Diarrhea Flashcards
watery non bloody diarrhea with fecal urgency and incontinence and patient uses naproxen
microscopic colitis
presentation of microscopic colitis
watery non bloody diarrhea and fecal urgency and incontinence and abdominal pain and fatigue and weight loss and arthralgias. See in middle aged women
triggers for microscopic colitis
smoking, medications: NSAIDS, PPIs, SSRI’s, ranitidine
diagnosis of microscopic colitis
colonoscopy biopsy with lymphocytic infiltration and lamina propria
two types:
collagenous: thickened subepithelial collagen band
lymphocytic: high levels of intraepithelial lymphocytes (>20 for every 100 epithelial cells and focal cryptitis may occur)
management of microscopic colitis
removed possible triggers antidiarrheal medications and oral budesonide
if refractory: get cholestyramine, bismuth, subsalicylate and TNF a inhibitors with (infliximab and adalimumab)
lactose intolerance diarrhea
abdominal discomfort and flatulence but rarely diarrhea also no changes on colonic biopsy
Clinical presentation of Giardiasis?
diarrhea, foul smelling due to malabsorption, sometimes described as explosive.
steatorrhea
fatigue and malaise
abdominal cramps,
flatulence, and bloating
significant weight loss despite good oral intake
Treatment of giardia
metronidazole
diagnosis of Giardiasis?
stool microscopy over stool antigen testing because Giardia cysts shed intermittently.
stool microscopy and look for giardia trophozoites and cysts.
who gets giardiasis?
giardia cysts live in cold water (rivers and streams) and water dwelling mammals. They infect hikers who drink water without adequate filtration, treatment or boiling
childcare workers,
men who have sex with men
secondary lactose intolerance
develops after acute infection or inflammation (viral gastroenteritis, Crohn’s dx flaire up)
lactose intolerance clinical features
crampy abdominal pain, bloating, increased flatulence, diarrhea, (happens after ingestion of lactose containing products) on PE only hear borborygmi (bowel sounds)
stool lab findings of lactose intolerance
elevated osmotic gap >125 mOsm/kg and decreased pH<6 of stool.
why does secondary lactose intolerance occur?
happens due to inflammatory destruction of the terminal villi and subsequent loss of lactase enzyme. There can be recovery of enzyme activity but this can take several months after inflammatory insult to cease and healing to begin
management of lactose intolerance
stop eating cheese. lactose restricted diet, enzyme replacement and vitamin D and calcium supplementation
what separates out chronic giardiasis from secondary lactose intolerance
giardiasis has weight loss and steatorrhea and malaise and fatigue. This is just abdominal pain, bloating and flatulence
treatment of irritable bowel syndrome is with
FODMAP diet with low diet of fermentable oligo, di, monosaccharide and polyols
management of acute diarrhea
supportive measures if on antibiotics stop them if possible and observe clinically
what to evaluate for with someone who has acute diarrhea
fever,
hypovolumia,
immunocompromised
or elderly
>6 stools in 24 hrs
symptoms duration >1 week
peritoneal signs
bloody diarrhea
if no to all do supportive measures and stop abx if able
if acute diarrhea and has one or more of the following: fever hypovolumia immunocompromised or elderly or hospitalized >6 stools in 24 hrs symptoms duration >1 week peritoneal signs bloody diarrhea what do you do?
If had any of those symptoms they need a diagnostic evaluation. fecal leukocyte ova and parasites stool culture and check C diff assay if on recent antibiotics.
if patient has inflammatory diarrhea then:
Give empiric abx until pathogen is identified
if pt has non inflammatory diarrhea then
supportive measures.
what is acute diarrhea
diarrhea that is <14 days in duration
acute diarrhea etiology:
can be infectious or non infectious and usually resolves within a few days
most common cause of acute antibiotic diarrhea
clindamycin, cephalosporin or amoxicillin clavulanate (most commonly but can happen with any abx)
common features of acute antibiotic diarrhea
And how to treat it
moderate in severity,
lacks systemic symptoms (fever, abdominal pain or fecal leukocytes)
resolves once antibiotic is stopped.
Tx: can use antimotility agents to relieve symptoms
when to order stool for ova and parasites?
persistent diarrhea in following a community waterborne illness, travel to certain geographical areas, exposure to infants in daycare centers (giardiasis) and men who have sex with men and pts with AIDS or bloody diarrhea with no leukocytes
when is it helpful to get a sigmoidoscopy
not usually need for diagnosis of acute abx diarrhea but helpful for differentiated infectious diarrhea and IBS and diagnosing CMV infection in immunocompromised pts
vomiting predominant gastroenteritis with negative stool culture
consider norovirus
most common cause of epidemic gastronterirtis and in adults and children
norovirus
what is associated with Norovirus
people in institutionalized or travel settings like SNF, nursing homes, restaurants and cruise ships
asymptomatic infection, fever with watery diarrhea - non inflammatory small bowel process
Norovirus can cause severe illness which is fever, vomiting, headache and systemic symtpoms
when do norovirus symptoms start
48-72 hrs after exposure. can be diagnosed via PCR or nucleic acid based testing
acute onset abdominal cramping abdominal pain and inflammatory diarrhea (stool culture confirms this)
campylobacter see mucus and blood in stool
watery diarrhea from eating contaminated food which has spores
C perfringens
traveler’s diarrhea is caused by
what’s the presentation for traveler’s diarrhea
Enterotoxigenic e coli.
presents with malaise, anorexia, abdominal cramps and then acute onset watery diarrhea
listeria monocytogenes is associated with
deli meats and soft cheeses see watery diarrhea, fever and nausea/vomiting and see myaglia and arthralgia and headache.
chart for foodborne causes of diarrhea
chronic diarrhea is defined
acute diarrhea is defined as
chronic diarrhea >4 weeks caused by non infectious
acute diarrhea- <2 weeks - generally caused by infectious
Chronic diarrhea is defined as
osmotic, secretory steatorrhea and inflmmatory and motility and misc.
Evaluation of suspected factitious diarrhea
we need a 24 hr stool sepcimen to document any liquid or solid stool. Liquid stool needs to be fresh to get osmolality, Na, K, and osmotic gap calculation.
Osmolality <250 means water was added and osmolality >400 means urine was added. Normal stool osmolality is 250-400.
If normal stool osmoality and osmotic gap LESS THAN 75 mOSM means secretory diarrhea (saline laxative, senna, bisacodyl)
If normal stool osmoality and osmotic gap GREATER THAN 75 mOSM then laxative use is from unmeasured solute (mg sulfate, lactulose, sorbitol).
what is most commonly the cause of factitious diarrhea?
laxative abuse, addition of substances (water) to dilute the stool.
Diagnose based on high index of suspicion
risk factors for factitious diarrhea?
RF are: female geneder, high education level, hihgly stressful environment nad low BMI (possibly indicating anorexia nervosa)
start to look for factitious diarrhea based on high index of suspicion.
clinical presentation of factitious diarrhea
nocturnal symptoms,, weight loss, orthostatic hypotension, hypokalemia from prolonged diarrhea, and hypermagnesemia if magnesium containing laxatives are used.
Can consider factitious diarrhea after excluding other organic causes.
what is seen on EGD and colonoscopy for factitious diarrhea?
EGD is normal. Colonoscopy may show melanosis coli due to chronic laxative abuse.
what does secretory diarrhea cause in the stool osmotic gap?
what causes secretory diarrhea
stool osmotic gap is <50.
Common causes of secretory diarrhea:
Crohn’s dx (positive fecal leukocytes),
collagenous colitis (microscopic colitis),
hyperthyroidism (increased stool frequency rather than volume)
VIPomas (uncommon neuroendocrine tumors of pancreas).
clinical features of microscopic colitis chart
how to treat diabetic diarrhea?
if no SIBO present can treat with antimotility agents like loperamide.
Diabetic diarrhea is
painless watery diarrhea that can occur at night and often ias associated with fecal incontinence.
May have normal periods with normal bowel movements and constipation.
what causes diabetic diarrhea?
autonomic neuropathy related to small bowel and colonic hypomotility and increased intestinal fluid secretion and anorectal dysfunction
Also thought to be related to bacterial overgrowth.
Associated foods that can tigger this: dietetic foods (sorbitol) and concurrent celiac sprue.
Diagnosis of diabetic diarrhea
diagnosis of exclusion and need to get stool studies, serum chemistry and endocrine studies and endoscopic biopsy
what is small intestinal bacterial overgrowth?
SIBO contributes to diabetic diarrhea as low Gi hypomotility causes excessive colonization and leads to abdominal discomfort, bloating and flatulence. Severe dx can cause malabsorption with steatorrhea and vitamin deficiency
Diagnosis of SIBO is via
how to treat SIBO
EGD and biopsy findings
carboydrate breath test
SIBO is treated with antibiotics (rifaximin)
if were to get EGD and biopsy: normal and non revealing.
What causes traveler’s diarrhea?
ETEC, camylobacter, salmonella
When do most people get traveler’s diarrhea?
4-14 days after arrival to endemic area.
Diarrhea is benign and self limited symtpoms for 1-5 days. Can see low grade fever, malaise, anorexia, abdominal cramps, nausea and vomiting and no blood or pus in the stool.
Empiric treatment of traveler’s diarrhea:
can it be done?
can be done without diagnostic confirmation
Fluoroquinolones, then azithromycin if allergic or rifaximin
Anti motility agents can be used.
Treatment of Traveler’s diarrhea
Tx: fluid replacement for volume depletion, antibiotics for moderate to severe diarrhea nad possible antimotility agents in combination with antibiotic.
No antimotility agents in bloody diarrhea. Should also be stopped if abdominal pain is present or worsens.
Fluoroquinolones are preferred tx for traveler’s diarrhea in adults.
azithromycin is meant for kids, or those who allergic to fluoroquinolones and those who went to Southeast Asia (has fluoroquinolone resistance.
Prevention of traveler’s diarrhea
drinking boiled water or filtered water (including ice) and avoiding food left outside for prolonged periods.
Why is systemic sclerosis (diffuse scleroderma) associated with SIBO?
there is collagen deposition and smooth muscle atrophy in GI tract causing reduced peristalsis and intestinal dilation.
Allows for colonization of small intestine by large numbers of colonic bacteria and this leads to small intestinal bacterial overgrowth (SIBO) in 30% of systemic sclerosis pts.
Systemic sclerosis pt develops bloating, abdominal discomfrot and diarrhea. See steatorrhea and weight loss. Labs show macrocytic anemia.
What do they have?
SIBO - from large amounts of colonic bacteria overgrowing and cuasing chronic diarrhea and fat malabsorption. See B12 deficiency causing anemia.
diagnosis of SIBO is with
positive carbohydrate breath test - or jejunal aspirate with culture growting bacterial with high concentrations.
Treatment of SIBO is with 14 days of antibitoics = rifaximin is most commonly used
45% of pts have recurrence of SIBO and need retreatment or prolonged therapy with multiple antibiotic regimens.
SIBO is associated with
systemic sclerosis
chronic pancreatitis - lack of proteolytic enzymes allows for bacterial overgrowth
can be associated with chronic steroid use.
Medications that cause diarrhea:
NSAIDS
PPI
antibiotics
colchicine
metformin
cholesterol lower statins
olmesartan - causing a sprue like dx.
2 weeks of water diarrhea and was in Mexico. Has Entamoeba histolytica in serology and stool antigen. What do you treat her with?
metronidazole.
Do not pick praqiquantel or albendazole.
