiac sprue
  • Bacterial overgrowth
  • Lactase deficiency
137
Q

malabsorption GOLD STANDARD dx

A

Quantitative stool fat test

  • Ingestion high fat diet for 2 days before and during collection -> 100 g of fat per day
  • Stool collected for 3 days- totals 5 days
138
Q

other malabsorption dx tests

A

Qualitative Sudan stain for fat

  • Determines the percentage of fat in stool
  • 90% sensitivity and specificity

Acid steatocrit

  • Inexpensive and reliable
  • Centrifugation of acidified stool in a liquid HCT capillary -> separates into solid, liquid and fatty layers
139
Q

is oral better than IV for tx of diarrhea?

A

yes!!!

-unless severe dehydration, then use IVF (normal saline, ringer’s lactate)

140
Q

what types of fluid solutions do you need to treat diarrhea?

A

ones that contain water, salt, and sugar (coke and sprite)

141
Q

are oral rehydration fluids for sweat replacement equivalent?

A

no!!!
-These replace electrolytes, but not the same as what you need when you are dehydrated from diarrhea

  • May however, be adequate in an otherwise healthy patient
  • Has to do with osmolarity: low osmolarity oral rehydration fluids have been shown to decrease: Stool output, Vomiting, And need for IV fluids
142
Q

antimotility meds as tx for diarrhea

A

Loperamide (Imodium)

Pepto-Bismal (Bismuth subsalicylate)

Lomotil (Atropine/Diphenoxylate)

Eluxadoline (combined opioid agonist/antagonist) - Slows down gut

Bile acid sequestrants

143
Q

how does loperamide work and caution in what when using it?

A

Works by slowing down gut motility -> decreases number of stool and makes diarrhea less watery

CAUTION in invasive bacteria -diarrhea is acting to flush out bacteria, don’t want to slow that down or will get toxic megacolon

144
Q

when are bile acid sequestrants used for tx of diarrhea? how do they work? how do bile acids cause diarrhea?

A

Used in patients with persistent diarrhea despite antidiarrheal use

Bile acids cause diarrhea by stimulating colonic secretion and motility

Cholestyramine, Colestipol, Colesevelam - will bulk up the stool

145
Q

50% of patients with IBS-D will have what?

A

50% of patients with IBS-D have bile acid malabsorption

146
Q

do all pts with diarrhea need antidiarrheal meds?

A

NO!!!

in some it is C/I!!!

Clin Med 3 (21 decks)

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