Diarrhea/Constipaton Flashcards
1
Q
what condition remains one of the MC causes of mortality in developing countries - Particularly infants?
A
acute infectious diarrhea
2
Q
definition of diarrhea?
A
- Passage of abnormally liquid or unformed stools
- Increased frequency - (+3 poos/day)
- Stool weight >200 g/24 h
3
Q
difference between acute, persistent, and chronic diarrhea?
A
- Acute - < 2 wks
- Persistent - 2 – 4 wks
- Chronic - > 4 wks
4
Q
MCC of acute diarrhea?
A
- infectious agents (viral or bacterial)
- Often accompanied by vomiting, fever, and abdominal pain
- other causes: meds, Toxic ingestions, Ischemia, Food indiscretions
5
Q
Infectious Agents causing acute diarrhea are MC acquired by?
A
-
Fecal - oral transmission
- Ingestion of food or water contaminated with pathogens from human or animal feces - Disturbances of flora by abx = overgrowth of pathogens (C. diff)
6
Q
Five high – risk groups in the United States
A
- travelers
- consumers of certain foods - Follows food consumption at a picnic, banquet, or restaurant
- Immunodeficient persons
- Daycare attendees and their family members
- Institutionalized persons
7
Q
pathogen of “traveler’s diarrhea”
A
E Coli & Giardia lamblia
8
Q
pathogens causing diarrhea from chicken?
A
Salmonella, Campylobacter, or Shigella
9
Q
pathogen in undercooked hamburger causing diarrhea?
A
E. Coli
10
Q
pathogen in fried rice or other reheated food causing diarrhea?
A
B cereus
11
Q
pathogen in dairy, produce, meats, eggs, salads that have been left out at room temp for too long causing diarrhea?
A
S. aureus
12
Q
pathogen from eggs causing diarrhea
A
Salmonella
13
Q
pathogen from undercooked shellfish causing diarrhea?
A
vibrio
14
Q
pathogen from uncooked foods, lunch meat or soft cheeses causing diarrhea?
A
listeria
15
Q
pathogen from improperly stored food/ canned food causing diarrhea?
A
Clostridium Botulinum
16
Q
higher incidence of diarrhea in pregnant women if they consume what pathogen/foods?
A
Listeria (uncooked foods, lunch meat or soft cheeses)
17
Q
pathogens from Daycare attendees and their family members causing diarrhea?
A
Shigella, Giardia, rotavirus, Hepatitis A
18
Q
One of the MC nosocomial infections/pathogen causing diarrhea
A
C. diff
19
Q
difference between inflammatory or noninflammatory diarrhea?
A
- Acute noninflammatory diarrhea
- Watery, nonbloody.
- mild, self-limited.
- Caused by a virus or noninvasive bacteria
- Associated with periumbilical cramps, bloating, n/v
- Disrupts normal absorption and secretory process in the small intestine
- Diagnostic evaluation is limited to pts w/ diarrhea that is severe or persists beyond 7 d - Acute inflammatory diarrhea
- Fever and bloody diarrhea (dysentery)
- Usually caused by an invasive or toxin-producing bacterium.
— causing colonic tissue damage - b/c in colon, smaller volume
— LLQ cramps, urgency, tenesmus
- requires stool bacterial cx (including E coliO157:H7) in all and testing as clinically indicated for C. diff toxin, and ova and parasites
20
Q
Dysregulation of the small bowel d/t infections lead to ?
A
watery diarrhea in large volume
- abd. cramping, bloating, gas, wt loss
- Fever rarely a significant sx
- Stool does not contain occult blood or inflammatory cells
21
Q
MC cause of watery diarrheas
A
Enteric Viruses
22
Q
what functions as a fluid/enzyme secretory and nutrient-absorbing organ
A
The small bowel
23
Q
what mainly functions to absorb fluid and salt and to excrete potassium
A
large bowel
24
Q
presentation of dysfunctional large bowel?
A
- frequent, regular, small-volume, painful bowel movements
- F and bloody/mucoid stools are common
- RBC and inflammatory cells can be routinely see on stool smear
25
what are more common causes of inflammatory, large intestinal diarrhea
bacterial pathogens
26
Most foodborne infections will typically manifest as ?
a mixture of diarrhea, nausea, vomiting, and abdominal discomfort
27
Ingested preformed toxins (staph. aureus and bacillus cereus) cause illness within ?
hours of exposure (gen. 1-6hrs)
28
Ingested pathogens which produce toxins (enterotoxigenic E. Coli) or directly damage or invade across epithelial cell wall (Salmonella, Shigella, Campylobacter) usually result in sx when?
24 hours or longer
29
ingested Protozoal pathogens (cryptosporidium, Giardia) will show sx when?
7 days
30
over ⅓ of GI viral outbreaks
readily transmitted
usually household/community spread
symptoms begin 24-48 hours after exposure and resolve in 48-72 hours
this incubation period is associated with what pathogens?
Norovirus and other enteric viruses
31
parasitic cause
daycares, mountainous streams
endemic areas, community swimming pools
7-14 days after exposure
can last for weeks and turn into chronic
this incubation period is associated with what pathogens?
Giardia, cryptosporidium, entamoeba hystolytica
32
1. typically occur in the setting of abx therapy
2. may take up to 1 month AFTER abx therapy; most within 2 wks
- though virtually any can predispose
this incubation period is associated with what pathogens?
Clostridioides (formerly Clostridium) Difficile
33
what abx are most frequently implicated to cause C. diff later on after abx therapy?
fluoroquinolones, clinda, cephalo, PCNs
34
Hospitalization is required in patients with diarrhea if they exhibit what s/s?
severe dehydration, organ failure, marked abdominal pain, and or altered mental status
35
what % of acute noninflammatory diarrhea is self-limited
90%
Responds within 5 days to simple rehydration or antidiarrheal agents
Typically does not require diagnostic investigation
36
If diarrhea persists more than 7 days, if dysentery present, or severe illness, what is the next step?
Send sample for stool studies for microbial assessment
Fecal leukocytes, Bacterial culture, O&P
37
positive fecal leukocytes indicates?
inflammatory
negative = inflammatory
38
stool cx typically detects what pathogens?
Salmonella, Shigella, and Campylobacter
May need to specify for others - E coliO157:H7
39
what diagnostic work-up Identifies protozoal disorders
Stool for O & P
40
do you need to order C. diff specifically for a stool cx?
yes
41
tx for acute diarrhea
1. Diet
- Adequate oral hydration - Fluids containing carbs and lytes
- Bowel rest - no high-fiber foods, fats, milk products, caffeine, alc
- Frequent feedings of easily digested foods - Soup, crackers, bananas, rice, applesauce, toast (BRAT)
2. Rehydration
- Oral rehydration with fluids containing glucose, Na+, K+, Cl- and bicarbonate
- Convenient mixture, pedialyte, gatorade
3. Antidiarrheal Agents
- Loperamide (Imodium)
- Bismuth subsalicylate (Pepto–Bismol)
- Diphenoxylate / atropine (Lomotil)
42
receipe for a convenient mixture for rehydration
½ tsp salt
1 tsp baking soda
8 tsp sugar
8 oz. orange juice
Diluted to 1L with water
43
when to admit for diarrhea
1. Severe dehydration
2. Organ failure
3. Marked abdominal pain
4. Altered mental status
5. Signs of hemolytic-uremic syndrome
- AKI, thrombocytopenia, hemolytic anemia
- Can be caused by severe case of E. Coli
44
indications for antidiarrheal agents?
- Safe with mild diarrheal illness to improve pt comfort
- Should not be used in patients with bloody diarrhea, high fever, or systemic toxicity
- d/c if diarrhea worsens despite therapy
45
which Antidiarrheal Agent binds to gut wall opioid receptor which inhibits peristalsis
Loperamide (Imodium)
46
CI of Loperamide (Imodium) - acute diarrhea
acute inflammatory diarrhea
47
which antidiarrheal agent reduces secretions in the gut
has some anti-inflammatory and antibacterial properties
Bismuth subsalicylate (Pepto–Bismol)
48
avoid Bismuth subsalicylate (Pepto–Bismol)
in who?
prego and child
49
which antidiarrheal agent has anticholinergic effects = inhibits excessive GI motility and GI propulsion
Diphenoxylate / atropine (Lomotil)
Contains atropine to discourage misuse
50
which antidiarrheal agent is CI in acute and inflammatory diarrhea bc of toxic megacolon
Diphenoxylate / atropine (Lomotil)
- slow GI motility and enhance bacterial overgrowth and release of bacterial exotoxins - can prolong/worsen diarrhea
- severe dehydration or lyte imbalance withhold until corrective therapy initiated.
inhibiting peristalsis may lead to fluid retention in the intestines aggravating electrolyte imbalance
51
indications for empiric Antibiotic Therapy for diarrhea?
1. Not indicated in acute diarrhea for all pts
- even inflammatory diarrhea will resolve within days
2. May be considered in high F, bloody stools, immunocompromised, severe dehydration
3. cx should be obtained prior to starting abx
52
empiric abx therapy for diarrhea?
1. _Drugs of choice - fluoroquinolones_
- **Ciprofloxacin** 500mg PO BID x3 days
- **Levofloxacin** 500mg PO daily x3 days
2. Alternatives
- Bactrim DS PO BID
- Doxycycline 100mg PO BID
53
specific abx therapy for diarrhea? (6)
1. Shigellosis - ciprofloxacin
2. Cholera - azithromycin
3. Salmonellosis - ciprofloxacin
4. Listeriosis - amoxicillin OR Bactrim
5. C. diff - vanc or Flagyl
6. Giardiasis - Flagyl (metronidazole)
54
MCC of chronic diarrhea
Medications
Osmotic diarrheas
Secretory conditions
Inflammatory conditions
Malabsorptive conditions
Motility disorders (including IBS)
Chronic infections
Systemic conditions
55
MC meds causing chronic diarrhea
Cholinesterase inhibitors
SSRIs
ARBs
PPIs
NSAIDs
Metformin
Allopurinol
Orlistat
56
how does osmotic diarrheas happen?
Results from presence of osmotically active, poorly absorbed solutes
this inhibits normal water and electrolyte absorption
57
MC osmotic diarrheas
1. carb malabsorption (lactose, fructose, sorbitol)
- Presents with abd distention, bloating, flatulence after eating
- Laxative abuse
- Malabsorption syndromes
58
Osmotic diarrheas resolve during ?
fasting
59
how does secretory disorder happen?
1. Increased intestinal secretion or decreased absorption results in high-volume watery diarrhea with a normal/low osmotic gap
- Little change in stool output during fasting
- vary from a few to up to 30 nonbloody, watery stools per day - can be explosive
- Dehydration and electrolyte imbalance may develop
60
MCC of secretory disorders?
1. Endocrine tumors - Stimulating intestinal or pancreatic secretion
2. Bile salt malabsorption - Stimulating colonic secretion
61
2 inflammatory conditions that may present with diarrhea, abdominal pain, fever, weight loss, and hematochezia
Ulcerative colitis
Crohn disease
62
MCC of malabsorptive conditions/diarrhea
Small mucosal intestinal diseases, intestinal resections, lymphatic obstruction, small intestine bacterial overgrowth, pancreatic insufficiency
63
Weight loss
Osmotic diarrhea
Steatorrhea
Nutritional deficiencies
these s/s are associated with what condition?
malabsorptive conditions
64
MCC of chronic diarrhea in young adults
Irritable bowel syndrome - Motility Disorders
65
presentation of IBS
1. Lower abdominal pain
2. Altered bowel habits
3. No evidence of serious organic disease
- No weight loss, nocturnal diarrhea, anemia, GI bleeding
- often exacerbated by stress
66
MC pathogens associated with chronic diarrhea:
Giardia
E. histolytica
Cyclospora
Intestinal nematodes
C. diff
67
MC systemic conditions causes chronic diarrhea
1. Thyroid disease
- hyperthyroid - hypermotility
- hypothyroid - hypomotility
2. Diabetes
- autonomic neuropathy
68
labs for chronic diarrhea
CBC, CMP, TSH, vitamin A and D, ESR, CRP, B12, folate, iron
Serologic testing for celiac disease
69
stool studies for chronic diarrhea
1. cx, Ova and parasites
2. electrolytes (to calculate osmotic gap)
3. staining for presence of fat
- If positive, suggests disorder of malabsorption
4. occult blood
5. Leukocytes
- If positive, may suggest inflammatory bowel disease
70
what diagnostic eval is used To exclude inflammatory bowel disease or colonic neoplasia for pts with chronic diarrhea?
Endoscopic/colonoscopy examination and mucosa biopsy
71
what meds for chronic diarrhea inhibit peristalsis
Both are opioid receptor agonists
Loperamide (Imodium)
Diphenoxylate (Lomotil)
Acts on mu opioid receptors in gut only
Slows peristalsis and gut transit
72
CI for Loperamide (Imodium) & Diphenoxylate (Lomotil) for chronic diarrhea
Not for use with bloody diarrhea or C. diff related diarrhea
Not for use in pts < 2 years of age
73
SE of Loperamide (Imodium) & Diphenoxylate (Lomotil) for chronic diarrhea
Constipation, abdominal cramps, dizziness
Serious: Paralytic ileus, toxic megacolon
74
SE of bismuth
Black stool
Black tongue
Constipation
Tinnitus
75
indication for Octreotide (Sandostatin)
Chronic secretory diarrhea (neuroendocrine tumors, AIDS-related)
76
which med Inhibits intestinal fluid secretion and stimulates intestinal absorption
Octreotide (Sandostatin)
77
SE of Octreotide (Sandostatin)
Cholelithiasis/Cholecystitis/Biliary Tract Disease; Edema; Constipation
78
caution with Octreotide (Sandostatin)
1. With DM, thyroid, pancreas, kidney, or liver ds, arrhythmias
- Inhibits production of multiple hormones (insulin, LH, TSH, etc.)
79
indications for Cholestyramine (Questran)
Chronic secretory or malabsorptive diarrhea (post small bowel resections, post cholecystectomy)
80
what med binds intestinal bile acids
Cholestyramine (Questran)
81
which med is formulated as a powder to sprinkle into food?
Cholestyramine (Questran)
82
SE of Cholestyramine (Questran)
Biliary/intestinal obstruction, fecal impaction, constipation, abdominal pain, flatulence
83
which med is also used to lower cholesterol?
Cholestyramine (Questran)
84
indications for Antispasmodics/Anticholinergics:
Hyoscyamine (Levsin), Dicyclomine (Bentyl)
Diarrhea associated with IBS
85
what med Relaxes intestinal smooth muscle, inhibits spasms and contraction
Antispasmodics/Anticholinergics:
Hyoscyamine (Levsin), Dicyclomine (Bentyl)
86
SE of Hyoscyamine (Levsin), Dicyclomine (Bentyl)
ileus, delirium, nervousness, constipation, palpitations, xerostomia, mydriasis
87
CI for Hyoscyamine (Levsin), Dicyclomine (Bentyl)
toxic megacolon, inflammatory bowel disease
88
which med is also indicated for bladder spasm
Hyoscyamine
89
constipation is MC in who?
women - Infrequent BMs, bloating, more common
Elderly predisposed due to comorbid medical conditions, medications, poor eating habits, decreased mobility
90
definition of constipation
Infrequent stools (fewer than 3 per week)
Hard stools
Excessive straining
Sense of incomplete evacuation
91
Normal colonic transit time is approx ?
35 hours
>72 is abnormal
Slow transit is usually idiopathic, but can be part of generalized GI dysmotility syndrome
92
Normal defecation requires coordination between ____ and _____ while abd. pressure is increased
relaxation of anal sphincter
pelvic floor musculature
93
pts may complain of excessive straining, sense of incomplete evacuation, or need for digital manipulation
they may have what type of disorder?
defecatory disorders (aka dyssynergic defecation)
impaired relaxation or paradoxical contraction of anal sphincter and or pelvic floor muscles during attempted defecation that impedes bowel movement
94
MCC of constipation
Inadequate fiber or fluid intake
Poor bowel habits
Other: Systemic disease, secondary disorders (hypothyroidism), meds, Structural abnormalities, Slow colonic transit, Pelvic floor dyssynergia, IBS
95
DRE for constipation to assess for:
Anatomic abnormalities
Anal stricture
Rectocele
Rectal prolapse
Perineal descent during straining
Pelvic floor motion during simulated defecation - The patient’s ability to “expel the examiner’s finger”
96
Further diagnostic workup for constipation should be performed if:
1. Severe constipation or age over 50
2. **Alarm sx - Hematochezia, wt loss, positive FOBT**
3. Fhx of colon cancer or inflammatory bowel dz
4. Refractory constipation not responding to routine medical management
97
diagnostic studies for constipation
CBC, CMP, TSH
Colonoscopy or sigmoidoscopy
98
tx for constipation
1. Dietary and lifestyle measures
- Increase fiber and fluid intake
- Regular exercise
- d/c causative meds
- Probiotics
- Adverse psychosocial issues should be identified and addressed
- Instruct patients on normal defecatory function and optimal toileting habits - regular timing, proper positioning, and abd. pressure
2. pharm - laxatives
99
what med promotes intestinal motility by increasing “bulk” of stool
draws more water into stool
Fiber/Bulk Forming Laxatives:
Psyllium (Metamucil)
methylcellulose (Citrucil)
calcium polycarbophil (FiberCon)
wheat dextran (Benefiber)
100
CI of Fiber/Bulk Forming Laxatives
GI obstruction
101
SE of Fiber/Bulk Forming Laxatives
GI obstruction, constipation, abdominal cramps and distention, flatulence
NO SYSTEMIC ABSORPTION
102
this med is an Emollient that covers stool and softens it - allowing it to pass through colon easier
Stool softeners/Surfactants:
Ducosate (Colace)
Mineral Oil
Not for use in severe constipation
Generally safe and well tolerated
Mineral oil can interfere with absorption of key nutrients
103
what med for constipation
Increase secretion of water into the intestinal lumen
Softens stools and promotes defecation
Usually works within 24 hours
Osmotic Laxatives:
Magnesium hydroxide (Milk of Magnesia)
Polyethylene glycol (Miralax)
lactulose (Enulose)
104
indication for osmotic laxatives
tx of opioid induced constipation and in chronic constipation in the elderly
105
SE of osmotic laxatives
(Generally safe and effective)
abdominal bloating and cramps, flatulence, diarrhea
106
Osmotic laxatives
Provide more rapid, complete “cleanse”
Used prior to colonoscopy, bowel surgeries
what are these meds?
Bowel Cleansers:
Polyethylene glycol (GoLYTELY)
Magnesium citrate
sodium phosphate (Fleets)
107
indications for Stimulant Laxatives
For pts with incomplete response to osmotic agents
“rescue” agent, or used 3 – 4 times per week
108
which laxative type Stimulates fluid secretion and colonic contraction
irritate intestinal wall, causing fluid accumulations and increased contractions of the intestines → increases motility
Stimulant Laxatives:
Bisacodyl (Dulcolax), Senna (Senekot), Cascara
Usually works within 6 – 12 hours
109
SE of Stimulant Laxatives
N/V/D, abdominal cramps
110
caution with Stimulant Laxatives
Not for long term or daily use
electrolyte abnormalities
111
Commonly used as adjunct to bowel cleanse (osmotic laxative) prior to surgical procedures/colonoscopy
Common in hospital setting if oral laxatives not successful
what method/med?
Enemas:
Tap water, Sodium phosphate (Fleets), Mineral Oil
Mineral Oil enema can be used to soften fecal impaction
112
what is fecal impaction?
Severe impaction of stool in the rectal vault may result in obstruction to further fecal flow
Can lead to partial or complete large bowel obstruction
113
risk factors for fecal impaction?
- Medications
- Severe psychiatric disease
- Prolonged bed rest
- Neurogenic disorders of the colon
- Spinal cord disorders
114
Decreased appetite
N/V
Abdominal pain and distention
May be paradoxical “diarrhea”
Liquid stool that leaks around the impacted feces
PE/DRE shows palpable firm feces
these s/s are associated with what dx?
fecal impaction
115
tx for fecal impaction
Initial
1. Relieving impaction with enemas
- Saline, mineral oil, soap suds
2. Digital disruption of the impacted fecal material
Long – term care
1. Maintaining soft stools and regular bowel movements
116
when to refer for diarrhea/constipation?
Refractory constipation
Defecatory disorders
Alarm symptoms
Be Aware of Laxative Abuse
