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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
how do you Dx and Tx lactase def
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
What is the DDx for acute diarrhea
**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
What are clues and causes of secretory diarrhea
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
what is IBS characterized by
**Altered bowel habits Abd pain Absence of detectable organic pathology**
29
what are PE of celiac dz
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
what is the etiology, Hx and PE of constipation
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
what is the etiology of celiac dz
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
how do you Dx IBS
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
what are the 3 types of clincal presentations of IBS
1. spastic colon (chronic abd pain & constipation) 2. alternating constipation and diarrhea 3. chronic, painless diarrhea
34
what is the pathophys of IBS
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
what is the **MCC of ABx-associated colitis**
_C. diff_ **= anaerobic, gram (+), spore forming bacillus** **cytotoxin (A & B) production** nosocomial, fecal-oral
36
what are characterisitics/classic sxs of malabs syndromes
**wt loss** **osmotic diarrhea** **_steatorrhea_** **nutritonal def** abd distention, weakness, M wasting, growth retardation
37
what is the prognosis of whipple dz
**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
What should be included in the initial diagnostic work-up for chronic diarrhea
**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
If needed, what should be completed after initial work-up
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** 2. crohn's dx, small bowel lymphoma, carcinoid, jejunal diverticula - SI imaging w/ barium, CT or MRI 3. neuroendocrine tumors (rare/secretory) -serologic tests * **vasoactive intestinal peptide** - VIPoma * **calcitonin** - medullary thryoid carcinoma * **gastrin** - zollinger-ellison * **urinary 5-hyrdoxyindoleacetic acid** - carcinoid
40
what is the etiology, Hx and PE of lactase deficiency
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
how do you tx/manage IBS
**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
What is the DDx for chronic diarrhea
1. **meds** 2. **IBS** 3. **lactose def/intolerance** 4. chronic infxn 5. malabs conditions 6. overflow incontinence/fecal impaction
43
What are the common medicinal offenders that can cause diarrhea
cholinesterase inhibitors SSRIs angiotensin II receptor blockers PPI NSAIDs Metformin allopurinol
44
how do you Dx and Tx Whipple
**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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