Diarrhea Up to Date

Question 1

Diarrhea is defined as

Answer 1

the passage of loose or watery stools, typically at least 3 times in a 24-hour period. Reflects increased water content of the stool, whether d/t impaired water absorption and/or active water secretion by the bowel

Question 2

Acute diarrhea

Answer 2

14 days or fewer in duration

Question 3

Persistent diarrhea

Answer 3

more than 14 but fewer than 30 days in duration

Question 4

Chronic diarrhea

Answer 4

more than 30 days in duration

Question 5

Invasive diarrhea, or dysentery definition

Answer 5

diarrhea with visible blood or mucus, in contrast to watery diarrhea. Dysentery is commonly associated with fever and abdominal pain.

Question 6

Most cases of acute diarrhea are due to

Answer 6

infections and are self-limited

Question 7

The major causes of acute infectious diarrhea include

Answer 7

viruses (norovirus, rotavirus, adenoviruses, astrovirus), bacteria (Salmonella, Campylobacter, Shigella, enterotoxigenic Escherichia coli, Clostridium difficile), and protozoa (Cryptosporidium, Giardia, Cyclospora, Entamoeba)

Question 8

Office evaluation for acute diarrhea is warranted for individuals with ??

Answer 8

persistent fever, bloody diarrhea, severe abdominal pain, symptoms of volume depletion (eg, dark or scant urine, symptoms of orthostasis), or a history of inflammatory bowel disease

Question 9

Diarrhea of small bowel origin is typically ??

Answer 9

watery, of large volume, and associated with abdominal cramping, bloating, and gas. Weight can happen if persistent, fever rare, and occult blood or inflammatory cells in the stool are rarely identified.

Question 10

diarrhea of large intestinal origin often presents ??

Answer 10

with frequent, regular, small volume, and often painful bowel movements. Fever and bloody or mucoid stools are common, and RBC’s and inflammatory cells can be seen routinely on stool microscopy

Question 11

These inflammatory signs associated with large bowel infection (fever, bloody or mucoid stools) suggest ?

Answer 11

invasive bacteria (eg, Salmonella, Shigella, or Campylobacter), enteric viruses (eg, cytomegalovirus [CMV] or adenovirus), Entamoeba histolytica, or a cytotoxic organism such as C. difficile

Question 12

Visibly bloody acute diarrhea is relatively uncommon and raises the possibility of ?

Answer 12

enterohemorrhagic E. coli (EHEC). Bloody diarrhea can also reflect noninfectious etiologies such as inflammatory bowel disease or ischemic colitis

Question 13

Syndromes that begin with diarrhea but progress to fever and systemic complaints, such as headache and muscle aches, should raise the possibility of other etiologies, such as ?

Answer 13

typhoidal illness (particularly in travelers from resource-limited settings) or infection with Listeria monocytogenes (particularly if a stiff neck is also present or the patient is a pregnant woman)

Question 14

timing/ onset of sx can indicate certain pathogens- within six hours suggests?

Answer 14

ingestion of a preformed toxin of Staphylococcus aureus or Bacillus cereus, particularly if nausea and vomiting were the initial symptoms

Question 15

timing/ onset of sx can indicate certain pathogens- at 8 to 16 hours ?

Answer 15

suggests infection with Clostridium perfringens

Question 16

timing/ onset of sx can indicate certain pathogens- at more than 16 hours ?

Answer 16

suggests either viral or other bacterial infection (eg, contamination of food with enterotoxigenic or EHEC or other pathogens)

Question 17

Exposure to animals (poultry, turtles, petting zoos) has been associated with

Answer 17

Salmonella infection.

Question 18

Occupation in daycare centers has been associated with infections with ?

Answer 18

Shigella, Cryptosporidium, and Giardia. Can consider Rotavirus but it has decreased substantially in US since the vaccine

Question 19

why is it important to ask about recent antibiotic use ?

Answer 19

possibility of cdiff

Question 20

why is it important to ask about PPI’s?

Answer 20

they can increase the risk of infectious diarrhea

Question 21

why is it important to know if pt is preggo?

Answer 21

pregnancy increases the risk of listeriosis following infections of contaminated meat products or unpasteurized dairy products approximately 20-fold

Question 22

important to know if pt has cirrhosis because?

Answer 22

cirrhosis has been associated with Vibrio infection

Question 23

hemochromatosis has been associated with?

Answer 23

Yersinia infection

Question 24

physical exam for diarrhea focused on?

Answer 24

valuating volume status and identifying complications

Question 25

s/s volume depletion?

Answer 25

dry mucous membranes, diminished skin turgor, postural or frank reductions in blood pressure, and altered sensorium. These signs can be mild or absent with early hypovolemia.

Question 26

lab tests for pt with diarrhea?

Answer 26

not routinely warranted for most patients with acute diarrhea

Question 27

If substantial volume depletion is present (suggested by signs or symptoms such as dark and concentrated urine) should order ?

Answer 27

serum electrolytes should be measured to screen for hypokalemia or renal dysfunction.

Question 28

is a CBC helpful at all?

Answer 28

yes- it does not reliably distinguish bacterial etiologies of diarrhea from others but may be helpful in suggesting severe disease or potential complications

Question 29

A low platelet count may prompt concern for the development of ?

Answer 29

hemolytic-uremic syndrome

Question 30

leukemoid reaction (seen on CBC) consistent with ?

Answer 30

consistent with the diagnosis of C. difficile infection

Question 31

For most patients who do not have severe illness or high-risk comorbidities, it is reasonable to continue expectant management for several days without performing stool cultures. But when should you get stool studies?

Answer 31

if pt with acute community acquired diarrhea also has:

• severe illness: profuse watery diarrhea with signs of hypovolemia, passage of ≥6 unformed stools per 24 hours, severe abdominal pain
• s/s of inflammatory diarrhea: bloody diarrhea, passage of many small volume stools containing blood and mucus, fever of 101.3 or higher
• is a high risk host: immunocompromised, 70+ years old, IBD, preggo, or has serious co-morbidities such as cardiac dx, which may be exacerbated by hypovolemia or rapid infusion of fluid
• if sx persist for longer than 1 week OR
• public health concerns (day cares, food handlers contaminating things)

Question 32

most infectious cases of acute diarrhea are self-limited and of viral etiology, and the rate of positive stool cultures in pts with acute diarrhea is generally low but if it is bacterial- 3 most common causes of bacterial diarrhea in the United States

Answer 32

Salmonella, Campylobacter, and Shigella

Question 33

testing for parasitic organisms is only reasonable in patients with persistent diarrhea which has not responded to empiric tx- 3 most common parasitic pathogens in patients with persistent diarrhea ?

Answer 33

Giardia, Cryptosporidium, and E. histolytica. (Infants/ day care centers associated with giardia and crypto more so)

Question 34

What should be a consideration in immunocompromised patients with persistent diarrhea?

Answer 34

Microsporidium

Question 35

The most critical therapy in diarrheal illness is?

Answer 35

rehydration- preferably by the oral route, with solutions that contain water, salt, and sugar. Such as- diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups

Question 36

The composition of the oral rehydration solution (per liter of water) recommended by the World Health Organization consists of:

Answer 36

●3.5 g sodium chloride
●2.9 g trisodium citrate or 2.5 g sodium bicarbonate
●1.5 g potassium chloride
●20 g glucose or 40 g sucrose

Question 37

empiric ab only used if:

Answer 37

(same as when to get stool studies)
●Severe disease (fever, more than six stools per day, volume depletion warranting hospitalization)
●Features suggestive of invasive bacterial infection (bloody or mucoid stools)
●Host factors that increase the risk for complications, including age >70 years old and comorbidities such as cardiac disease and immunocompromising conditions
●Prolonged disease (more than one week) that has not improved with conservative measures
●Public health concerns (such as diarrheal illness in food handlers, health care workers, and individuals in day care centers)

Question 38

most cases of infectious diarrhea are likely ?

Answer 38

viral; however, bacterial causes are responsible for most cases of severe diarrhea

Question 39

T or F- Most adults with acute diarrhea do not present to medical care.

Answer 39

True. because of the mild or transient nature of the symptoms.

Question 40

For those who present to medical care, the initial evaluation should assess ?

Answer 40

for extracellular volume depletion (eg, dark yellow urine or scant amount of urine, decreased skin turgor, orthostatic hypotension) and determine the duration of symptoms, the frequency and characteristics of the stool, and associated symptoms (eg, fever and peritoneal signs). Laboratory tests are not usually warranted except in cases of substantial volume depletion, high fevers, or systemic illness.

Question 41

Inflammatory features (eg, fever, or bloody or mucoid stool) suggest infection of ?

Answer 41

the large bowel, which is associated with pathogens distinct from small bowel infection

Question 42

Further diagnostic testing depends on the presenting features. Grossly bloody diarrhea warrants testing for

Answer 42

Shiga toxin (to identify enterohemorrhagic Escherichia coli [EHEC]) and fecal leukocytes or lactoferrin, if available

Question 43

Testing for parasites is not warranted in the majority of patients with acute diarrhea. It is useful, however, in patients with ?

Answer 43

persistent diarrhea, in men who have sex with men, in immunocompromised hosts, during a community waterborne outbreak (associated with Giardia and Cryptosporidium), or with bloody diarrhea with few or no fecal leukocytes (associated with intestinal amebiasis)

Question 44

most of the time abx for diarrhea

Answer 44

can reduce the duration of diarrhea and other symptoms by several days, but potential drawbacks include side effects, promotion of bacterial resistance, eradication of normal flora (and increased susceptibility to C. difficile infection), and cost. The benefit of symptom reduction does not outweigh these drawbacks in most individuals with acute diarrhea

Question 45

empiric antibiotic therapy for patients with ?

Answer 45

severe disease, features suggestive of invasive bacterial infection (bloody or mucoid stools), host factors that increase the risk for complications, or disease longer than one week, and in cases of public health concern

Question 46

For patients in whom empiric antibiotic therapy is warranted, we suggest

Answer 46

Fluoroquinolones- given for three to five days.

Question 47

even if you want to tx with abx, should rule out this first before you start them

Answer 47

EHEC or Shiga toxin production. EHEC specifically should NOT be treated with antibiotics.

Question 48

For patients who desire symptomatic therapy, could give

Answer 48

the antimotility agent loperamide can be used cautiously in patients in whom fever is absent or low grade and the stools are not bloody

Question 49

For patients with clinical features suggestive of dysentery (fever, bloody or mucoid stools) ?

Answer 49

avoid antimotility agents unless antibiotics are also given because of concerns of prolonging disease in such infections- could use bismuth salicylate in these pts