Diarrhea & constipation Flashcards
Constipation:
-definition
def: passage of stool infrequently or with difficulty, stool frequency of less than 3/wl.
- straining, hard stool, incomplete evacuation
Causes of Constipation
Etiologies:
- MC lifestyle*
- inadequate fiber in diet
- inadequate hydration
- inactivity
- meds:
- -opiates/narcotics
- -anticholinergics (xanax, cetirizine, benadryl, codiene)
- -calcium channel blockers
- -antiparkinsonians
- -antidepressants
- carcinoma
- ischemia
- volvulus
- megacolon (hirschsprungs)
- anorectal disorders:
- -prolapse
- -rectocele(tissue between rectum and vagina weakens)
- -pelvic flood dysfunction (MC in pregnancy, MS, and autonomic neuropathy; DM)
- Hypokalemia
- hypothyroidism*
- hyperparathyroidism
- addisons dz
- hypercalcemia
- MS
- Parkinsons
- Hirschprung
- Chagas
- spinal cord lesions
- amyloidosis
- scleroderma (Hardening of CT)
- pregnancy
- surgical (abd, pelvic, colonic, anorectal)
- depression
- eating disorder
Constipation:
- examination
- Tx In pts less than 50YO with no alarming sx
- further tx should be performed on pts with any of the following risk factors?
- what are alarming sx?
Examination: full history, PE (DRE**)
Tx in pts less than 50YO with no alarming sx may be started with empiric tx.
Further tx should be performed on pts with any of the following:
- over 50YO
- severe constipation
- signs of an organic disorders
- hematochezia
- weight loss
- positive FOBT (fecal occult blood test)
Alarming sx:
-weight loss, hematochezia, hematemasis, FHx of colon CA, anemia
Constipation:
-labs and procedures you should order
Labs:
- KUB, barium enema, colonoscopy**
- colonic transit study
- Glucose
- CBC (anemia)
- Thyroid
- Calcium
- Magnesium
- Phosphorus
Constipation:
- management
- tx
management:
* first & foremost is prevention!!!!
- educate pts:
- -exercise (stimulates peristalsis and defication)
- -fluid intake
- -fiber intake (unless already constipated)
Tx:
- Stool softeners:
- -colace, ducosate calcium
- Laxative:
- -bulking agents: Psyllium (metamucil) benefiber, fibercon, methylcellulose (citrucel)
- -Osmotics: lactulose, polyethylene glycol (miralax), sorbitol
- Stimulant Laxative: bisacodyl (ducolax), senna (xlax)
- Opiod receptor antagonist: methylnaltrexone
- digital disimpaction
Diarrhea
- definition
- what frequency of stool is considered abnormal?
- pathophysiology
Def:
increase in daily stool weight above 200-300g/24hr OR increase in stool liquidity and/or frequency
-more than 3 stools/day is considered abnormal.
Pathophysiology:
-osmotic: non-absorbable substance draws out excess water into the intestine & increases stool weight and volume.
- secretory: mucosal secretion of fluid and electrolytes 2ndry to bacterial enterotoxins, neoplasms, or exotoxins.
- Motility: food is not mixed properly, digestion is impaired and motility is increased.
Diarrhea :
-classification of acute, persistent, and chronic
Acute: less than 14 days in duration
Persistent: more than 14 days duration
Chronic: more than 30 days duration
Acute Diarrhea
- causes
- sx
Acute Causes:
- infections with viruses and bacteria and are self limited; usually not lasting beyond 7 days.
- Viral:
- -norovirus; nursing home/cruise ship
- -rotavirus; daycare
- -adenoviruses
- -astrovirus
Bacterial:
- salmonella; pet ducklings, rattle snake meat, sprouts, meat
- campylobacter; poultry, raw milk, cheese. Think guillian barre.
- shigella; daycare, veggies
- enterotoxigenic E. coli, C. Diff; travelers to developing world, hospitilization.
Protozoa:
- cryptosporidium
- giardia
- cyclospora
- entamoeba
Noninfectious:
-drugs, food allergies, dz such as thyrotoxicosis & carcinoid syndrome.
Sx: fever, cramping pain, dehdration in elderly/children
Acute Diarrhea
–indications for diagnostic evaluation
perfuse watery diarrhea with signs of hypovolumeia
- bloody diarrhea
- temp greater than/= 38.5C.
- sever abd pain
- hospitalized pts or use of recurrent abx
- diarrhea in elderly or in immunocompromised
- systemic illness with diarrhea esp in pregos.
Chronic Diarrhea;
- causes
- types
cause:
-medications: Cholinesterase inhibitors( Aricept), metformin, SSRI, ARBS, PPI, NSAIDS
- Osmotic
- Secretory
- inflammatory
- malabsorptive
- motility disorders
- chronic infections
Osmotic diarrhea:
- clues to dx
- medications that cause this
- other cause
Clues: diarrhea occurs with eating and goes away when they fast, increased stool osmotic gap
medications: antacids, lactulose, sorbitol
Disaccharide deficiency = lactose intolerance
Secretory Diarrhea
- clues to dx
- causes
clues:
- large volumes of stool (greater than 1L/d), little change with fasting, normal stool osmotic gap.
Causes:
-hormonally mediated: carcinoid, medullary carcinoma of thryoid, zollinger-ellision syndrome
- villous adenoma
- bile salt malabsorption
- meds
Inflammatory Conditions causing diarrhea
- clues to dx
- causes
Clues:
-fever, hematochezia, abd pain
Cause:
- IBD**
- Ulcerative colitis
- Crohns Dz
- Malignancy: lymphoma, adenocarcinoma
- radiation enteritis
Malabsorption syndromes causing diarrhea;
- clues to dx
- cause
Clues:
-weight loss, abnormal lab values, fecal fat greater than 10g/24hrs
Cause:
-Small bowel disorders: Celiac sprue, whipple dz, eosinophilic gastroenteritis, small bowel resection, Crohns dz
Lymphatic obstruction:
-lymphoma, carcinoid, infectious, kaposi sarcoma
Pancreatic Dz: chronic pancreatitis, pancreatic carcinoma
Bacterial overgrowth: motility disorders, scleroderma, fistulas, small intestinal diverticula
Motility Disorders causing diarrhea
- clues
- causes
Clues: systemic dz or prior abd surgery
Cause:
- post-surgical
- systemic disorders: IBS
Chronic Infections causing diarrhea
-causes
Causes:
- AIDS related: CMV, HIV
- Bacterial: C diff, Mycobacterium avium complex (MAC)
- Protozoal: giardia, cryptosporidium
Factitious Diarrhea
-cause
cause:
- magnesium (antacids, laxatives)
- laxative abuse; senna
Diarrhea Work up
Hx: travel hx, longevity of sx, FHx, food intake
Fecal Analysis:
- fecal leukocytes
- fecal occult blood
- fecal fats
- enteric pathogen cultures
- C. diff toxin
- ova & parasites
TSH, CBC, CMP w/ LFT, ESR, CRP
Colonoscopy w/ mucosal bx; to exlude IBD, microscopic colitis, and colonic neoplasia
Upper Endoscopy when small intestine disorder is suspected such celiac sprue or whipple dz.
24hr stool collection
Significance of the components of the fecal analysis?
- fecal leukocytes
- fecal occult blood
- stool for culture and sensitivity
- stool for ova parasite
- c diff toxin assay
- fecal fat
- fecal leukocytes: presence indicates bowel mucosal inflammation, commonly occuring in invasive bacterial enteritis and ulcerative colitis.
- fecal occult: immunochemical tests for fecal blood.
-Culture and sensitivity:
enterococcus, e. coli, clostridium
-stool for ova/parasite:
salmonella?, shigella, giardia
-c diff toxin assay:
releases toxin that causes necrosis of colonic epithelium leading to diarrhea
- fecal fat: confirms steatorrhea, sprue(celiac?), Crohns, Whipples Dz
Tx of Diarrhea
Fluid replacement
abx therapy (bacteria and parasite)
bismuth subsalicylate (pepto-bismol)
Opiate antidiarrheal agents (Diphenoxylate/Lomotil, Loperamide/immodium) (Mild to moderate secretory diarrhea)
Cholestyramine (questran; diarrhea cause by ileal bile salt malabsorption)
If a pt comes in with a bowel complaint and anemia always think what???
What are peritoneal signs?
can you give fiber bulking agent to someone with constipation?
MC cause of bright red stool?
WHat is the cause of white/paste colored feces?
if fecal elastase less than 100mg think?
always think GI bleed! (constipation and anemia d/t adenocarcinoma)
Peritoneal signs = rebound tenderness
NO!!!! it will turn their poop into cement!!
MC cause of b right red stool is internal hemorrhoids
cause of white/colored feces is liver, gallbladder issues
fecal elastase = pancreatic insufficiency
Tx of viral or bacterial diarrhea?
Tx Protozoa?
bacterial diarrhea: ciprofloxacin**, 2nd line azithro or doxy
protozoa = flagyl (metronidazole)
Listeria and what dont mix?
Whats the difference between IBS and IBD?
Listeria and pregnancy dont mix!!!
IBS: just diarrhea and constipation; either they rotate between diarrhea and constipation or have just one. No weight loss, blood, fever, or mucus.
IBD: Ulcerative colitis or Crohns, HLAB27 autoimmune dz. Hallmarks are blood, mucus, weight loss, abd pain, and fever.
What might you suspect if you found each of the following:
- anemia
- hypoalbuminemia
- hyponatremia
- elevated ESR/CRP
anemia: colon cancer
hypoalbuminemia: malabsorption
hyponatremia: secretory diarrhea
Elevated ESR/CRP: Crohns or Ulcerative Colitis
If all of the above are normal think IBS.
WHen to admit pt?
-bloody diarrhea, severe abd pain, look septic, HUS, severe dehydration
