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GI: Clin Med IIA > Diarrhea/Constipaton > Flashcards

Diarrhea/Constipaton Flashcards

1
Q

what condition remains one of the MC causes of mortality in developing countries - Particularly infants?

A

acute infectious diarrhea

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2
Q

definition of diarrhea?

A
  • Passage of abnormally liquid or unformed stools
  • Increased frequency - (+3 poos/day)
  • Stool weight >200 g/24 h
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3
Q

difference between acute, persistent, and chronic diarrhea?

A
  1. Acute - < 2 wks
  2. Persistent - 2 – 4 wks
  3. Chronic - > 4 wks
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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
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5
Q

Infectious Agents causing acute diarrhea are MC acquired by?

A
  1. Fecal - oral transmission
    - Ingestion of food or water contaminated with pathogens from human or animal feces
  2. Disturbances of flora by abx = overgrowth of pathogens (C. diff)
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6
Q

Five high – risk groups in the United States

A
  1. travelers
  2. consumers of certain foods - Follows food consumption at a picnic, banquet, or restaurant
  3. Immunodeficient persons
  4. Daycare attendees and their family members
  5. Institutionalized persons
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7
Q

pathogen of “traveler’s diarrhea”

A

E Coli & Giardia lamblia

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8
Q

pathogens causing diarrhea from chicken?

A

Salmonella, Campylobacter, or Shigella

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9
Q

pathogen in undercooked hamburger causing diarrhea?

A

E. Coli

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10
Q

pathogen in fried rice or other reheated food causing diarrhea?

A

B cereus

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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

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12
Q

pathogen from eggs causing diarrhea

A

Salmonella

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13
Q

pathogen from undercooked shellfish causing diarrhea?

A

vibrio

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14
Q

pathogen from uncooked foods, lunch meat or soft cheeses causing diarrhea?

A

listeria

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15
Q

pathogen from improperly stored food/ canned food causing diarrhea?

A

Clostridium Botulinum

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16
Q

higher incidence of diarrhea in pregnant women if they consume what pathogen/foods?

A

Listeria (uncooked foods, lunch meat or soft cheeses)

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17
Q

pathogens from Daycare attendees and their family members causing diarrhea?

A

Shigella, Giardia, rotavirus, Hepatitis A

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18
Q

One of the MC nosocomial infections/pathogen causing diarrhea

A

C. diff

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19
Q

difference between inflammatory or noninflammatory diarrhea?

A
  1. 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
  2. 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
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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
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21
Q

MC cause of watery diarrheas

A

Enteric Viruses

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22
Q

what functions as a fluid/enzyme secretory and nutrient-absorbing organ

A

The small bowel

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23
Q

what mainly functions to absorb fluid and salt and to excrete potassium

A

large bowel

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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
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25
Q

what are more common causes of inflammatory, large intestinal diarrhea

A

bacterial pathogens

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26
Q

Most foodborne infections will typically manifest as ?

A

a mixture of diarrhea, nausea, vomiting, and abdominal discomfort

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27
Q

Ingested preformed toxins (staph. aureus and bacillus cereus) cause illness within ?

A

hours of exposure (gen. 1-6hrs)

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28
Q

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?

A

24 hours or longer

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29
Q

ingested Protozoal pathogens (cryptosporidium, Giardia) will show sx when?

A

7 days

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30
Q

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?

A

Norovirus and other enteric viruses

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31
Q

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?

A

Giardia, cryptosporidium, entamoeba hystolytica

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32
Q
  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?

A

Clostridioides (formerly Clostridium) Difficile

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33
Q

what abx are most frequently implicated to cause C. diff later on after abx therapy?

A

fluoroquinolones, clinda, cephalo, PCNs

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34
Q

Hospitalization is required in patients with diarrhea if they exhibit what s/s?

A

severe dehydration, organ failure, marked abdominal pain, and or altered mental status

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35
Q

what % of acute noninflammatory diarrhea is self-limited

A

90%
Responds within 5 days to simple rehydration or antidiarrheal agents
Typically does not require diagnostic investigation

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36
Q

If diarrhea persists more than 7 days, if dysentery present, or severe illness, what is the next step?

A

Send sample for stool studies for microbial assessment
Fecal leukocytes, Bacterial culture, O&P

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37
Q

positive fecal leukocytes indicates?

A

inflammatory
negative = inflammatory

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38
Q

stool cx typically detects what pathogens?

A

Salmonella, Shigella, and Campylobacter
May need to specify for others - E coliO157:H7

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39
Q

what diagnostic work-up Identifies protozoal disorders

A

Stool for O & P

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40
Q

do you need to order C. diff specifically for a stool cx?

A

yes

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41
Q

tx for acute diarrhea

A
  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)
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42
Q

receipe for a convenient mixture for rehydration

A

½ tsp salt
1 tsp baking soda
8 tsp sugar
8 oz. orange juice
Diluted to 1L with water

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43
Q

when to admit for diarrhea

A
  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
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44
Q

indications for antidiarrheal agents?

A
  • 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
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45
Q

which Antidiarrheal Agent binds to gut wall opioid receptor which inhibits peristalsis

A

Loperamide (Imodium)

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46
Q

CI of Loperamide (Imodium) - acute diarrhea

A

acute inflammatory diarrhea

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47
Q

which antidiarrheal agent reduces secretions in the gut
has some anti-inflammatory and antibacterial properties

A

Bismuth subsalicylate (Pepto–Bismol)

48
Q

avoid Bismuth subsalicylate (Pepto–Bismol)
in who?

A

prego and child

49
Q

which antidiarrheal agent has anticholinergic effects = inhibits excessive GI motility and GI propulsion

A

Diphenoxylate / atropine (Lomotil)

Contains atropine to discourage misuse

50
Q

which antidiarrheal agent is CI in acute and inflammatory diarrhea bc of toxic megacolon

A

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
Q

indications for empiric Antibiotic Therapy for diarrhea?

A
  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
Q

empiric abx therapy for diarrhea?

A
  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
Q

specific abx therapy for diarrhea? (6)

A
  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
Q

MCC of chronic diarrhea

A

Medications
Osmotic diarrheas
Secretory conditions
Inflammatory conditions
Malabsorptive conditions
Motility disorders (including IBS)
Chronic infections
Systemic conditions

55
Q

MC meds causing chronic diarrhea

A

Cholinesterase inhibitors
SSRIs
ARBs
PPIs
NSAIDs
Metformin
Allopurinol
Orlistat

56
Q

how does osmotic diarrheas happen?

A

Results from presence of osmotically active, poorly absorbed solutes
this inhibits normal water and electrolyte absorption

57
Q

MC osmotic diarrheas

A
  1. carb malabsorption (lactose, fructose, sorbitol)
    - Presents with abd distention, bloating, flatulence after eating
    - Laxative abuse
    - Malabsorption syndromes
58
Q

Osmotic diarrheas resolve during ?

A

fasting

59
Q

how does secretory disorder happen?

A
  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
Q

MCC of secretory disorders?

A
  1. Endocrine tumors - Stimulating intestinal or pancreatic secretion
  2. Bile salt malabsorption - Stimulating colonic secretion
61
Q

2 inflammatory conditions that may present with diarrhea, abdominal pain, fever, weight loss, and hematochezia

A

Ulcerative colitis
Crohn disease

62
Q

MCC of malabsorptive conditions/diarrhea

A

Small mucosal intestinal diseases, intestinal resections, lymphatic obstruction, small intestine bacterial overgrowth, pancreatic insufficiency

63
Q

Weight loss
Osmotic diarrhea
Steatorrhea
Nutritional deficiencies

these s/s are associated with what condition?

A

malabsorptive conditions

64
Q

MCC of chronic diarrhea in young adults

A

Irritable bowel syndrome - Motility Disorders

65
Q

presentation of IBS

A
  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
Q

MC pathogens associated with chronic diarrhea:

A

Giardia
E. histolytica
Cyclospora
Intestinal nematodes
C. diff

67
Q

MC systemic conditions causes chronic diarrhea

A
  1. Thyroid disease
    - hyperthyroid - hypermotility
    - hypothyroid - hypomotility
  2. Diabetes
    - autonomic neuropathy
68
Q

labs for chronic diarrhea

A

CBC, CMP, TSH, vitamin A and D, ESR, CRP, B12, folate, iron
Serologic testing for celiac disease

69
Q

stool studies for chronic diarrhea

A
  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
Q

what diagnostic eval is used To exclude inflammatory bowel disease or colonic neoplasia for pts with chronic diarrhea?

A

Endoscopic/colonoscopy examination and mucosa biopsy

71
Q

what meds for chronic diarrhea inhibit peristalsis
Both are opioid receptor agonists

A

Loperamide (Imodium)
Diphenoxylate (Lomotil)

Acts on mu opioid receptors in gut only
Slows peristalsis and gut transit

72
Q

CI for Loperamide (Imodium) & Diphenoxylate (Lomotil) for chronic diarrhea

A

Not for use with bloody diarrhea or C. diff related diarrhea
Not for use in pts < 2 years of age

73
Q

SE of Loperamide (Imodium) & Diphenoxylate (Lomotil) for chronic diarrhea

A

Constipation, abdominal cramps, dizziness
Serious: Paralytic ileus, toxic megacolon

74
Q

SE of bismuth

A

Black stool
Black tongue
Constipation
Tinnitus

75
Q

indication for Octreotide (Sandostatin)

A

Chronic secretory diarrhea (neuroendocrine tumors, AIDS-related)

76
Q

which med Inhibits intestinal fluid secretion and stimulates intestinal absorption

A

Octreotide (Sandostatin)

77
Q

SE of Octreotide (Sandostatin)

A

Cholelithiasis/Cholecystitis/Biliary Tract Disease; Edema; Constipation

78
Q

caution with Octreotide (Sandostatin)

A
  1. With DM, thyroid, pancreas, kidney, or liver ds, arrhythmias
    - Inhibits production of multiple hormones (insulin, LH, TSH, etc.)
79
Q

indications for Cholestyramine (Questran)

A

Chronic secretory or malabsorptive diarrhea (post small bowel resections, post cholecystectomy)

80
Q

what med binds intestinal bile acids

A

Cholestyramine (Questran)

81
Q

which med is formulated as a powder to sprinkle into food?

A

Cholestyramine (Questran)

82
Q

SE of Cholestyramine (Questran)

A

Biliary/intestinal obstruction, fecal impaction, constipation, abdominal pain, flatulence

83
Q

which med is also used to lower cholesterol?

A

Cholestyramine (Questran)

84
Q

indications for Antispasmodics/Anticholinergics:
Hyoscyamine (Levsin), Dicyclomine (Bentyl)

A

Diarrhea associated with IBS

85
Q

what med Relaxes intestinal smooth muscle, inhibits spasms and contraction

A

Antispasmodics/Anticholinergics:
Hyoscyamine (Levsin), Dicyclomine (Bentyl)

86
Q

SE of Hyoscyamine (Levsin), Dicyclomine (Bentyl)

A

ileus, delirium, nervousness, constipation, palpitations, xerostomia, mydriasis

87
Q

CI for Hyoscyamine (Levsin), Dicyclomine (Bentyl)

A

toxic megacolon, inflammatory bowel disease

88
Q

which med is also indicated for bladder spasm

A

Hyoscyamine

89
Q

constipation is MC in who?

A

women - Infrequent BMs, bloating, more common

Elderly predisposed due to comorbid medical conditions, medications, poor eating habits, decreased mobility

90
Q

definition of constipation

A

Infrequent stools (fewer than 3 per week)
Hard stools
Excessive straining
Sense of incomplete evacuation

91
Q

Normal colonic transit time is approx ?

A

35 hours

> 72 is abnormal
Slow transit is usually idiopathic, but can be part of generalized GI dysmotility syndrome

92
Q

Normal defecation requires coordination between ____ and _____ while abd. pressure is increased

A

relaxation of anal sphincter
pelvic floor musculature

93
Q

pts may complain of excessive straining, sense of incomplete evacuation, or need for digital manipulation

they may have what type of disorder?

A

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
Q

MCC of constipation

A

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
Q

DRE for constipation to assess for:

A

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
Q

Further diagnostic workup for constipation should be performed if:

A
  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
Q

diagnostic studies for constipation

A

CBC, CMP, TSH
Colonoscopy or sigmoidoscopy

98
Q

tx for constipation

A
  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
Q

what med promotes intestinal motility by increasing “bulk” of stool
draws more water into stool

A

Fiber/Bulk Forming Laxatives:
Psyllium (Metamucil)
methylcellulose (Citrucil)
calcium polycarbophil (FiberCon)
wheat dextran (Benefiber)

100
Q

CI of Fiber/Bulk Forming Laxatives

A

GI obstruction

101
Q

SE of Fiber/Bulk Forming Laxatives

A

GI obstruction, constipation, abdominal cramps and distention, flatulence

NO SYSTEMIC ABSORPTION

102
Q

this med is an Emollient that covers stool and softens it - allowing it to pass through colon easier

A

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
Q

what med for constipation
Increase secretion of water into the intestinal lumen
Softens stools and promotes defecation
Usually works within 24 hours

A

Osmotic Laxatives:
Magnesium hydroxide (Milk of Magnesia)
Polyethylene glycol (Miralax)
lactulose (Enulose)

104
Q

indication for osmotic laxatives

A

tx of opioid induced constipation and in chronic constipation in the elderly

105
Q

SE of osmotic laxatives

A

(Generally safe and effective)
abdominal bloating and cramps, flatulence, diarrhea

106
Q

Osmotic laxatives
Provide more rapid, complete “cleanse”
Used prior to colonoscopy, bowel surgeries

what are these meds?

A

Bowel Cleansers:
Polyethylene glycol (GoLYTELY)
Magnesium citrate
sodium phosphate (Fleets)

107
Q

indications for Stimulant Laxatives

A

For pts with incomplete response to osmotic agents
“rescue” agent, or used 3 – 4 times per week

108
Q

which laxative type Stimulates fluid secretion and colonic contraction
irritate intestinal wall, causing fluid accumulations and increased contractions of the intestines → increases motility

A

Stimulant Laxatives:
Bisacodyl (Dulcolax), Senna (Senekot), Cascara

Usually works within 6 – 12 hours

109
Q

SE of Stimulant Laxatives

A

N/V/D, abdominal cramps

110
Q

caution with Stimulant Laxatives

A

Not for long term or daily use
electrolyte abnormalities

111
Q

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?

A

Enemas:
Tap water, Sodium phosphate (Fleets), Mineral Oil

Mineral Oil enema can be used to soften fecal impaction

112
Q

what is fecal impaction?

A

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
Q

risk factors for fecal impaction?

A
  • Medications
  • Severe psychiatric disease
  • Prolonged bed rest
  • Neurogenic disorders of the colon
  • Spinal cord disorders
114
Q

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?

A

fecal impaction

115
Q

tx for fecal impaction

A

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
Q

when to refer for diarrhea/constipation?

A

Refractory constipation
Defecatory disorders
Alarm symptoms

Be Aware of Laxative Abuse

GI: Clin Med IIA (12 decks)

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