Diarrhea and Constipation - Exam 3 Flashcards
What are the 7 different types of stool as described by the Bristol stool chart.
What is considered acute diarrhea? persistent? chronic?
acute: less than 2 weeks
persistent: 2-4 weeks
chronic: greater than 4 weeks
More than 90% of cases of acute diarrhea are caused by _________
infectious agents either viral or bacterial
How are the 2 most infectious agents of acute diarrhea acquired?
- fecal-oral transmission
- Disturbances of flora by antibiotics allowing overgrowth of
pathogens, such as Clostridium difficile
**What are the 5 high risk groups for acute diarrhea in the United States?
travelers
consumers of certain foods
immunodeficient persons
daycare attendees and their family members
institutionalized persons
** What are the 2 MC pathogens for traveler’s diarrhea?
E Coli & Giardia lamblia
** What 3 pathogens are associated with chicken?
Salmonella, Campylobacter, or Shigella
**What pathogen is associated with undercooked hamburger?
E. Coli
**What pathogen is associated with fried rice or other reheated foods?
Bacillus cereus
**What pathogen is associated with dairy, produce, meats, eggs, salads that have been left out at room temp for too long?
Staph aureus
** What pathogen is associated with eggs?
salmonella
**What pathogen is associated with undercooked shellfish?
vibrio
**What pathogen is associated with uncooked foods, lunch meat or soft cheeses?
Listeria
higher rates in preg women
** What pathogen is associated with improperly stored food/canned food?
Clostridium Botulinum
What do community outbreaks suggest?
viral etiology or a common food source
**What pathogens are associated with daycare attendees and their family members?
Shigella, Giardia, rotavirus, Hepatitis A
**What pathogen is associated with institutionalized persons?
C diff
What does bloody diarrhea indicate? non-bloody?
bloody= inflammatory if gross or occult blood
non-bloody= non-inflammatory
What are the s/s of acute non-inflammatory diarrhea? What type of cramps? What is included in the diagnostic evaluation?
watery and NON-bloody
periumbilical cramps
Diagnostic evaluation is limited to patients with diarrhea that is severe or persists beyond 7 days
What are the s/s of acute inflammatory diarrhea? What type of cramps? What is included in the diagnostic evaluation?
fever and bloody diarrhea
LLQ cramps
Diagnostic evaluation requires routine stool bacterial cultures (including E coliO157:H7) in all and testing as clinically indicated for Clostridium difficile toxin, and ova and parasites.
What is the function of the small bowel? What does dysregulation lead to? Is fever a significant symptom?
The small bowel functions as a fluid/enzyme secretory and nutrient-absorbing organ
Dysregulation of these d/t infections lead to a watery diarrhea in large volume with cramping, bloating, gas and weight loss
Fever is RARELY a significant symptom
** ______ are the MC cause of watery diarrheas
Enteric Viruses
What is the main function of the large bowel?How does large bowel s/s present? **Is fever typically associated? What 2 things are routinely seen on stool smear?
The main function of the large bowel is to absorb fluid and salt and to excrete potassium
present with frequent, regular, small-volume, often painful bowel movements
**Fever and bloody/mucoid stools are COMMON
Red blood cells and inflammatory cells can be routinely see on stool smear
** ______ are more common causes of inflammatory, large intestinal diarrhea
Bacterial pathogens
How will most foodborne infections present?
as a mixture of diarrhea, nausea, vomiting, and abdominal discomfort
Ingested preformed toxins (staph. aureus and bacillus cereus) cause illness within ________
hours of exposure (gen. 1-6hrs
Ingested pathogens which produce toxins (enterotoxigenic E. Coli) or directly damage or invade across epithelial cell wall (Salmonella, Shigella, Campylobacter) usually result in symptoms __________
approx. 24 hours or longer
Protozoal pathogens (cryptosporidium, Giardia) usually take ______ to start showing illness s/s
generally 7 days
norovirus and other enteric viruses, symptoms usually start _______ and resolve _______. How is it transmitted?
symptoms begin 24-48 hours after exposure and resolve in 48-72 hours
usually household/community spread
Giardia, cryptosporidium, entamoeba hystolytica s/s usually start _______ and last for _______. How are they usually transmitted?
7-14 days after exposure
can last for weeks and turn into chronic
parasite that is found in daycares and mountainous streams, endemic areas and community swimming pools
What setting does C. diff usually occur? What is the timeframe?
after abx
may take up to 1 month AFTER antibiotic therapy; most within 2 weeks
What abx are most frequently associated with C diff?
fluoroquinolones, clindamycin, cephalosporins, and penicillins
On the PE, what 3 things do you need to note? When would you want to hospitalize them?
- level of hydration
- mental status
- presence of abdominal tenderness or peritonitis
severe dehydration, organ failure, marked abdominal pain, and or altered mental status
_____ of acute noninflammatory diarrhea is self-limited. What is the tx?
90%
Typically does not require diagnostic investigation
What presenting s/s makes you think diarrhea is self- limiting?
present for less than 2 weeks
no fever
non-bloody
When would you want to consider working a pt up for diarrhea? What would you order?
If diarrhea persists more than 7 days, if dysentery present, or severe illness
fecal leukocytes
stool culture
stool O&P
stool for c. diff
What does a positive fecal leukocyte indicate? negative?
Positive = inflammatory
Negative = non-inflammatory
What are you looking for in a stool culture?
Typically detects Salmonella, Shigella, and Campylobacter
e coli
What is the tx for acute diarrhea?
hydration
bowel rest: avoid high fiber, fats, milk products, caffeine, alcohol
easily digested foods (BRAT diet)
When should you NOT use an antidiarrheal agent?
Should not be used in patients with bloody diarrhea, high fever, or systemic toxicity
_____ MOA binds to gut wall opioid receptor which inhibits peristalsis. **When is it CI?
Loperamide (Imodium)
**contraindicated in acute inflammatory diarrhea
_____ MOA reduces secretions in the gut. What two pt populations should this medication be avoided?
Bismuth subsalicylate (Pepto–Bismol)
avoid in pregnant pts and kids
_____ MOA has anticholinergic effects =_______ inhibits excessive GI motility and GI propulsion
Diphenoxylate / atropine (Lomotil)
Diphenoxylate
**What is the CI to Diphenoxylate/ atropine? What part is added to discourage misuse?
Contraindicated in acute and inflammatory diarrhea. Can cause toxic MEGACOLON
atropine to discourage misuse
Why does using Diphenoxylate/atropine (Lomotil) in acute/inflammatory diarrhea cause toxic megacolon?
use may slow GI motility and enhance bacterial overgrowth and release of bacterial exotoxins
also can lead to severe dehydration by inhibiting peristalsis may lead to fluid retention in the intestines aggravating electrolyte imbalance
When would abx be considered for diarrhea?
May be considered in patients with high fever, bloody stools, immunocompromised, or severe dehydration
NOT indicated for acute diarrhea
What is the abx treatment of choice for diarrhea? What are the 2 alternatives? What should you do before starting abx?
Cipro/Levo
bactrim or doxy
Culture should be obtained prior to starting abx therapy
What is the specific abx treatment for shigellosis?
cipro
What is the specific abx treatment for cholera?
azithromycin
What is the specific abx treatment for salmonellosis?
cipro
What is the specific abx treatment for listeriosis?
amoxicillin or bactrim
What is the specific abx treatment for C. diff?
Vanc or flagyl
What is the specific abx treatment for giardiasis?
metronidazole (Flagyl)
What is considered chronic diarrhea? What are the top 4 highlighted meds from lecture?
present for longer than 4 weeks
SSRIs
Metformin
allopurinol
orlistat
What does osmotic diarrhea result from? What are the MC forms? **Osmotic diarrheas resolve _______
Results from the presence of osmotically active, poorly absorbed solutes this inhibits normal water and electrolyte absorption
carbohydrate malabsorption: think lactose intolerance
during fasting
What is the pathophys behind secretory disorders? **Do secretory disorders improve with fasting? What are 2 listed causes?
increased intestinal secretion or decreased absorption results in high-volume watery diarrhea
**Little change in stool output during fasting
endocrine tumors
bile salt malabsorption
How do secretory disorders present? What are these pts at high risk for?
may vary from a few to up to 30 nonbloody, watery stools per day
can be explosive
high-volume watery diarrhea
Dehydration and electrolyte imbalance may develop
What does diarrhea with abdominal pain, fever, weight loss, and hematochezia make you think?
inflammatory conditions: UC or Crohn dz
What does Weight loss, Osmotic diarrhea, Steatorrhea and Nutritional deficiencies make you think?
Malabsorptive Conditions
______ is the MC cause of chronic diarrhea in young adults. How does it present? What makes it worse?
Irritable bowel syndrome
Lower abdominal pain
Altered bowel habits
No evidence of serious organic disease
exacerbated by stress
What are the top 5 MC pathogens associated with chronic infectious diarrheas?
Giardia
E. histolytica
Cyclospora
Intestinal nematodes
C. diff
What effect does your thyroid gland have on GI motility? How does DM effect?
hyperthyroid - hypermotility
hypothyroid - hypomotility
autonomic neuropathy of the GI track, slows everything down
If chronic diarrhea persists, would want to order ________. What are you looking for?
Endoscopic/colonoscopy examination and mucosa biopsy
To exclude inflammatory bowel disease or colonic neoplasia
What forms does Imodium come in? Lomotil? Which one is OTC?
Imodium: OTC: oral suspension
Lomotil: rx. tablet or oral suspension
What are the 2 CI for antidiarrheals?
DO NOT USE with bloody diarrhea or C. diff related diarrhea
Not for use in pts < 2 years of age
What is the serious adverse reaction for antidiarrheals: loperamide and diphenoxylate?
Serious: Paralytic ileus, toxic megacolon
What are the 4 common reactions for bismuth?
Antidiarrheals:
Bismuth (Pepto-Bismol, Kaopectate, Maalox)
Black stool
Black tongue
Constipation
Tinnitus
NEED TO TELL PTS BECAUSE IT WEIRDS THEM OUT
_______ MOA inhibits intestinal fluid secretion and stimulates intestinal absorption and is indicated for chronic secretory diarrhea
Octreotide (Sandostatin)
Where else is Octreotide (Sandostatin)
commonly used?
it is a somato statin analogue and used for a tx for giagantism
________ is indicated for chronic secretory or malabsorptive diarrhea (post small bowel resections, post cholecystectomy). What is the important pt education point?
Cholestyramine (Questran)
POWDER form!! must sprinkle on food to ingest
What are the 2 medications used PRN for diarrhea associated with IBS?
Hyoscyamine (Levsin)
Dicyclomine (Bentyl)
______ MOA relaxes intestinal smooth muscle, inhibits spasms and contraction. Which one is also indicated for bladder spasm?
Hyoscyamine (Levsin), Dicyclomine (Bentyl
Hyoscyamine is also indicated for bladder spasm
What are the 4 different definitions of constipation?
Infrequent stools (fewer than 3 per week)
Hard stools
Excessive straining
Sense of incomplete evacuation
How long is the normal colon transit time? What is considered abnormal?
approx 35 hours
> 72 is abnormal
What are the 2 MC causes of constipation?
Inadequate fiber or fluid intake
Poor bowel habits
Need to perform ____ as part of the PE
DRE
When should you need to further work a pt up for constipation?
Severe constipation or age over 50
Alarm symptoms: Hematochezia, weight loss, positive FOBT
Family history of colon cancer or inflammatory bowel disease
Refractory constipation not responding to routine medical management
What are the alarm symptoms as related to constipation?
Hematochezia, weight loss, positive FOBT
What are the lifestyle modifications associated with constipation?
Increase fiber and fluid intake
Regular exercise
What are the 4 fiber/bulk forming laxatives? What is the MOA?
Psyllium (Metamucil)
methylcellulose (Citrucil)
calcium polycarbophil (FiberCon)
wheat dextran (Benefiber)
Fiber promotes intestinal motility by increasing “bulk” of stool. Fiber draws more water into stool
When are fiber/bulk forming laxatives CI? What is important to note about their pharmacology?
GI obstruction
NO SYSTEMIC ABSORPTION
______ MOA is an emollient that covers stool and softens it - allowing it to pass through colon easier. When should you NOT use them? What form?
Ducosate (Colace) and Mineral Oil
Not for use in severe constipation
can take orally or rectal suppository
What are the 3 osmotic laxatives? What is the MOA?
Magnesium hydroxide (Milk of Magnesia) Polyethylene glycol (Miralax)
lactulose (Enulose)
Increase secretion of water into the intestinal lumen
Softens stools and promotes defecation
Usually works within 24 hours
________ are often used in the treatment of opioid induced constipation and in chronic constipation in the elderly. How long does it usually take to work?
Osmotic Laxatives:
Magnesium hydroxide (Milk of Magnesia)
Polyethylene glycol (Miralax)
lactulose (Enulose)
usually works within 24 hours and are safe to use daily
Polyethylene glycol (GoLYTELY), Magnesium citrate, Sodium phosphate (Fleets) are considered ________
bowel cleansers
used before colonoscopy
What are the 3 stimulant laxatives? When are they indicated?
Bisacodyl (Dulcolax)
Senna (Senekot)
Cascara
For patients with incomplete response to osmotic agents
“rescue” agent, or used 3 – 4 times per week
_______ MOA stimulates fluid secretion and colonic contraction by irritating the intestinal wall and cause fluid accumulations and increased contractions of the intestines
How long does it take to work?
Stimulant Laxatives:
Bisacodyl (Dulcolax), Senna (Senekot), Cascara
works within 6-12 hours
Which laxative variant is NOT safe for everyday or long term use?
Stimulant Laxatives:
Bisacodyl (Dulcolax), Senna (Senekot), Cascara
are NOT safe for everyday or long term use
**What is the stepwise approach to constipation?
What are the 5 predisposing factors for fecal impaction?
1) Medications
2) Severe psychiatric disease
3) Prolonged bed rest
4) Neurogenic disorders of the colon
5) Spinal cord disorders
What is paradoxical “diarrhea” associated with fecal impaction? How do you determine?
Liquid stool that leaks around the impacted feces
DRE will feel firm feces
What is the treatment for fecal impaction? What is the long-term care?
Relieving impaction with enemas: saline, mineral oil, soap suds and digital disruption of the impacted fecal material
Maintaining soft stools and regular bowel movements
go back and look at the case studies in the lecture with practice questions
do it!
