Diarrhea

Question 1

acute D eti

Answer 1

• < 2 wks
• inf (bact, toxin, drug): anal sex (G, spyh, HSV)
• non-inf: drug rxn, UC, Crohn’s, ischemic, impaction, lax abuse, s/p rad, stress
• inflammatory: shigellosis, salmonellosis, campylobacter, yersinia, CDAD, G, listeria. s/s: blood, pus, F (fecal leuks usually present). D smaller in quantity, assoc w/ LLQ cramp/urgency/tenesmus. wu: stool cx (CDAD, ova, parasites)
• non-inflam: viral, protozoa (staph, clostridium, giardia). s/s: water, nonbloody (NO fecal leuks), may have periumbilical cramp, bloat, N/V (V suggest food poisoning/viral enteritis). Eval pt if > 7 days/worsens

Question 2

when to eval acute D further

Answer 2

• inflammatory D (F > 101.3), bloody, abd pain
• > 6 loose BM in 24 hr
• profuse watery D & dehydration
• frail/older/immunocomp’d/hospital acquired D
• fecal leuks, stool cx, CDAD, 3x ova, parasites (if > 10 d, travel, community water outbreak, HIV)

Question 3

acute D mgmt

Answer 3

• rehydration
• anti D (if non-inf)
• Pepto for traveler’s D (b/c antibact & anti-inflam)
• abx if immunocomp’d/sig dehydration/mod-sev F/tenesmus/bloody/+ fecal lactoferrin (cipro, septra, doxy)
• admit if sev dehydration, worsening blood, sev abd pain, septic, worsening D in pts > 70 y.o.
• NO ABX if nontyphoid salmonella, campylobacter, yersinia

Question 4

chronic D eti

Answer 4

> 4 wks (not attributed to viruses or bact, other than CDAD)

Question 5

chronic D ddx

Answer 5

• osmotic: stool vol change w/ fasting
• secretory: > 1 L stool/day, little change w/ fasting
• inflammatory: F, hematochezia, abd pain, anemia, hypoalbuminia, high ESR/CRP
• meds: SSRIs, cholinesterase inhibs, NSAIDs, PPIs, ARBs, metformin, allopurinol
• malabsorption: wt loss, elevated fecal fat, anemia, hypoabluminia
• motility d/o: sys dz, prior surg
• chronic inf: parasites, AIDs

Question 6

chronic D wu

Answer 6

• D at night?
• r/o acute causes
• initial tests: CBC, CMP, Ca, P, albumin, TSH, vit A/D, INR, ESR/CRP, IgA (celiac)
• stool studies: ova, parasites, lytes, fat stain, occult blood, leuks or lactoferrin
• +/- antigen for giardia
• consider acid stain for crypto
• ref for CSY w/ bx

Question 7

chronic D mgmt

Answer 7

• loperamide
• clonidine
• octreotide (neuroendocrine tumors, AIDs D)
• Cholestyramine (bile acid sequestrant: helps body remove bile acids)