Diarrhoea Flashcards
What should be included in a travel history?
- Rural or urban area?
- Departure and return dates
- Did they take prophylactic medication e.g. malarone for malaria
- Did they get vaccinations
- What activities did they do e.g. water-based activities/animal contact
- Accommodation e.g. malaria bed nets
- Insect bites or injuries e.g. breaks to the skin
- Food well cooked, did they eat out anywhere
- Drink bottled or tap water?
- Come in contact with any sick people?
- Take part in any sexual activity? Tattos or piercings?
- Red flags: unexplained weigh loss, change in bowel habit
- Occupation: if it is culinary or clinical environment - may need time off
What are common causes of travellers diarrhoea?
- Yersinia spp.
- Salmonella spp.
- Shigella spp.
- EHEC E.coli 0157:H7
- Campylobacter spp.
- Parasites: Isospora belli, Entamoeba
What samples are done for potential travel infection?
- Stool for culture/ova/parasite - need 3 stool samples
- Urine and blood culutre - bacteraemia can complicate bacterial diarrhoeal infections
- FBC, U+E, CRP, LFT - infection markers, anaemia, deranged liver/renal function which could indicate severe disease and dehydration
- HIV test: certain bacterial causes of diarrhoeas (salmonella, shigella and campylobacter) are clinical indicator conditions for HIV hence HIV test should be offered
What is the management for shigella infections?
- Shigella infections usually resolve after 5-7 days. Most important advice is to stay hydrated and increase oral fluids and take rehydration salts.
- Abx would be need if there was shigella bacteraemia with positive blood cultures.
- Abx resistance is a concern with Shigella and would need to involve microbiology and infection specialists in the case of bacteraemia.
Why is follow-up important in shigella infections?
Post-infection arthritis occurs 1-4 weeks after infection and affects ~2% of patients with shigella, hence, follow-up required to ensure symptoms resolved, renal function is stable and need to be advised regarding arthritis complications. This usually presents early in first few days of travel). Most common cause is faecal-oral transmission from eating contaminated food or water.
What are complications of traveller’s diarrhoea?
Bacteraemia and dysentery (intestinal inflammation) can occur with any bacterial cause of traveller’s diarrhoea would require admission and abx. This form of arthritis can also occur with any other bacterial organism and can last for years.
- Usually have joint pain and then can have uveitis and urethritis
- Also at risk of post infectious IBS causing changes in bowel habit and abdo pain.
How is GBS associated with infective diarrhoea?
Infective diarrhoea (particularly campylobacter) can be associated with GBS. This can present 1-3 weeks after infection and involves progressive weakness of the limbs, cranial nerves and respiratory muscles requiring ventilation. Recovery can take months and some are left with persistent neurological complications. Importantly, infection and immune response so it can be a differential for neuro symptoms.
What is suspected when there is acute onset diarrhoea in transplant patients?
Virus, bacteria and parasites should all be considered in a post transplant patient on immunosuppressive therapy with acute onset diarrhoea. In these patients blood on the glove following a DRE does not restrict the diagnosis to only common causes of bloody diarrhoea, as tissue damage and invasion can be seen with a broader spectrum of opportunistic pathogens.
What investigations should be done for diarrhoea in a transplant patient?
- FBC, U+Es, LFTs, clotting, lactate, CRP
- Blood cultures
- Urinalysis and culture
- Faecal sample for culture and microscopy (ova, cysts and parasites) as well as C.diff toxin - mention on request they are post transplant and immunocompromised
- ABG - metabolic acidosis in sepsis
- ECG
Who needs to be involved with diarrhoea in a transplant patient?
Contact the Transplant team, the transplanted organ needs to be protected (at the same time as resuscitating the patient); early discussion is essential to obtain more info on usual blood results, discuss immunosuppressive medication and if there is anything additional they need for the patient.
What needs to be investigated if there is continuous diarrhoea and pyrexia after treatment?
- HIV tests: anyone presenting with gastroenteritis should be offered an HIV test
- Refer to gastro for urgent flexible sigmoidoscopy to exclude colitis
- CMV PCR (blood): indicate reactivation of infection, latent CMV infection status would be known as part of the pre-transplant infection serology work-up
What are potential later causes of infection?
- Candidaema
- Contracted resistant bacterium such as MRSA, VRE or CPE from ward
Need to do beta-D-glucan test, urinalysis/culture and blood cultures
How would infective causes of diarrhoea present?
Can contain blood or mucus, be profuse and watery, patient may also have signs of being systemically unwell, with fever and joint pain. Infective diarrhoea can be caused by bacteria, viruses and parasites. At risk patients include recent travellers, immunosuppressed, care home residents and hospital patients.
How would non-infective causes of diarrhoea present?
Not accompanied by systemic illness but the patient can present dehydrated and still needs medical attention.
What needs to be asked about in a history of diarrhoea?
A thorough dietary history is indicated as consumption of certain foods such as raw meat or dairy products could be the source of infection.
