diarrhea - IBS Flashcards
Antibiotic associated diarrhea - etiology
although clindamycin may be associated with the highest incidence diarrhea and C. Diff, any antibiotc can potentially cause diarrhea
antibiotics associated diarrhea - characteristics of the diarrhea
blood + white cells in the stool
antibiotics associated diarrhea - time
several days or weeks after the start of antibiotivs
antibiotics associated diarrhea - best initial test
stool C. diff toxin test or PCR
antibiotics associated diarrhea - best initial therapy
ORAL metronidazole
antibiotics associated diarrhea - therapy
best initial: oral metronidazole
if no response: switch to oral vancomycn or fidaxomicin
repeated episode of antibiotics associated diarrhea
AGAIN oral metronidazole
antibiotics associated diarrhea - IV metronidazole
onky if oral cannot be used (such as adynamic ileus)
C. diff - culture
never –> not grow in culture
the source of the name
C. diff - endoscopy
diagnose antibiotic associated diarrhea –> NOT necessary step given the availability of stool toxin assay
antibiotics associated diarrhea - IV vancomycin
always wrong –> it will not pass the bowel wall
Diarrhea after antibiotic use - management
C diff positive? NO: consider alternative causes YES: oral metronidazole: - if improvement --> continue - if no improvement --> switch to oral vancomycin or fidaxomicin
Malabsorption - etiology
- Celiac (one of the MCC)
- Chronic pancreatitis
- tropical sprue (rare)
- Whipple disease (rare)
all form of malabsorption present with
steatorrhea, deficiency of fat soluble vitamines (and their manifestation), wight loss
steatorrhea - definition
oily, greasy, floating an foul smelling stools
VIT D deficiency - manifestation
hypocalcemia, osteoporosis
- rickets in children
- osteomalacia in adults
VIT K deficiency - manifestation
bleeding, easy brusing
VIT B12 -deficiency
anemia, hypersegmented neutrophils
neuropathy
Vitamin B12 malabsorption
need an intact bowel and pacreatic enzymes to be absrobed
how t distinguish clinically tropical spure from celiac disease
no way
celiac disease - is aka
gluten sensitive enteropathy
celiac disease - is associated ith
- dermitis herpetiformis in 10% of cases
2. increased risk of malignancy (eg. T-lemphoma)
celiac disease - affects
distal duodenume and/or proximal jejunum
Whipple disease - manifestations beside malabsorption
- arthralgias 2. ocular findings 3. fever
- neurological abnormalities (dementia seizures)
- lymphadenpathy
Whipple disease - treatment
ceftriaxone followed by TMP/SMZ
one of the main lab distinctions between chronic pancreatitis and celiac spure is the … (explain)
presence of iron deficiency in celiac sprue
this is because iron needs an intact bowel wall to be absorbed, but it does not need pancreatic enzymes
celiac sprue - unique tests (which is first)
- anti-tissue transglutaminase (first)
- antiendomysial antibody
- IgA antigliadin antibody
celiac spure - the most accurate test
small bowel biopsy –> flattening of the vill
Whipple disease - the most accurate test
small bowel biopsy –> specific organism
tropic sprue - the most accurate test
small bowel biopsy –> specific organism
celiac spure - beside diagnosis, biopsy is essential to
exclude lymphoma
Chronic pancreatitis - specific diagnostic tests (only names) (which is the most accurate)
- abdominal x-ray
- abdominal CT
- secretin stimulation testing (the most accurate)
Chronic pancreatitis - abdominal x-ray - specificity and sensitivity
very specific
50-60% sensitive for calcification of the pancreas
Chronic pancreatitis - abdominal CT scan - sensitivity
80-90%
Chronic pancreatitis - secretin stimulation testing - describe
place a nasogastric tube –> an unaffected pancreas will release a large volume of bicarbonate-rich fluid after the IV injection of secretin
Chronic pancreatitis - most accurate test
secretin stimulation testing
rice and wine in celiac sprue
safe
chronic pancreatitis - treatment
enzyme replacement
celiac sprue - treatment
avoid gluten containing foods such as wheat, oats, rye, barley
whipple disease - treatment
ceftriaxone followed by TMP/SMZ
tropical sprue
TMP/SMZ, tetracycline
test to distinguish chronic pancreatitis from bowel wall abnormalities
D-xylose –> normal in chronic pancreatitis
old test
carcinoid syndrome - presentation
- intermittent diarrhea
- flushing
- wheezing
- cardiac abnormalities of the right side of the heart
carcinoid syndrome - best initial diagnostic test
5-hydroxyindoleacetic (5-HIAA) test
carcinoid syndrome - therapy
octreotide –> control diarrhea
a symptoms that occurs in almost every malabsorption syndrome, but not in lactose intolerance
weight loss –> lactose is only one of several sugars to absorb. Also lactose intolerance does not alter the absorption of any other nutrient such as fat so there is no deficiency in calories
lactose intolerance - calories
it does not alter the absorption of any other nutrient such as fat so there is no deficiency in calories
lactose intolerance - vitamins
normal
lactose intolerance - diarrhea due to
increased stool osmolarity
lactose intolerance - the usual way to make diagnosis
remove all milk containing products from the diet and wait a single day for resolution of symptoms
lactose intolerance - treatment
- avoid milk products except yogurt
- oral lactose replacement is also good and is available over the counter
over the counter medications - definition
no prescription is needed
Irritable bowel syndrome - presentation (like definition)
pain syndrome that can have diarrhea, constipation or both
Irritable bowel syndrome - weight loss
no
pain does not automatically mean malabsorption
Irritable bowel syndrome - diagnosis
there is no specific test
diagnosis of exclusion in association with a complex of symptoms
Irritable bowel syndrome - characteristics of pain
- relieved by bowel movement
- less at night
- relieved by a change in bowel habit such as diarrhea
Irritable bowel syndrome - treatment
- fiber in the diet
- antispasmodic agents (hyoscyamine, diclomine)
- TCA
- antimotility agents such as loperamide for diarrhea
- Lubiprostone
Irritable bowel syndrome - antispasomodic agents such as
- hyoscyamine
2. diclomine
Irritable bowel syndrome - Lubiprostone
Cl- channel activator that increases bowel movements frequent –> also treats the constipation that is predominant in IBS
inflammatory bowel disease - idiopathic disorder that presents with
- diarrhea
- blood in stool
- weight loss
- fever
iflammatory bowel disesase - both Crohn and ulcerative colitis have extraintestinal manifestations that can be IDENTICAL in both diseases:
- arthralgias 2. Uveitis, iritis
- skin manifestations
- sclerosing cholangitis (more frequent in Ulcerative)
IBD - cancer
bot forms of IBD can lead to colon cancer. The risk of cancer is elated to the duration of involvement of the colon. Crohn that involves the colon has the same risk of as ulcerative colitis
differences between crohn and ulcerative colitis
crohn –> skp lesions, tranmural granulomas, fistulas and abscess, masses and obstruction, perianal disease
UC –> curable by surgery, entirely mucosal, no fistulas, no abscesses, no obstruction, no perianal
IBD - when should screening occur
afet 8-10 years of colonic involvement, with colonoscopy every 1-2 years
IBD - diagnostic tests - only the names of the tests (most accurate?)
- endoscopy (most accurate when can be reached)
- radiologic studies (barium)
- serologic testing
IBD - endoscopy
the most accurate when the disease can be reached by a scope
IBD - radiologic studies
For crohn that is mainly in the small bowel, radiologic tests such as BARIUM will detect the lesions
IBD serologic testing
if unclear. All IBD is associated with anemia. also:
- ANCA: UC
- ASCA: Crohn
IBD - ANCA?
antineutrophil cytoplasmic antibody –> ulcerative colitis (not in corhn)
IBD - ASCA?
antisaccharomyces cerevesiae antibody –> Crohn (not in ulcerative)
IBD - treatment of acute exacerbations
steroids in both IBD and UC
prednisone or budesonide
IBD - chronic maintenance or remission
5-ASA derivatives:
UC –> asacol, rowasa (if limited to the rectum)
CD –> pentasa
IBD - how to wean patients off of steroids
- azathiprine
- 6-mercaptopurine
when the disease is so severe that severe recurrence develop as the steroids are stop
every IBD needs … (additional treatment)
calcium and vit D
perianal CD is tread with
- ciprofloxacin + metronidazole
IBD - TNF agents
FISTULAE and severe disease unresponsive to other agents is treated with TNF agents such as infiximab
IBD - fistulae treatment?
TNF agents such as infiximab
If no response –> surgery
IBD - surgery?
neither form is routinely treated with surgery. UC can be cured, however, with colectomy. In CD, surgery is used exclusively for bowel obstruction. CD will tend to recur at the site of surgery
Budesonide - IBD
budesonide is a steroid sepcific for IBD. First pass effect is good
Divrticulosis - epidemiology
outpocketing of the colon are so common on a standard meat-filled diet as to be routinely expected in those above 65-70. Vegeterians rarely develop diverticulosis
diverticulosis - presentation
- asymptomatic most of the time
- left lower quadrant abdominal pain
- constipation
- bleeding
- sometimes infection (diverticulitis
diverticulosis - most accurate test
colonoscopy
diverticulosis - Barium
acceptable, but not as accurate
diverticulosis - treatment
Bran (πίτουρο), psyllium, methylcelluose (μεθυλοκυτταρίνη) and increased dietary fiber are used to decrease the rate of progression and complications
diverticulitis - presentation
- LLQ pain and TENDERNESS
- fever
- Leukocytosis
- palpable mass (sometimes)
- nausea, constipation, bleeding (nonspecific)
Diverticulitis - best initial test
diverticulitis
Colonoscopy and barium - diverticulitis
both are DANGEROUS in acute diverticulitis because of increased risk of perforation
infection weakens the colonic wall
Treatment of diverticulitis is with antibiotics that cover …
E. coli and anaerobes of the bowel
Treatment of diverticulitis - antibiotics
- ciprofloxacin + metronidazole OR
- beta lactam + lactamase (amoxicillin/clavulanate)
- ticarcillin / clavulanate
- ertapenem (carbapenems)
diverticulitis - surgery indications
- no response to medical therapy
2 frequent recurences of infection - perforation, fistula formation, absecess, strictures or obstruction (complications)
surgery of devirticulitis - who is more likely to get recommendation of surgery - young or old
younger should have the colon resected more often because of the greater total number of recurrent episodes that will occur. Diverticular disease does not disappear despite treating episodes of diverticulitis or the use of fiber on the diet
diverticulitis - food
patients with acute diverticulitis should not be fed
