Diarrhea Flashcards
_______ is defined as an intestinal disorder
characterised by abnormal frequency and liquidity of
faecal evacuations
Diarrhoea
In Australia most infective cases of diarrhea are _____
viral
Disorders of the ______ tend to produce
diarrhoea stools that are copious, watery or fatty,
pale yellow or green
upper GIT
______ tends to produce stools that are
small, of variable consistency, brown and may
contain blood or mucus
Colonic disorder
T or F
Acute gastroenteritis should be regarded as a
diagnosis of exclusion
T
Chronic diarrhoea is more likely to be due to
_______than bacillary dysentery
protozoal infection (e.g. amoebiasis, giardiasis or Cryptosporidium )
Certain antibiotics can cause an overgrowth
of Clostridium difficile, which produces
__________
pseudomembranous colitis
Diarrhoea can be classified broadly into
4 types:
— acute watery diarrhoea
— bloody diarrhoea (acute or chronic)
— chronic watery diarrhoea
— steatorrhoea
Red flag pointers for diarrhoea
- Unexpected weight loss
- Persistent/unresolved
- Fever
- Overseas travel
- Severe abdominal pain
- Family history: bowel cancer, Crohn disease
Important causes of chronic infectious diarrhea
Giardia lamblia, C. difficile, Yersinia, Entamoeba
histolytica, Cryptosporidium and HIV infection
In children, ________can present as chronic diarrhoea while intussusception, although not causing true diarrhoea, can present as loose, redcurrant jelly-like stools and should not be misdiagnosed (as gastroenteritis
coeliac disease and fibrocystic disease
Infection with enterohaemorrhagic strains
of E. coli (e.g. O157:H7, O111:H8) may lead to
the _____ or ______ particularly in children.
haemolytic uraemic syndrome or thrombotic
thrombocytopenic purpura,
Death cap mushroom (the world’s most lethal)—
_________ —causes severe
gastroenteritis followed by delayed hepatic failure
and AKF
Amanita phalloides
General pitfalls
• Not considering acute appendicitis in acute
diarrhoea—can be _______
• Missing _______ with spurious diarrhoea
• Failing to consider _________ in an
elderly patient with the acute onset of bloody
diarrhoea stools (following sudden abdominal
pain in preceding 24 hours)
retrocaecal or pelvic appendicitis
faecal impaction
acute ischaemic colitis
This colitis can be caused by the use of any antibiotic,
especially clindamycin, lincomycin, ampicillin and
the cephalosporins (an exception is vancomycin
Pseudomembranous colitis (antibioticassociated diarrhoea
Cause of Pseudomembranous colitis
overgrowth of C. difficile, which
produces a toxin that causes specific inflammatory
lesions, sometimes with a pseudomembrane
Character of Pseudomembranous colitis
• Within 2 days of taking antibiotic (can start up to
4 to 6 weeks after usage)
• Persists 2 weeks (up to 6) after ceasing antibiotic
Mx of Pseudomembranous colitis
Cease antibiotic
Mild to moderate: metronidazole 400 mg (o) tds
for 10 days
Severe: vancomycin 125 mg (o) qid for 10 days
(in consultation with specialist
The________ which is a
very common condition, may reflect underlying
psychological factors and most patients find that
the symptoms are exacerbated by stress
irritable bowel syndrome,
In children chronic diarrhoea can occur with the socalled
______ characterised
by growth and developmental retardation due to
adverse psychosocial factors
‘maternal deprivation syndrome’,
Central colicky abdominal pain indicates involvement
of the _____, while lower abdominal pain points
to the_____
small bowel
large bowel
If small volume, consider ________
of colon; if large volume, consider ______
inflammation or carcinoma
laxative abuse and
malabsorption
If there is profuse bright red bleeding, consider
____________, and if small
amounts with mucus or mucopus consider
______
diverticulitis or carcinoma of colon
inflammatory bowel disorder
In______ the stools are distinctively pale,
greasy, offensive, floating and difficult to flush. It is
exacerbated by fatty foods.
steatorrhoea
______stool is characteristic of cholera and
_______ stool of typhoid fever.
‘Rice water’
‘pea soup’
Loose with bits of faeces
Watery, offensive, bubbly ____
Liquid or semiformed, mucus ± blood_____
Bulky, pale, offensive ______
Pellets or ribbons ____
Colonic disorder
Giardia lamblia infection
Entamoeba histolytica
Malabsorption
Irritable bowel syndrome
China clay \_\_\_\_\_\_\_ Black stool \_\_\_\_\_ Pea soup \_\_\_\_\_\_\_ Rabbit pellets \_\_\_\_\_\_ Redcurrant jelly\_\_\_\_\_\_\_\_ Rice water \_\_\_\_\_\_ Silver stool \_\_\_\_\_\_ Toothpaste \_\_\_\_\_\_
Obstructive jaundice Melaena (blood) in faeces Typhoid fever Irritable bowel syndrome Intussusception Cholera Carcinoma of ampulla of Vater Hirschsprung disease
It must be emphasised that______are never indicated for management of acute
diarrhoea in infants and children
antimotility
drugs
Common causes of malabsorption syndromes
coeliac disease, chronic pancreatitis and postgastrectomy
Vitamin deficiencies associated with malabsorption
ADEK
What type of anemia associated with malabsorption
Hypochromic or megaloblastic anaemia
What is the pathology causing malabsorption
Gluten-sensitive enteropathy (coeliac disease)
Tropical sprue
Lactose intolerance (lactase deficiency)
Crohn disease (regional enteritis)
Whipple disease
Parasite infections (e.g. Giardia lamblia)
Lymphoma
Primary mucosal disorders
Non-GIT presentation of Celiac disease
tiredness.
diarrhoea, weight loss, iron/folate deficiency, abdominal bloating
Diarrhoea with constipation (alternating)
Pale and thin patient
No subcutaneous fat
Coeliac disease
Celiac disease
Characteristic duodenal biopsy: ____
(key test
villous atrophy
Ab testing in Celiac disease
• _______ (screening—limited)
• _______ (>90% sensitivity and specificity
_________ (>90% sensitivity and specificity)
IgA antigliadin antibodies
IgA anti-endomysial antibodies
IgA transglutaminase antibodies
Associations of Celiac dse 1 2 3 4 5 6 7 8 9 10 11 12
• Iron-deficiency anaemia • Type 1 diabetes • Pernicious anaemia • Primary biliary cirrhosis • Subfertility • Malignancy, especially lymphoma • Dermatitis herpetiformis • IgA deficiency • Autoimmune thyroid disease • Osteoporosis • Neurological (e.g. seizures, ataxia, peripheral neuropathy) • Down syndrome
What type of diet in Celiac disease
high complex carbohydrate and
protein, low fat, gluten-free (no wheat, barley,
rye and oats)
What vaccination in Celiac
Give pneumococcal vaccination (increased risk of
pneumococcus sepsis)
This is a rare malabsorption disorder usually affecting
white males. It may involve the heart, lungs and CNS.
Whipple disease
Causative agent of Whipple disease
It is caused by the bacillus Tropheryma
whipplei.
Type of Arthralgia in Whipple
Arthralgia (migratory seronegative arthropathy
mainly of peripheral joints
Dx of Whipple
- PCR for T. whipplei
* Jejunal biopsy—stunted villi
Tx of Whipple
IV ceftriaxone for 2 weeks then cotrimoxazole or
tetracycline for up to 12 months
This is due to atheromatous occlusion of mesenteric
vessels (low blood flow)
Ischaemic colitis
PE of ischemic colitis
maybe loud bruits over central abdomen
• other evidence of generalised atherosclerosis
Barium enema of ischemic colitis
‘thumb printing’ sign due
to submucosal oedema
Definitive test for ischemic colitis
the definitive test is aortography and selective
angiography of mesenteric vessels
MC cause of diarrhea in children
infective gastroenteritis and antibiotic-induced diarrhoea
__________from gastroenteritis is an
important cause of death, particularly in obese infants
(especially if vomiting accompanies the diarrhoea
Dehydration
It is an illness of acute onset, of less than 10 days’
duration associated with fever, diarrhoea and/or
vomiting, where there is no other evident cause for
the symptoms
Acute gastroenteritis
AGE causes
Mainly \_\_\_\_\_\_ (developed countries) and \_\_\_\_\_\_: viruses account for about 80%
rotavirus
adenovirus
MC bacterial causes
Bacterial: _____________. (two
commonest), E. coli and Shigella sp.
C. jejuni and Salmonella sp
Diarrhoea often follows acute gastroenteritis when
milk is reintroduced into the diet
Sugar/CHO/Lactose intolerance
Character of stools for Lactose intolerance
Stools may be watery, frothy,
smell like vinegar and tend to excoriate the buttocks.
They contain sugar.
Study management of acute diarrhea in children
Okay
Simple test for glucose intolerance
Line the napkin with thin plastic and collect fluid
stool.
• Mix 5 drops of liquid stool with 10 drops of water
and add a Clinitest tablet (detects lactose and
glucose but not sucrose).
• A positive result indicates sugar intolerance.
dx of lactose intoleranc
lactose breath hydrogen test
A clinical syndrome of loose, bulky, non-offensive
stools with fragments of undigested food in a well,
thriving child. The onset is usually between 8 and 20
months. Associated with high fructose intake (fruit
juice diarrhoea).
Toddler’s diarrhoea
This is not as common as lactose intolerance.
Diarrhoea is related to taking a cow’s milk formula
and relieved when it is withdrawn
Cow’s milk protein intolerance
These disorders, which include Crohn disease and
ulcerative colitis, can occur in childhoo
Inflammatory bowel disorders
Organisms for chronic enteric infection
Responsible organisms include Salmonella sp.,
Campylobacter, Yersinia, G. lamblia and E. histolytica.
____________– can
mimic coeliac disease.
Giardiasis
The symptoms are usually as above but very severe
diarrhoea, especially if associated with blood or mucus,
may be a feature of a more serious bowel infection such
as amoebiasis
Traveller’s diarrhoea
Most traveller’s
diarrhoea is caused by ______, which produces a watery
diarrhoea within 14 days of arrival in a foreign
country.
E. coli
Any traveller with persistent diarrhoea after visiting
less developed countries, especially India and China,
may have a protozoal infection such as ____ and ________—-
amoebiasis or
giardiasis
_______ is characterised
by abdominal cramps, flatulence and bubbly, foulsmelling
diarrhoea.
Giardiasis
MX of diarrhea in adults
How to hydrate (moderate)
use oral rehydrate solution 2–3 L orally
over 24 hours if mild to moderate dehydration
How to hydrate severe dehydration
intravenous rehydration with N saline is
recommended
Abx for Shigella dysentery (moderate to severe
Cotrimoxazole (double strength) 1 tab (o) 12 hourly
for 5 days: use in children (children’s doses)
or
norfloxacin 400 mg (o) 12 hourly for 5 days
(preferred for adults)
or
ciprofloxacin 500 mg (o) bd for 5 days
Abx for Giardiasis
Tinidazole 2 g (o), single dose (may need repeat)
or
metronidazole 400 mg (o) tds for 7 days
(in children: 30 mg/kg/day [to max. 1.2 g/day] as
single daily dose for 3 days)
T or F
Salmonella enteritis
Antibiotics are not generally advisable but if severe or
prolonged use:
T
Abx for Salmonella enteritis
ciprofloxacin 500 mg (o) bd for 5–7 days
or
azithromycin 1 g (o) day, then 500 mg for 6 days
or
ceftriaxone IV or ciprofloxacin IV if oral therapy
not tolerated
Salmonella is a notifiable disease; infants
under____________are at risk of invasive Salmonella
infection
15 months
A zoonosis that is usually self-limiting.
Antibiotic therapy indicated in severe or prolonged
cases
Campylobacter
Abx for Campylobacter
azithromycin 500 mg (o) 12 hourly for 3 days
or
ciprofloxacin 500 mg (o) 12 hourly for 3 days
or
norfloxacin 400 mg (o) 12 hourly for 5 days
Usually self-limiting, may need fluid and electrolytes
and anti-motility agents.
If severe, nitazoxamide
What organism?
Cryptosporidium species
Pathogenicity is disputed: give therapy only if severe.
Associated with poor hygiene (travel, pets, dam/tank
water, oysters).
Blastocystitis hominis (a parasitic infection
Mx of Blastocystitis hominis (a parasitic infection
metronidazole for 7 days
Abx for typhoid/paratyphoid fever
azithromycin 1 g (o) daily for 7 days
or
(if not acquired in the Indian subcontinent or SE
Asia)
ciprofloxacin 500 mg (o) 12 hourly for 7–10 days
(use IV if oral therapy not tolerated)
If ciprofloxacin is contraindicated (e.g. in children)
or not tolerated, then use:
ceftriaxone 3 g IV daily until culture and
sensitivities available, then choose oral regimens
Tx of Cholera
azithromycin 1 g (child 20 mg/kg up to 1 g)(o) as
a single dose
or
ciprofloxacin 1 g (o) as a single dose
Tx of Cholera For pregnant women and children
amoxycillin (child: 10 mg/kg up to) 250 mg (o)
6 hourly for 4 days
Ulcerative colitis
Begins in rectum (continues proximally)—affects
only the colon: it usually does not spread beyond
______
the ileocaecal valve
Ulcerative colitis
increased risk of carcinoma after _____
7–10 years
Dx of Ulcerative colitis
________: a sensitive test
_________: a granular red proctitis
with contact bleeding
Barium enema: characteristic changes
Faecal calprotectin
Proctosigmoidoscopy
Prognosis of UC
- 5% mortality in an acute attack
* Recurrent attacks common
regional enteritis, granulomatous colitis.
The cause is unknown but there is a genetic link.
Crohn disease
Signs of Crohn disease
Signs include perianal disorders (e.g. anal fissure,
fistula, ischiorectal abscess), mouth ulcers
Describe skip areas of crohns
Skip areas in bowel: ½ ileocolic, ¼ confined to
small bowel, ¼ confined to colon, 4% in upper GIT
Sigmoidoscopy findinfs Crohn disease
‘cobblestone’ appearance (patchy
mucosal oedema)
_____: useful to differentiate from UC
Colonoscopy
Tx for UC
________mainly UC): sulfasalazine (mainstay), olsalazine, mesalazine
— corticosteroids (mainly for acute flares): oral, parenteral, topical (rectal foam, suppositories or enemas)
— for severe disease, ___ and ____
5-aminosalicylic acid derivatives (
immunomodifying drugs (e.g. azathioprine, cyclosporin, methotrexate) and biological agents (e.g. infliximab
Alternating diarrhoea and constipation are wellknown
symptoms of_____ and _____
incomplete bowel obstruction
(cancer of colon and diverticular disease) and irritable
bowel syndrome
Dx criteria for IBS
In the preceding 3 months, the patient has had abdominal discomfort for at least 3 days per month with two of the following three features:
1
2
3
• relieved by defecation • onset associated with a change in stool frequency • onset associated with a change in form (appearance) of stool (loose, watery or pellet-like)
Red flag pointers for non-IBS disease
- Age of onset >50 years
- Fever
- Unexplained weight loss
- Rectal bleeding
- Pain waking at night
- Persistent daily diarrhoea/steatorrhoea
- Recurrent vomiting
- Major change in symptoms
- Mouth ulcers
- ↑ CRP, ESR
- Anaemia
- Family history bowel cancer or IBD
What is the FODMAP diet for IBS
fermentable oligosaccharides,
disaccharides, monosaccharides and polyols, which
are poorly absorbed
________ is a problem of the colon (90% in descending colon) and is related to lack of fibre in the diet. It is usually symptomless
Diverticular disorder
Diverticular DO Sx
- Constipation or alternating constipation/diarrhoea
- Intermittent cramping lower abdominal pain in LIF
- Tenderness in LIF
Oral antidiarrhoeal drugs are contraindicated
in children; besides being ineffective they may prolong ________
intestinal recovery
_____can readily provoke dystonic reactions
in children, especially if young and dehydrated.
Anti-emetics
Acute diarrhoea is invariably self-limiting (lasts
2–5 days). If it lasts longer than 7 days, investigate with______
culture and microscopy of the stools
If diarrhoea is associated with episodes of
facial flushing or wheezing, consider
carcinoid
syndrome.
Recurrent pain in the right hypochondrium is
usually a feature of ________
IBS (not gall bladder disease
Recurrent pain in the right iliac fossa is more likely to be______
IBS than appendicitis
Undercooked chicken is a common source of
_____
enteropathic bacterial infection.
Consider_______ if a patient’s diarrhoea
resolves spontaneously on hospital admission
alcohol abuse
