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GI/GU II Exam 1 > DSA 6: Diarrhea > Flashcards

DSA 6: Diarrhea Flashcards

1
Q

what are causes of constipation

A

MC: inadequate fiber/fluid intake

hypothyroid, hyperparathyroidism, paraplegia

opiods, anticholinergics, Ca2+ & Fe supplements

colonic mass w/ obstruction- adenoCA

colonic stricture: radiation, ischemia, diverticulosis

IBS

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2
Q

what is dual-energy x-ray densitometry recommended for

A

recommended for all pts w/ celiac to screen for osteoporosis

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3
Q

what is the etiology, Hz & PE of C. diff

A

hospitalized, ill, received ABx - Sxs begin during/right after ABsx therapy

mild-mod greenish, foul smelling watery diarrhea 5-15x/day

low abd pain, cramping, fever

PE: LLQ - normal/mild tenderness; severe/fulminant dz - hemodynamic instability, profuse diarrhea (30x/day)

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4
Q

How do you Dx Celiac dz

A

Abn serologic findings, small bowel Bx

Serology: IgA tTG antibody (recommended)
IgA anti-endomysial Ab
Anti-gliadin Ab (not tested any more)
Levels of all Ab undetectable after 3–12 months of dietary gluten withdrawal
IF pt = IgA deficiency –> IgG Ab to deamidated gliadin peptides (anti-DGP) & IgG tTG Ab

Endoscopy w/ Bx: Proximal and distal duodenum
atrophy or scalloping of the duodenal folds may be observed

Histology = intraepithelial lymphocytosis alone –> extensive infiltration of lymphocyte & plasma cell into LP –> hypertrophy of intestinal crypts and blunting or complete loss of intestinal villi
An adequate normal Bx excludes the Dx

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5
Q

what should be considered when pt complains about diarrhea

A

pseudo-diarrhea: freq passage of small vol stools; associated w/ rectal urgency, tenesmus, or feeling of incomplete evacuation, accompanies IBS/proctitis

fecal incontinence: involuntary discharge of rectal contents; caused by neuromuscular disorders or structural anorectal prob; diarrhea & urgency (esp if severe-may cause incontinence)

overflow diarrhea: severe consipation but only liquid gets by (elderly/nursing home pts); detect fecal imaction by rectam exam

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6
Q

what are characteristics of bile salt malabsorption

A
  • bile salts resorbed in terminal ileum ; resection/dz of this area (eg, crohns)–> insufficient intraluminal bile salts
  • destruction/loss of bile salts caused by bacterial overgrowth, massive acid hypersecretion, or meds that bind bile salts (eg, cholestyramine)
  • mild steatorrhea (due to malabsorption of FA & monoglycerides) minimal wt. loss
  • impaired abs of fat soluble vits (ADEK) –> b_leeding tendencies, osteoporosis, & hypoCa2+_
  • watery secretory diarrhea
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7
Q

What are clues, Sx, Hx and MCC of osmotic diarrhea

A

Clues: stool vol decrease w/ fasting; increased osmotic gap (>50; 75)

Sx: abd distention, bloating, flatulence (increased gas production)

ask about intake of dairy, fruits & artificial sweetners & alc

MCC:

  • Meds
  • Disaccharidase def/Carb malabs: lactose intolerance; Carb malabs Dx by elimination trial for 2-3 wks or by H+ breath test
  • laxative abuse (coule be osmotic/secretory)
  • malabs syndromes
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8
Q

what are clinical manifestations of IBS

A

onset <30; F>M

abd pain (crampy/low abd) & irregular bowel habits

continuous or intermittent :

  1. abd distention,
  2. relief w/ BM,
  3. increase freq of stool w/ pain,
  4. loose stool w/ pain,
  5. mucus in stool
  6. sense of incomplete evacuation
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9
Q

What are the MCC of chronic diarrhea

When is it necessary to do further work up

A

medication, IBS, lactose intolerance

BUT presence of nocturnal diarrhea, wt. loss, anemia, fecal occult blood test (+) (FOBT) –> inconsistent w/ common causes & need further work up

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10
Q

What are characteristics of pancreatic insufficiency

A

Chronic pancreatitis, CF, or pancreatic CA

sig steatorrhea (bc malabs of triglycerides)–> wt loss, gaseous distention & flatulence, large, greasy, foul-smelling stools

digestion of proteins & carbs affected far lesser degree

micellar fxn & intestinal abs = normal –> signs nutrient or vit def rare

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11
Q

what are signs of malabs

A

loss of M mass or subQ fat

pallor

easy bruising (vit K def)

hyperkeratosis (vit A def)

bone pain due to osteomalacia (vit D def)

neurologic signs (peripheral neuropathy, ataxia)- Vit B12 & E def

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12
Q

what signs will make you want to further investigate bc they are incompatible w/ dx of IBS

A
  • acute onset –> increase chance of organic dz, esp > 40–50 yo
  • nocturnal diarrhea
  • severe constipation or diarrhea
  • hematochezia
  • wt loss
  • fever
  • FHx CA, IBD, or celiac dz
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13
Q

what could be causes of malabs syndromes

A

small bowel mucosal disorders

pancreatic dz/insufficiency

bacterial overgrowth

lymphatic obstruction

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14
Q

what are the treatments and complications of C. diff

A

minimize transmission - wash hands w/ soap & water & use disposable gloves

D/C ABx if possible

complication: toxic megacolon/hemodynamic instablity –> perforation –> death

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15
Q

chronic use of laxatives can lead to..

A

melanosis coli

a benign hyperpigmentation of colon

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16
Q

how do you Dx C. diff

A

stool assay (for toxin A & B)

NAAT (PCR); fecal leukocytes -/+

CBC: leukocytosis: > 15K

imaging for severe/fulminant sxs - abd radiograph, noncontrast abd CT scan - look for evidence of colic dilation & wall thickening detection of perforation

flexible sigmoidoscopy: not in most pts; see pseudomembranous colitis - yellow adherent plaque; Bx - reveal epithelial ulcerations w/ “volcano” exudate of fibrin & neutrophils

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17
Q

what pts are at high risk fo acquiring C. diff

A

eldery, debilitated, immunocompromised

hospitalized (> 3 days)

on multiple ABx or prolonged Abx (>10 days): amplicilin, clindamycin, 3rd-gen cephalosporin, fluorquinolones

enteral tube feeding

PPI

chemotherapy

pt w/ IBD

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18
Q

what is apart of the Hx and PE of whipple dz

A

fever (intermittent, low grade), LAD, arthralgia

wt. loss, malabs, chronic diarrhea

hypoalbuminemia & edema, HF/valvular regurg, dementia, lethargy, coma, seizure, myoclonus, ophthalmoplegia or nystagmus

late finding = hypotension

LAD, heart murmur, peripheral joints enlarged/warm, peripheral edema

19
Q

What are characteristics of ABx associated diarrhea

A

most cases not attributable to C. dff (DIFFERENTIATE FROM ABx associated COLITIS)

mild & self-limited

during the period of ABx exposure: dose related, resolves spotaneously after discontinuation of ABx (ex Augmentin)

doesn’t require any specific lab evaluation

20
Q

what is the etiology of whipple dz

A

rare multi-system dz - infxn w/ gram (+) bacilli, not acid fast (tropheryma whipplei)

MC - white men 40-60s

source is unknown

21
Q

how do you Tx/manage celiac dz

A

lifelong removal of all gluten

check: meds

Dietary supplements: (folate, Fe, zinc, Ca2+, and vit A, B6, B12, D, and E) –> initial stages of therapy but usually not required long-term

MC reason for treatment failure: is incomplete removal of gluten

may be associated w/ other autoimmune disorders

22
Q

What are the extraintestinal sxs associated w/ celiac dz

A
  • Fatigue
  • Depression
  • Fe def anemia
  • Osteoporosis
  • Short stature
  • Delayed puberty
  • Amenorrhea
  • Reduced fertility
23
Q

what pathogens are MC associated with chronic diarrhea

A

Protozoan: giardia, E. histolytica, cyclospora

intestinal nematodes: strongyloidiasis stercoralis

bacterial: c. diff

immunuocompromised/AIDs related - viral CMV, HIV; bacterial c. diff, mycobacterium avium complex; protozoal - micosporida, cryptosporidium, isospora beli & cyclospora

24
Q

what are the sxs of pts w/ celiac dz

A

typical: wt loss, chronic diarrhea, dyspepsia, flatulence, abd distention/bloating, growth retardation, fatigue
atypical: dermatitis herpetiformis, Fe def anemia, osteoporosis

older kids & adults - less likely for serious malabs

25
Q

how do you Dx and Tx lactase def

A

symptomatic improvement of lactose-free diet –> confirm by H+ breath test

pt finds “threshold” of intake that causes sxs

OTC lactase enzyme replacemnt - caplets/drops of lactase taken w/ milk products –> improve lactase abs

*pt that restrict/eliminate milk –> risk for osteoporosis (recommend Ca2+ supplements)

26
Q

What is the DDx for acute diarrhea

A

Infectious: viral, bacterial, protozoal

Non-infectious (even if >14 days/<4 weeks)

  • medication (MC): ABx, NSAIDs, antidepressants, chemo agents, antacids/laxatives (Mg2+)
  • food allergies/intolerance
  • artificial sweateners: Sorbitol, ​chewing gum
  • tube feeding
  • acute diverticulitis
  • GVH dz
  • ingestion of toxin
  • chronic illnesses
27
Q

What are clues and causes of secretory diarrhea

A

Clues: DOESNT improve w/ fasting, normal osmotic gap, increased intestinal secretion/decreased abs; high-vol watery diarrhea –> dehydration & electrolyte imbalance (hyponatremia, non-anion gap metoblic acidosis)

causes:

  • endocrine tumors: stimulate intestinal/pancreatic secretion, zolinger ellison, carcinoid syndrome, medullary thryoid carcinoma
  • bile salt malabs: stimulate colonic secretion; idiopathic, ileal resection, crohn ileitis, post-chlecystectomy
  • factitious dirrhea: laxative abuse
  • vilous adenoma
28
Q

what is IBS characterized by

A

Altered bowel habits
Abd pain
Absence of detectable organic pathology

29
Q

what are PE of celiac dz

A

may be normal in mild cases
signs of malabs

Dermatitis herpetiformis

= cutaneous variant of celiac disease

pruritic papulovesicles over the extensor surfaces of the extremities and over the trunk, scalp, and neck

30
Q

what is the etiology, Hx and PE of constipation

A

impaction –> obstruct fecal flow more –> partial/complete large bowel obstruction

predisposing factors (opioids) sever psychiatric dz, prolonged bed rest, neurogenic disorders of the colon & spinal cord disorders

-decreased appetite, N/V, abd pain/distention, paradoxial “diarrhea” as liquid stool leaks –> overflow incontinence

DRE –> firm feces palpable

31
Q

what is the etiology of celiac dz

A

immune response to gluten –> diffuse damage to proximal SI mucosa w/ malabs of nutrients (only 10% have sxs–> most cases undiagnosed. bc asymp)

n. european ancestry

sxs in pt w/ HLA-DQ2 and D8 class II molecules

gluten –> digested in intestal lumen into Glu-rich peptides –> glutamines are deamidated by tTG –> (-) glutamic acid residue; inappropriate T cell mediated activation –> destruction of mucosal enterocytes & humoral response –> Ab to gluten and tTG

32
Q

how do you Dx IBS

A

chronic > 6 months (sxs for atleast 3 months before considering in DDx)

utilize rome IV clinical dx criteria

sigmoidoscopy & barium radiograph to exclude DDx (IBD, malignancy, giardiasis, lactase def, hyperthyroid)

33
Q

what are the 3 types of clincal presentations of IBS

A
  1. spastic colon (chronic abd pain & constipation)
  2. alternating constipation and diarrhea
  3. chronic, painless diarrhea
34
Q

what is the pathophys of IBS

A

visceral hyperalgesia to mechanoreceptor stimuli

  1. altered colonic motility (rest,w/ stress, cholinergic drugs, CCK)
  2. altered SI motility
  3. enhanced visceral sensation (lower pain threshold in response to gut distention)
  4. abn extrinsic innervation of the gut

may be post-infxn (ie after gastroenteritis)

i_ncreased frequency of psychological disturbances_ (depression, hysteria, OCD)

35
Q

what is the MCC of ABx-associated colitis

A

C. diff

= anaerobic, gram (+), spore forming bacillus

cytotoxin (A & B) production

nosocomial, fecal-oral

36
Q

what are characterisitics/classic sxs of malabs syndromes

A

wt loss

osmotic diarrhea

steatorrhea

nutritonal def

abd distention, weakness, M wasting, growth retardation

37
Q

what is the prognosis of whipple dz

A

If untreated, the disease is fatal.
bc some neurologic signs may be permanent –> goal of tx =prevent progression
Pt must be followed closely after Tx for signs recurrence

38
Q

What should be included in the initial diagnostic work-up for chronic diarrhea

A

routine lab tests

stool studies:

  • osmotic/secretory;
  • malabs;
  • inflam fecal leukocytes, calprotectin, lactoferrin (may suggest IBD)
  • infxn: ova/parasite, wet mount/fecal Ag (more sensitive) (= giardia & E. histolytica)
  • acid-fast staining

endoscopic exam & mucosal Bx: colonoscopy w/ mucosal Bx to exclude IBD, colitis, colonic neoplasia; EGD w/ small bowel Bx: suspicion of small intestinal malabs; pts w/ advanced AIDS

39
Q

If needed, what should be completed after initial work-up

A
  1. if malabs suspected:
  • pancreatic insufficiency - fecal elastase < 100 mcg/g;
  • chronic pancreatitis: calcification on plain abd radiograp
  • Breath test: Small bowel bacterial overgrowth -noninvasive breath test (glucose/lactose) ; carb malabs: H+ breath test
  1. crohn’s dx, small bowel lymphoma, carcinoid, jejunal diverticula - SI imaging w/ barium, CT or MRI
  2. neuroendocrine tumors (rare/secretory) -serologic tests
  • vasoactive intestinal peptide - VIPoma
  • calcitonin - medullary thryoid carcinoma
  • gastrin - zollinger-ellison
  • urinary 5-hyrdoxyindoleacetic acid - carcinoid
40
Q

what is the etiology, Hx and PE of lactase deficiency

A

lactase = brush border enzyme that hydrolyze lactose into glucose & galactose

other GI disodors (crohns, celiac, viral gastroenteritis, giardiasis, short bowel syndome & malnutrition) can affect proximal SI –> secondary lactose def

diarrhea, bloating, flatulence, abd pain after ingestion of milk

41
Q

how do you tx/manage IBS

A

medication directed towards diarrhea, constipation, pain

avoid stress or precipitating factors (psychotherapy, exercise)

LOW FODMAPs: fermentable oligosac, disaccharides, monosaccharides & polyols (fermentable carbs may improve sxs)

frutose, wheat-based products, sorbitol, raffinose

42
Q

What is the DDx for chronic diarrhea

A
  1. meds
  2. IBS
  3. lactose def/intolerance
  4. chronic infxn
  5. malabs conditions
  6. overflow incontinence/fecal impaction
43
Q

What are the common medicinal offenders that can cause diarrhea

A

cholinesterase inhibitors

SSRIs

angiotensin II receptor blockers

PPI

NSAIDs

Metformin

allopurinol

44
Q

how do you Dx and Tx Whipple

A

Endoscopy w/ Duodenal Bx - periodic acid Schiff (PAS)- (+) macrophages w/ bacillus

Lab findings: evidence of malabs & steatorrhea

Also could use: (PCR) or immunohistochemistry of duodenal Bxor extraintestinal fluids (cerebrospinal, synovial) or tissue (LN, synovium, endocardium)

ABx therapy - dramatic improvement w/i several weeks; prefer drugs that cross BBB

GI/GU II Exam 1 (16 decks)

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