Diarrhea/Constipation Flashcards
A 32-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. On the ship they both ate the “usual foods” in addition to oysters. Findings on examination are negative, and a stool specimen is negative for white blood cells.
Which one of the following is the most likely cause of his illness? (check one)
Escherichia coli
Rotavirus
Norovirus
Hepatitis A
Giardia
Norovirus
Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norovirus infections due to waterborne or foodborne spread. In the United States these viruses are responsible for about 90% of all epidemics of nonbacterial gastroenteritis. The noroviruses are common causes of waterborne epidemics of gastroenteritis, and have been shown to be responsible for outbreaks in nursing homes, on cruise ships, at summer camps, and in schools. Symptomatic treatment by itself is usually appropriate.
A 25-year-old male presents for a pretravel consultation prior to embarking on a 10-day mission trip to Central America with his church. His past medical history includes GERD, irritable bowel syndrome, and generalized anxiety disorder. The last time he traveled internationally he experienced a prolonged bout of traveler’s diarrhea, despite his best efforts at practicing good hand hygiene and careful food and drink selection. He asks if there are any medications that he can take to prevent a similar experience this time.
Which one of the following is most appropriate for prophylactic use in this situation? (check one)
Bismuth subsalicylate (Pepto-Bismol)
Calcium carbonate (Tums)
Ciprofloxacin (Cipro)
Omeprazole
A probiotic containing Lactobacillus acidophilus
Bismuth subsalicylate (Pepto-Bismol)
Bismuth subsalicylate has been shown to decrease the risk of contracting traveler’s diarrhea by 50%–65% and may be considered for patients who are at increased risk. Drawbacks include the frequent dosing of four times daily and the risk of developing a black tongue and black stool. Bismuth subsalicylate is contraindicated in the setting of aspirin allergy, kidney disease, breastfeeding, or concurrent anticoagulant use. Medications that decrease gastric acidity, such as proton pump inhibitors, H2-blockers, and antacids, substantially increase one’s risk of contracting traveler’s diarrhea. Therefore, avoiding calcium carbonate and omeprazole would be preferable for this patient. Prophylactic antibiotics typically are not recommended in this situation although may be considered for those who are at particularly high risk of health complications from a gastrointestinal illness. If a prophylactic antibiotic is desired, rifaximin should be considered. Fluoroquinolones such as ciprofloxacin, however, should be avoided for prophylactic use due to risks of inducing antibiotic resistance and causing central nervous system side effects, QTc prolongation, medication interactions, and tendon injuries. Probiotics have insufficient evidence of benefit for preventing traveler’s diarrhea.
A 3-year-old male is brought to your office by his parents for evaluation of constipation that began about a year ago. They report that he cries before bowel movements, has resisted toilet training, and has unusually large stools about every 3 days, including this morning. He had normal bowel movements in infancy and his growth and development have been normal.
An examination shows a healthy child with a soft, nondistended, nontender abdomen. A rectal examination reveals normal sphincter tone and minimal soft stool.
Which one of the following would be the most appropriate next step in correcting his functional constipation? (check one)
Increasing fluid intake
Increasing physical activity
Adding docusate (Colace)
Adding polyethylene glycol (MiraLAX)
Adding probiotic supplements with Bifidobacterium or Lactobacillus species
Adding polyethylene glycol (MiraLAX)
Polyethylene glycol is the most effective treatment for functional constipation in children. Increased fluid intake does not affect stool frequency in children. While evidence indicates that increased physical activity may improve functional constipation in adults, it does not have the same effect in children. There is conflicting evidence regarding the effectiveness of docusate in pediatric patients with functional constipation. Probiotic supplements do not have enough evidence to be recommended.
A healthy 33-year-old male sees you for a pretravel consultation. He plans to attend a 4-week intensive Spanish language course in Antigua, Guatemala. You discuss immunizations, malaria prophylaxis, injury prevention, and traveler’s diarrhea.
Which one of the following interventions is most likely to prevent traveler’s diarrhea? (check one)
Avoiding food from street vendors
Avoiding the use of ice in beverages
Taking a probiotic
Taking a prophylactic antibiotic
Washing hands frequently
Washing hands frequently
Traveler’s diarrhea is caused predominantly by bacterial pathogens (up to 80%–90%) and is associated with hygiene practices. Handwashing has been shown to reduce the risk of traveler’s diarrhea by 30%. The use of alcohol-based hand sanitizer is also effective. Although it is considered traditional advice, avoiding street vendor foods, tap water, ice, and raw foods has not been shown to reduce the risk of traveler’s diarrhea. There is not sufficient evidence to recommend taking a probiotic to reduce the risk of traveler’s diarrhea. Due to concerns about antimicrobial resistance and altering protective bowel flora, taking prophylactic antibiotics is generally not recommended for healthy travelers. However, using an antibiotic for as-needed treatment is appropriate.
You see a 3-year-old female with a 2-day history of intermittent abdominal cramps, two episodes of emesis yesterday, and about five watery, nonbloody stools each day. She does not have a fever, her other vital signs are normal, and she has not traveled recently. Today she has tolerated sips of fluid but still has mild fatigue and thirst. An examination is normal except for mildly dry lips. A friend at preschool had a similar illness recently.
Which one of the following would be the most appropriate initial management of this patient? (check one)
A sports drink and food on demand
Half-strength apple juice and food on demand
Ginger ale and no food yet
Water and no food yet
A bolus of intravenous normal saline and no food yet
Half-strength apple juice and food on demand
Family physicians often see patients with diarrheal illnesses and most of these are viral. Patients sometimes have misconceptions about preferred fluid and feeding recommendations during these illnesses. The World Health Organization recommends oral rehydration with low osmolarity drinks (oral rehydration solution) and early refeeding. Half-strength apple juice has been shown to be effective, and it approximates an oral rehydration solution. Its use prevents patient measurement errors and the purchase of beverages with an inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda and most sports drinks. Water increases the risk of hyponatremia in children. This patient is not ill enough to need intravenous fluids. Early refeeding has been shown to decrease the duration of illness.
A 76-year-old female presents with a 3-month history of watery diarrhea with up to 12 episodes per day. She has no hematochezia and no travel history. You suspect microscopic colitis.
Which one of the following is the test of choice to confirm the diagnosis? (check one)
A barium enema
A stool test of calprotectin
A celiac panel
A biopsy of the colon
A jejunal biopsy
A biopsy of the colon
Microscopic colitis is characterized by intermittent secretory diarrhea in older patients, although all ages can be affected. The cause is unknown, but there is some evidence that more than 6 months of NSAID use increases the risk. Only a biopsy from the transverse colon can confirm the diagnosis. Two histologic patterns are found: lymphocytic colitis and collagenous colitis. The other diagnostic studies listed do not confirm the diagnosis.
A 12-year-old male is brought to your office with a 3-day history of nausea, vomiting, and fever. His fever has resolved but he continues to have vomiting and diarrhea. He has had large-volume, loose, nonbloody stools, as well as abdominal cramping. A stool culture is positive for Salmonella .
Which one of the following would be the most appropriate treatment? (check one)
Supportive care only
Ampicillin
Ceftriaxone (Rocephin)
Ciprofloxacin (Cipro)
Trimethoprim/sulfamethoxazole (Bactrium)
Supportive care only
Salmonella is a common cause of gastroenteritis. Transmission is most often associated with eggs, poultry, undercooked ground meat, and dairy products from contaminated animals, or produce contaminated by their waste. Salmonella infection is usually associated with nausea, vomiting, diarrhea, and fever starting 6–48 hours after ingestion of contaminated water or food. Stools are usually moderate-volume, loose, and nonbloody, although they can be large-volume watery stools with blood. While Salmonella can cause severe infection, it is usually self-limited. Antibiotics should not be routinely used to treat uncomplicated Salmonella gastroenteritis and may prolong the duration of Salmonella excretion in stool. Antibiotic treatment should be reserved for patients who are severely ill or suspected of being bacteremic. The threshold for treatment should also be decreased in those who are considered to be at higher risk for severe illness and invasive disease, such as infants, the elderly, patients with sickle cell disease, and immunosuppressed patients. Chronic fecal carriers of Salmonella may also benefit from treatment. If treatment is required, ciprofloxacin, ampicillin, ceftriaxone, and trimethoprim/sulfamethoxazole are all treatment options.
A mother brings in her 11-year-old daughter, stating that the child has not had a bowel movement in 5 days. Although she is very embarrassed to talk to you, the daughter confirms that this is the case, and that it has happened several times since she started middle school earlier this year, where the bathrooms are very unpleasant. Both the mother and the daughter state that this has not been a problem in the past.
The mother reports that the daughter is otherwise healthy, takes no medications, and has no past surgical history. The patient has no discomfort with urination but does have some abdominal pain that has grown worse over the last day or so. She is not having any trouble breathing. She reports a decreased appetite over the last 3 days. The physical examination reveals normal vital signs, a normal BMI, and no abdominal distention or tenderness to palpation.
Which one of the following would you advise at this point?
(check one)
Observation only, as this problem will resolve on its own
Dedicated “toilet time” before and after school and nightly before bed
A phosphate soda (Fleet) enema nightly
Polyethylene glycol (MiraLAX)
An abdominal radiograph
Polyethylene glycol (MiraLAX)
Childhood constipation is a very common problem encountered in outpatient practice. Most childhood constipation is functional, which appears to be the case with this patient. She has no evidence of organic disease, and she had a change in lifestyle that caused her to retain stool, resulting in a cycle of constipation. Polyethylene glycol is easily tolerated, safe, and easy to use. For this reason, it is the first-line therapy. A daily dose should resolve this issue, although it is likely that the child will need another course of treatment, as functional constipation is likely to recur. It is not reasonable in this case to provide no treatment, as the child is uncomfortable. An enema would be unnecessary since oral therapies are very likely to be effective. Behavioral therapies have not been shown to be as effective as laxatives for functional constipation, and stringent therapy that is not related to food intake
is likely to increase the stress surrounding going to the toilet. There is no role for imaging in a case where the suspicion of an organic cause is so low.
A 34-year-old female sees you because of cramping diarrhea for the past several months following resection of her terminal ileum as treatment for Crohn’s disease. She is not aware of any exposure to individuals with similar symptoms. She has not had any fever, chills, nausea, vomiting, or myalgias, and she has not noticed any blood in her stool. She is passing several loose stools daily, mostly after meals. She has not been able to identify any clear relationship to the type of food she eats.
Which one of the following would be the best initial treatment option for this patient? (check one)
A dairy-free diet
Cholestyramine (Questran) daily
A Lactobacillus probiotic supplement (Lactinex) 4 times daily
Loperamide (Imodium) as needed
Psyllium fiber (Metamucil) twice daily
Cholestyramine (Questran) daily
Diarrhea that develops in patients with ileal Crohn’s disease or following ileal resection is usually due to increased amounts of bile acid remaining in the stool. This affects colonic secretion and motility and various protein factors in the gut, resulting in the development of bile acid diarrhea (BAD). Although various tests can be performed to evaluate the stool, gut flora, and bowel function, a therapeutic trial with a bile acid sequestrant such as cholestyramine is most often used for both the diagnosis and treatment of BAD. Reducing fat intake may also be beneficial. Loperamide can lessen the diarrhea in some patients but should not be the primary treatment because chronic use can result in constipation. Fiber supplementation may help to produce a more formed stool and could be used as an adjunct treatment when appropriate.
A 44-year-old female presents for a pretravel consultation and asks about medication options for traveler’s diarrhea. She will be on an organized tour traveling to a country with a very low risk for this problem. She plans to take all precautions to further reduce her risk but would also like you to recommend a medication she can take.
Which one of the following would be an appropriate recommendation? (check one)
A short course of azithromycin (Zithromax) if she develops diarrhea
Loperamide (Imodium) daily, starting 1 day prior to travel and continued until 1 day after returning home
Probiotics daily, starting 1 week prior to travel and continued until 1 week after returning home
Ciprofloxacin (Cipro) daily, starting 2 weeks prior to travel and continued until 4 weeks after returning home
Bismuth subsalicylate daily, starting 2 weeks prior to travel and continued until 4 weeks after returning home
A short course of azithromycin (Zithromax) if she develops diarrhea
Traveler’s diarrhea is the most common infection in international travelers. A short course of antibiotics
can be taken after a traveler develops diarrhea and usually shortens the duration of symptoms (SOR A).
Azithromycin is preferred to treat severe traveler’s diarrhea. Rifaximin or fluoroquinolones may be used
to treat severe nondysenteric traveler’s diarrhea. Prophylactic antibiotics are not routinely recommended.
For patients at high risk, bismuth subsalicylate reduces the risk but does not need to be initiated prior to
travel. There is insufficient evidence for the use of probiotics to prevent traveler’s diarrhea. Loperamide
can be used with or without antibiotics after symptoms develop but is not recommended for prophylaxis.
