Diarrhoeal illness Flashcards
What is the WHO definition of diarrhoea?
>3 loose or watery stool per day
What does WHO define as acute diarrhoea?
<14 days’ duration
What is the WHO definition of chronic diarrhoea?
>14 days
What are 4 conditions which can cause acute diarrhoea?
- Gastroenteritis
- Diverticulitis
- Antibiotic therapy
- Constipation causing overflow
What are 5 causes of chronic diarrhoea?
- Irritable Bowel Syndrome
- Ulcerative colitis
- Crohn’s disease
- Colorectal cancer
- Coeliac disease
What are 4 further conditions associated with diarrhoea?
- Thyrotoxicosis
- Laxative abuse
- Appendicitis
- Radiation enteritis
What are 3 classic features of diverticulitis?
- Left lower quadrant pain
- Diarrhoea
- Fever
What type of antibiotics most commonly cause diarrhoea?
broad spectrum antibiotics
C. difficile seen with antibiotic use
Of Crohn’s disease and ulcerative colitis, which more commonly features bloody diarrhoea?
ulcerative colitis
What are 5 possible features of Crohn’s disease?
- Crampy abdominal pains + diarrhoea
- Malabsorption
- Mouth ulcers
- Perianal disease
- Intestinal obstruction
What are 3 ways that coeliac disease may present in children?
- failure to thrive
- diarrhoea
- abdominal distension
What are 5 possible features of coeliac disease in adults?
- lethargy
- anaemia
- diarrhoea
- weight loss
- other autoimmune conditions
What is the most common cause of infectious diarrhoea?
viruses (rather than bacteria or parasites)
How long do nearly half of episodes of diarrhoea last for?
less than 1 day
What are 4 routes via which transmission of GI infection from person to person may occur?
- Faecal-oral
- Foodborne
- Environmental
- Airborne
What causes ‘food poisoning’?
usually caused by enterotoxins produced by the microorganism rather than the microorganism itself
How long does food poisoning usually last for?
last than 24 hours
What are the 3 most common causes of bacterial gastroenteritis from food, and which foods are they found in?
- Clostridium perfringens - meat
- Bacilus cereus - rice, pasta, meat, vegetable dishes, dairy products
- Staphylococcus aureus - cooked meats and cream products
What is the most common cause of viral gastroenteritis in children?
rotavirus (reduction in prevalence due to vaccine)
How are most viral causes of gastroenteritis transmitted between people?
faecal-oral route (more rarely, by contact with contaminated surfaces)
What are 4 possible symptoms of viral gastroenteritis?
- Diarrhoea
- Vomiting
- Fever
- Abdominal pain
How long does it take viral gastroenteritis to settle?
vomiting usually settles within 1-3 days, diarrhoea within 5-7 days
but can persist for 2 weeks
Why is viral gastroenteritis infection uncommon in adults?
immunity is long-lasting
What is the commonest cause of gastroenteritis in England and Wales?
Norovirus
When is the prevalence of norovirus higher?
during colder months
Why can infection of norovirus occur in people of all ages?
immunity is not long-lasting
What is the time scale of norovirus?
symptoms begin 24-48 hours after infection and last for 12-60 hours
most people make full recovery within 1-2 days
What are the typical symptoms of norovirus?
- sudden onset nausea followed by projectile vomiting and watery diarrhoea
- fever, headache, abdominal pain, myalgia
What is the typical transmission of norovirus? What are 2 other routes?
- faecal-oral route
- can also be transmitted by consumption of contaminated food (e.g. oysters) or water
- contact with contamined surfaes e.g. toilets, soft furnishings, floors
In which environments are norovirus outbreaks common?
semi-closed environments e.g. schools, hospitals, care-homes, cruise-ships
What are 3 viruses that can cause gastroenteritis?
- Rotavirus
- Norovirus
- Adenovirus
What are 5 bacterial causes of gastroenteritis (non-food)?
- Campylobacter jejuni and Campylobacter coli
- Escherichia coli
- Salmonellosis: Salmonella typhia and Salmonella paratyphi
- Shigella dysenteriae, Shigella flexneri, Shigella boydii, Shigella sonnei
- Yersinia enterocolitica
What are the most commonly reported bacterial causes of infectious intestinal disease in England and Wales?
Campylobacter (jejuni and coli)
What are 6 features of campylobacter infection?
- Asymptomatic (25-50%)
- Diarrhoea (may be bloody)
- Nausea
- Vomiting
- Abdominal cramps
- Fever
How long does campylobacter usually last for?
most cases self-limiting within 2-3 days, usually resolve within 1 week
What is commonly the cause of campylobacter infection?
usually associated with the consumption of contaminated food and drink e.g. undercoorked meat (esp. poultry), unpasteurised milk, untreated water
Which age group is most commonly affected by E. coli gastroenteritis?
children aged 1-4 years
How long does E. coli gastroenteritis usually last for?
usually resolves within 10 days, self-limiting
What are 4 ways E. coli infection can be transmitted?
- contaminated food - meat, salad, water, unpasteurised milk
- Person-to-person: faecal oral
- Infected animals (cattle, sheep, goats)
- Environmental exposure to contamined water
What is the commonest cause of salmonellosis?
ingestion of contaminated foods: red and white meats, raw eggs, milk and dairy products
What are 6 typical features of salmonellosis?
- Watery and sometimes bloody diarrhoea
- Abdominal pain
- Headache
- Nausea
- Vomiting
- Fever
How long does salmonellosis usually last for?
usually lasts for 4-7 days, people usually recover spontaneously
How is shigella most commonly transmitted?
person-to-person by faecal oral routine
in households, nurseries, and schools
In what age gorup does shigellosis most commonly occur?
children less than 5 years of age, but infection can occur in all ages
In the UK at what time of year do shigellosis infections peak?
late summer
What are 7 of the features of shigella?
- diarrhoea (may have blood and mucus)
- fever
- abdominal cramps
- nausea
- vomiting
- headache
- malaise
What is the usual time course of shigella infection?
symptoms 1-3 days after infection
resolves in 5-7 days
In what age group does Yersinia infection typically occur?
children
What are 4 possible features of Yersinia infection?
- Watery diarrhoea (often bloody)
- Fever
- Abdominal pain
- Right-sided abdominal pain (older children/adults)
What is the usual time course of Yersinia infection?
Symptoms typically develop 4–7 days after exposure and may last 2 days to 6 weeks
What is the method of transmission of Yersinia infection?
direct contact with infected animals and person-to-person (faecal-oral route), and through contaminated food (especially raw pork and pork products) and water
What are 3 types of parasites which can cause gastroenteritis?
- Cryptosporidium
- Entamoeba histolytica (amoebiasis)
- Giardia intestinalis or Giardia lamblia
What is the most common protozoal cause of gastroenteritis in the UK?
cryptosporidiosis
What proportion of cases of cryptosporidiosis are associated with foreign travel?
20%
What proportion of cryptosporidiosis show recurrence of symptoms?
1/3
How much of amoebiasis is related to foreign travel?
most cases
What proportion of amoebiasis is asymptomatic?
90%
What are symptoms of amoebiasis when symptomatic?
amoebic dysentery can occur: fever, severe abdo pain, blood and mucus in faeces
What foreign travel are many cases of giardiasis associated with?
particularly from SE Asia
What are 6 features of giardiasis?
- diarrhoea
- malaise
- abdominal pain
- loss of appetite
- flatulence
- bloating
What is the most commonly identified pathogen in returning travellers with prolonged diarrhoea?
giardiasis
What are 17 complications of gastroenteritis?
- Dehydration, electrolyte disturbance, AKI
- Haemorrhagic colitis
- Haemolytic uraemic syndrome (HUS)
- Thrombotic thrombocytopaenic purpura (TTP)
- Reaction arthritis including Reiter’s syndrome
- Aortitis, osteomyelitis
- Sepsis
- Toxic megacolon
- Pancreatitis, sclerosing cholangitis, liver cirrhosis
- Faltering growth
- Chronic diarrhoea
- IBS
- IBD
- Acquired or secondary lactose intolerance
- Guillain-Barré syndrome
- Meningitis
- Invasive entamoeba infection
What are 5 symptoms that should make yous suspect gastroenteritis?
- Sudden-onset diarrhoea
- Nausea or sudden onset of vomiting
- Fever or general malaise
- Abdominal pain or cramps
- Associated headache, myalgia, bloating, flatulence, weight loss, malabsorption, depending on underlying cause of infection
What are 7 important aspects of the management of suspected gastroenteritis?
- History
- Examination - features of shock, sepsis, malnutrition
- Stool culture and sensitivity testing if indicated
- Stool culture and sensitivity if contact with affected person or outbreak of diarrhoea
- Do not routinely arrange blood tests for acute gastroenteritis
What are 2 types of drugs in the history that can cause gastroenteritis?
- PPIs
- Antibiotics
What are 2 types of drugs that may need to be stopped during acute diarrhoeal illness?
ACEi and diuretics
What are 3 types of drugs that may be affected by severe diarrhoea and vomiting?
COCP, warfarin, anticonvulsants
What are 9 situations when you should arrange for stool culture and sensitivity testing in gastroenteritis?
- Systemically unwell or immunocompromised
- Acute painful diarrhoea or blood, mucus and/or pus in stool (suggesting possible dysentery, such as caused by Shiga toxin-producing E. coli)
- If recent antibiotic or PPI treatment, or recent hospital admission (C. diff)
- Diarrhoea has not resolved by day 7
- Suspected food poisoning
- If recent travel abroad other than W Europe, N America, Australia, N Zealand
- send additional 3 specimens for ova, cysts and parasites 2-3 days apart to exclude parasite infection
- All children 5 years old or under who attend
- If in person at risk of transmission or infection e.g. food handlers
- Uncertainty about diagnosis to help exclude alternative causes
What are 5 symptoms of clinical dehydration in children?
- Appears to be unwell or deteriorating
- Altered responsiveness e.g. irritable, lethargic
- Decreased Urine output
- Skin colour unchanged
- Warm extremities
What are 3 clinical symptoms of shock in children?
- Decreased level of consciousness
- Pale or mottled skin
- Cold extremities
What are 11 signs of clinical dehydration in children?
- Altered responsiveness
- Skin colour unchanged
- Warm extremities
- Sunken eyes
- Dry mucous membranes (except for mouth breathing)
- Tachycardia
- Tachypnoea
- Normal peripheral pulses
- Normal capillary refill time
- Reduced skin turgor
- Normal BP
What are 8 signs of clinical shock in children?
- Decreased level of consciousness
- Pale or mottled skin
- Cold extremities
- Tachycardia
- Tachypnoea
- Weak peripheral pulses
- Prolonged capillary refill
- Hypotension (decompensated shock)
What are 3 situations to arrange urgent hospital admission in gastroenteritis?
- Systemically unwell and/or clinical features suggesting severe dehydration and/or progression to shock
- Intractable vomiting or high-output diarrhoea
- Suspected serious complication, such as sepsis
What are 4 situations to consider arranging hospital assessment in gastroenteritis?
- Clinical features suggesting potentially life-threatening or serious alternative diagnosis
- Inadequate response to oral rehydration salt solution, unable to take it, or clinically deteriorating
- Risk factors for developing dehydration e.g. in elderly, immunocompromised, those with co-morbid conditions or concurrent illness
- Person/carers are unable to provide appropriate management safely at home
What are 8 aspects of the management of gastroenteritis in adults?
- Provide advice on support and information e.g. patient.info leaflets, NHS leaflets
- Advise on how to monitor fluid intake and prevent/treat dehydration - encourage fluid intake, use of oral rehydration salt (ORS) solution as supplemental fluid
- Advise drug treatment with anti-diarrhoeal (or antimotility) drugs, antiemetics, and probiotics NOT routinely recommended
- Don’t routinely prescribe antibiotics - only following stool culture and sensitivity
- Advise on methods to prevent transmission of infection - washing hands, flush toilet, don’t share towels
- Advise not to attend work for at least 48 hours after last episode of diarrhoea or vomiting
- Advise need for follow up and went ot seek urgent medical advice
- Notify local health protection team immediately by completing notification if notifiable disease
What should you advise adults with signs of dehydration who can be maanged at home?
advise to use ORS solution frequently and in small amounts, such as 200-400ml given after every loose motion, dose according to fluid loss
after rehydration gradually reintroduce usual diet - small, light, non-fatty, non-spicy meals
When are anti-diarrhoela drugs used in adults?
if mild-to-moderate diarrhoea when rapid resolution would enable person to resume essential activities
(can purchase over counter)
What are 2 situations when you should not use anti-diarrhoeals?
- Blood, mucus and/or pus in stools or high fever (possible dysentery)
- Shigellosis or confirmed probably or suspected Shiga toxin-producing E. coli (STEC) infection following stool culture and sensitivity
What are 5 notifiable gastroenteritis situations to the local health protection team?
- Food poisoning (e.g. Bacillus cereus, Campylobacter, Clostridium perfringens, Cryptosporidium, Entamoeba histolytica)
- Haemolytic uraemic syndrome
- Infectious blood diarrhoea e.g. Shigella
- Enteric fever (typhoid or paratyphoid)
- Cholera
What is the recommended management of confirmed campylobacter?
antibiotics not usually needed
if symptoms severe or immunocompromised, clarithromycin 250-500mg twice daily for 5-7 days within 3 days of onset
What is the treatment of confirmed amoebiasis / amoebic dysentery?
drug treatment such as metronidazole following anti-protozoal drug diloxanide
seek specialist advice regarding need for microbiological clearance to confirm treatment success, 1 week after completing treatment
What is the treatment for confirmed E. coli gastroenteritis?
no effective abx treatment
2 consecutive negative stool samples usually needed, taken at least 24 hours apart, once person symptom free for at least 48h, before can return to work
What is the specific treatment for giadiasis?
tinidazole 2g as single dose
What is the treatment of confirmed salmonellosis?
antibiotic treatment not usually needed
What is the treatment for confirmed shigellosis?
antibiotic treatment not usually needed if mild symptoms
if severe/immunocompromised, seek specialist advice on need for abx treatment
What are the 2 types of anti-diarrhoeal agents?
- Loperamide
- Diphenoxylate
What is the drug class of antidiarrhoeal agents?
opioid agonists
