Mcgowen Acute Diarrhea and Small Bowel/Colon

Question 1

Definition of Diarrhea

Answer 1

• Adult: >200 grams/day
• Child >20 g/Kg/day
• Clinically: 3 or more loose or watery stools/day or decreased consistency and increase in frequency of BM

Question 2

What is lost with diarrhea

Answer 2

bicarb and K+

Question 3

Medications that can cause diarrhea

Answer 3

• antibiotics
• Antidysrhythmics
• antihypertensives
• NSAIDS
• certain antidepressants
• Chemo
• bronchodilaters
• antacids
• laxatives

Question 4

What is the most common/likely non-infectious etiology of diarrhea for more than 14 days

Answer 4

medications

Question 5

non medicinal Non-infectious diarrhea causes

Answer 5

• Food sweeteners (sorbitol)
• food allergies (Anaphylaxis)
• Tube feeding
• Acute diverticulitis
• Graft vs. Host disease
• ingestion of toxins (insecticides, amanita and mushrooms, arsenic, preformed environmental toxins in seafood, like ciguatera and scombroid
• Chronic illness early in course (IBD and microscopic colitis, endocrine diseases, tumors: VIPoma, carcinoid, colorectal
• Occlusive or nonocclusive ischemic colitis (over 50, acute lower abdominal pain preceding watery–>bloody diarrhea, . . acute inflammatory changes in sigmoid or left colon while sparing rectum

Question 6

5 high risk groups for infectious diarrhea?

Answer 6

• travelers
• Immunodeficient
• Daycare work/attendees and family (shigella, Giardia, Cryptosporidium, Rotavirus)
• Institutionalized persons (nursing homes/assisted living/hospitals)
• Certain foods

Question 7

• Frequent passage of small volumes of stool
• Rectal urgency, tenesmus, feeling of incomplete evacuation
• accompanies IBS or PROCTITIS

Answer 7

Psuedo-diarrhea

Question 8

• involuntary discharge of rectal contents

- most often caused by neuromuscular disorders or structural anorectal problems

Answer 8

Fecal incontinence

Question 9

• elderly/nursing home patients

- fecal impaction that is readily detectable by rectal exam

Answer 9

Overflow diarrhea

Question 10

what do routine bacterial stool cultures include

Answer 10

• Salmonella
• Shigella
• E. Coli (ask for Shiga toxin detection for 0157:H7 EHEC)
• Most detect campylobacter but may need to requents

Question 11

What cultures do you specifically need to ask for

Answer 11

• C. diff PCR/toxin
• Ova parasites (increase yield by obtaining 3 samples sequentially)
• Stool antigen (parasites - giardia and cryptosporidium)

Question 12

What Virus is not detected with routine and study and PCR is better

Answer 12

Norwalk

Question 13

Picnic, banquet, or restaurant food: Chicken

Answer 13

• Salmonella
• Campylobacter
• Shigella

Question 14

Picnic, banquet, or restaurant food: Undercooked hamburger

Answer 14

-EHEC (0157:H7)

Question 15

Picnic, banquet, or restaurant food: Fried rice or other reheated food

Answer 15

Bacillus cereus

Question 16

Picnic, banquet, or restaurant food: potato salad, mayonnaise, or cream pastries

Answer 16

Staph. aureus

Question 17

Picnic, banquet, or restaurant food: eggs

Answer 17

Salmonella

Question 18

Picnic, banquet, or restaurant food: uncooked foods, LUNCH MEATS, or soft cheeses

Answer 18

Listeria

Question 19

Picnic, banquet, or restaurant food: seafood, especially if raw

Answer 19

Vibrio species, Salmonella, acute hepatitis A

-Norwalk, Campylobacter

Question 20

Staph Aureus: toxin?

symptoms?

type of diarrhea?

Onset?

Resolution?

Causes?

Answer 20

• Preformed enterotoxins
• N/V
• WATERY
• rapid . .within 6 hours of ingestion
• rapid . . 24-48 hours
• Ham, poultry, Dairy, eggs, CREAM PASTRIES, POTATO SALAD, MAYO

Question 21

Bacillus Cereus: Toxin?

Symptoms?

Onset?

Resolution

Cause?

type of diarrhea?

Answer 21

• Preformed enterotoxins
• Vomiting is main symptom
• Rapid . .within 6 hours of ingestion
• Rapid . . 24-48 hours
• Fried rice
• Watery diarrhea . . happens occasionally

Question 22

Clostridium Perfringens: toxin?

Type of diarrhea?

symptoms?

Onset?

Resolution?

Cause?

Answer 22

• Preformed Enterotoxins
• Watery diarrhea
• Crampy abd pain
• Rapid . . within 8-16 hours of ingestion . . Need to ingest large quantity of organisms
• Rapid . .within 24-48 hours
• Beef, ham, poultry, legumes, gravy (heat resistant spores inadequately cooked

Question 23

Shigells: Toxin?

Age?

foods?

type of diarrhea?

associated symptoms?

Stool cultures?

duration?

treatment?

complications?

Answer 23

• enterotoxin Shiga Toxin
• any age, but primarily children (daycare and families)
• Potato or egg salad, lettuce, raw veggies
• BLOODY, small volume
• Abdominal cramps, FEVER for 3-4 days, FECAL LEUKOCYTES
• distinguish from IBD . . . lactose neg.
• 1-2 weeks duration
• Bismuth, Amp., Fluoro., or Trimethorpim/sulfamethoxazole
• Respiratory complaints and seizures in children and Post infectious reactive arthritis and HUS

Question 24

Gram-negative , non-lactose fermenting, motile rod-shaped bacteria

Answer 24

Salmonella typhimurium

Question 25

Salmonella typhimurium: Diarrhea? Ass. Symptoms? Resolution? Foods? Animal exposure? Increased risk? Stool culture? Antibiotics? Complications?

Answer 25

Watery -->BLOODY Fever, Abd cramping, N/v, + fecal leukocytes Self limited . . 5-10 days Eggs, poultry Reptiles (turtles), ducks, birds HIV, leukemia, and SICKLE CELL pts Lactose -, motile NOT indicated . . can prolong course reactive arthritis, endocarditis, septic arthritis, oseomyelitis

Question 26

Salmonella Typhi: Risk factors? Prevention? Spread? Ass. symptoms? Diagnosis? Treatment?

Answer 26

- International travel, poor sanitation - good food prep, hand washing, vaccine - fecal-oral - Typhoid Fever: systemic SUSTAINED FEBRILE illness, 103 to 104, sometimes accompanied by weakness, headache, anorexia, RLQ pain, rash of flat rose-colored spots, and diarrhea - Stool and blood samples, fecal leukocyte + - Fluoroquinolones, ceftriaxone, and azithromycin

Question 27

Campylobacter Jejuni: diarrhea? Ass. symptoms? Resolution? complications? Stool culture? Foods? Hosts? Spread?

Answer 27

Watery -->BLOODY - Fever, crampy abd pain, fecal leukocytes + - Self limited 7 days, supportive treatment - Late onset, 1-8 weeks after diarrhea resolved, reactive arthritis, GUILLAN-BARRE syndrome - gram- curved rod, Campy blood agar, Spiral (S shaped), Oxidase +, motile with flagellum - raw undercooked meats (POULTRY), dairy (raw milk) - Wild birds including ducks - cross contamination during food prep, contaminated water

Question 28

Vibrio Cholera: Diarrhea? Ass. symto.? Gram stain of stool? Source? duration? Treatment? Variants?

Answer 28

RICE WATER , profulse up to 1 L/hour vomiting and dehydration: hypotension, renal failure, death Curved/comma shaped, anaerobic gram- bacilli with flagellum, Darting, motile waterborn, salt water, raw oysters, underdeveloped nations 1 week Rehydration/electrolyte replacement . . prevent with sanitation and vaccination O1 and O139

Question 29

Vibrio Parahemolyticus: Variants? Toxin? Ass. Sym? Diarrhea? duration? Food?

Answer 29

NON-O1 and NON-O139 Cytotoxin production N/V/Abd cramps, Fecal leukocyte + Watery-->BLOODY diarrhea (colonic) 2-5 days Sea food associated

Question 30

Vibrio Vulnificus: stain and shape? Found where? Foods? Ass. Symp.? you get this how?

Answer 30

- Gram - bacillus - Warm, shallow COASTAL SALT WATER Raw shellfish Vomiting, diarrhea, abdominal within 16 hrs of ingestion Open wound in water: bullous skin lesions, life threatening in immunocompromised especially CIRRHOSIS pts

Question 31

Aeromonas Hydrophila: describe? Source? get this how? location? 2 types? Treatments?

Answer 31

Gram -, non spore forming, rod shaped, facultative anaerobeic bacteria, motile with flaggelum Fresh water or brackish water (more salt than fresh but less than salt) Wounded in water; foot and ankle most common; necrotizing fasciitis aka flesh eating bacteria Eating rish or shellfish Scuba divers that swallow small amounts of fresh water cholera-like: Non bloody watery rice water stools Boody mucoid stools Ampicillin

Question 32

Travelers Diarrhea (TD): locations? Onset? Symptoms? What is UNCOMMON? resolution? Risk factors?

Answer 32

-Asia, South and Central America, Mexico 3 days - 2 weeks after travel N/V, WATERY diarrhea, bloating, Abd cramps, fatigue/malaise, loss of appetite and LOW grade fever Bloody diarrhea and fever Self limited; 1-5 days H2blocker/PPI use . . . lowers pH

Question 33

Travelers Diarrhea (TD): most common, Enterotoxin production, water salads meats cheese, affect small intestine? Asia Misc. other causes Visitors to Russia (St. Petersburg); Campers, backpackers and swimmers in wilderness Visitors to Nepal Cruise ships

Answer 33

- ETEC - Campylobacter Jejuni Salmonells, shigella, Aeromonas, EAEC, Norovirus, Coronavirus Giardia associated diarrhea Cyclospora Norovirus

Question 34

E. coli; ETEC: Diarrhea? Fecal leukocyte? onset? Diagnose? source? Treatment?

Answer 34

Watery neg sudden . . lasts 3-6 days Clinically contaminated food or water Antibx may reduce infection by 1-2 days - Trimethoprim/sulfamethoxazole, Coxycycline, ciprofloxacin, - Bismuth may help

Question 35

EHEC: diarrhea? Ass. Symp? Stool culture Acquired complications Treatment

Answer 35

- watery-->BLOODY (can lead to ischemic colitis) - Abd tenderness, NO FEVER, + peripheral leukocytes, + fecal leukocytes or lactoferrin Shiga-like toxin under cooked hamburger; raw veggies; animal contact HUS (more often than shigella) more likely to happen in children treated with antibiotics Supportive, rehydration

Question 36

Yersinia Enterocoitica: Higher risk in? Transmission? Diarrhea? Ass. Sym? location of pain? Indistinguishable from? duration? complications? Treat?

Answer 36

-IRON OVERLOAD SYNDROMEs, diabetes and preexisting GI disorders Contaminated food/water; dairy, contaminated domestic animal feces (maybe a puppy?) Bloody (and non bloody) . . + fecal leukocytes Abd pain + PHARYNGITIS Terminal ileum: right sided abd pain . . mimic APPENDICITIS or Crohns Salmonella or shigella 10-20 days Rash, reactive arthritis, hemochromatosis supportive care

Question 37

Listeria monocytogenes: Who gets it? Sympt. duration confirm by? source? complication

Answer 37

anyone: predilection for PREGNANT WOMEN Fever, NON bloody diarrhea, headache, N/V 2-3 days BLOOD CULTURE unpasteurized dairy, DELI MEATS, rarely cantaloupe Menengoencephalitis

Question 38

Clostridium Difficile: Describe? Ass. Symt? PCR? other associations? Treatment? complications?

Answer 38

Anaerobic, Gram +, spore forming baciliius Watery diarrhea, Abd pain and fever, Pseudomembranes Toxins A and B -recent hospitalization; antibiotics (PPIs, Clindamycin, cephalosporins, fluroquinolones) . . WASH hands with soap and water PO/IV metronidazole, ORAL vancomycin Toxic megacolon

Question 39

Nosocomial infections

Answer 39

- C. diff | - Norovirus (nursing homes)

Question 40

"wagon Wheel appearance on electon microscopy

Answer 40

Rotavirus

Question 41

Rotavirus: age? symp? onset and duration? detection? spread? Death by? Treatment?

Answer 41

Most common cause of acute diarrhea in INFANTS (under 2) . . in winter months Vomiting and watery diarrhea --> severe dehydration in 72 hr . . . last 2-3 days up to 5 viral culture or PCR fecal oral dehydration Supportive care . . . vaccine available

Question 42

Norovirus: age? sympt? onset and duration? transmission and common link? treatment?

Answer 42

Older children and adults Vomiting and Watery diarrhea in 24-48 hrs and lasts 3 days fecal oral . . . CRUISE SHIPS Supportive care

Question 43

Adenovirus (serotypes 40 and 41): age? Sympt? course? treatment

Answer 43

- Children - Fever (103-104) chills, myalgias, sore throat, Watery diarrhea, CONJUNCTIVITIS, PHARYNGITIS, Prolonged . . . 10 days supportive care

Question 44

CMV: what pts? sympt? duration? diagnose how?

Answer 44

Immunosuppressed . . AIDS and organ transplant. CD4<200 Fever, Abd pain, bloody diarrhea several weeks endoscopy with biopsy of ulcerated lesions using CMV special stains

Question 45

Most common cause of dysentery in the world

Answer 45

Entamoeba Histolytica

Question 46

"Flask shaped ulcer"

Answer 46

Entamoeba Histolytica

Question 47

Entamoeba histolytica: complications? duration? stool? found in what situations? treatment?

Answer 47

-can penetrate bowel and into portal circulation: liver abscesses or lung or brain. Toxic megacolon or pneumatosis coli days to weeks Stool for ova and parasites or Stool antigen (PCR or DNA) Crowded living conditions (fecal oral); mental health institutions, poor sanitation, endemic areas, Asia, Africa, Central and south american Metronidazole and Paromomycin

Question 48

Pear-shaped, 4 flagella, 2 nuclei protozoan

Answer 48

Giardia lamblia

Question 49

Giardia Lamblia: transmission? Diarrhea? Ass. Sympt? Duration? Stool? Acquired how? Treatment?

Answer 49

fecal-oral Watery (malodorous), Steatorrhea, flatulence, abd pain, belching, weight loss, nasuea, malaise, cramps, anorexia, bloating 14-28 days ova parasites (3 samples sequentially); STOOL ANTIGEN DETECTION Water (lakes, streams) from hiking camping; Zoonosis, beaver, cattle, dogs, rodents, big horn sheep, person-person. conatminated water in russia . . IgA deficiency more susceptible Metronidazole

Question 50

What are the 2 main clinical syndromes from cryptosporidium?

Answer 50

Self limited diarrhea in immunoCOMPETENT . .. 7-14 days no treatment other than rehydration Life-threatening intractable in immunoSUPPRESSED pts . . . AIDS . .CD4 <200 . . biliary dx RUQ pain and fever

Question 51

outbreaks for cryptosporidium

Answer 51

Swimming pools . . can be resistant to chlorine

Question 52

Nematode/roundworm that enters body through exposed skin such as bare feet on contaminated soil? who is more susceptible? Ass. Sym? Whats in Stool? Treatment?

Answer 52

Strongyloides stercoralis those with HTLV-1 infection Abd pain, bloating, diarrhea, cough, SOB, perianal urticaria, migratory rash Rhabdiform larvae and eosinophils Ivermectin

Question 53

Cyclospora: source? duration in immunocompetent? suppressed? Resistance? Stool? Treatment

Answer 53

-PRODUCE imported from endemic areas (lettuce, fresh basil, imported respberries); Travel to endemic areas up to 21 days indefinite Chlorine and iodine unlikely to kill oocysts oocysts TMP/SMX

Question 54

Stain for Cystoisospora belli? What pts? Treatment?

Answer 54

modified acid fast stain Immunosuppressed Bactrim (TMP/SMX)

Question 55

hook worm . .bowel obstruction

Answer 55

Ascaris lumbricoides

Question 56

fish tapeworm

Answer 56

Diphyllobothrium

Question 57

esophageal varices . .freshwater snails . . . bladder cancer and liver cysts

Answer 57

Schistosoma mansoni

Question 58

Pork tape worm; causes cysticercosis . . seizure and muscle or eye disease

Answer 58

Taenia solium

Question 59

sheep and dog tapeworm - cysts in liver or lungs - looks like free flowing "hydatid sand" on CT

Answer 59

Echinococcus granulosus

Question 60

General Nutritional advice for infectious colitis?

Answer 60

- BRAT diet (bananas, Rice, Applesauce, Toast) - Easily digestible foods (boiled potatos, crackers, yogurt, soup) - Rice water - avoid lactose containing products as they can make diarhea worse - Avoid high fiber roots, fats, caffeine, and alcohol

Question 61

General advice to make you feel better

Answer 61

- drink 8-10 glasses of clear fluids/day - drink at least 1 cup of liquid every time you have a loose BM - Eat small meals throughout the day instead of 3 big meals - Eat some salty foods such as pretzels, soups, and sports drinks - Eat some high K+ foods such as bananas, potatoes without the skin

Question 62

Alcohol gels are ineffective against what

Answer 62

norovirus and C. diff

Question 63

What viral vaccines are there

Answer 63

- rotavirus - S. typhi - V. cholerae - Hep A

Question 64

``` Reactive Arthritis (Reiter's syndrome) -Arthritis, urethritis, conjunctivitis ```

Answer 64

- Salmonella - campylobacter - shigella - Yersinia

Question 65

yersiniosis may lead to what?

Answer 65

- autoimmune thyroiditis - pericarditis - glomerulonephritis

Question 66

Guillian-Barre syndrome

Answer 66

Campylobacter jejuni

Question 67

HUS-->high mortality rate

Answer 67

- EHEC | - shigella

Question 68

Pathogens that usually affect the small bowel present with what? What is in stool? Location of pain? other associ? specific organisms

Answer 68

-Large volume, watery stools, abd cramps weight loss WBC absent . . NON inflammatory Mid abdomen or diffuse dehydration/malabsorption -Salmonella, vibrio cholerae, ETEC, EPEC, Yersinia, Rotavirus, Norovirus, CMV, Adenovirus, Giardia, Cyrptosporidium, Cyclospora, Clostridium perfringens, staph. aureus, Bacillis cereus

Question 69

pathogens that usually affect Large bowel present with what? Associted with? Locatiion? what organisms?

Answer 69

-Frequent small volume stools Fever, Blood or WBC in stool (inflammatory), fecal leukocytes common lower abd or rectum . . (tenesmus) -Campylobacter, Salmonella, Shigella, yersinia, EIEC, EHEC, C. diff, vibrio parahaemolyticus, E. histolytica, CMV, Adenovirus, Herpes simplex

Question 70

Persons with Hemochromatosis susceptible to what? should avoid what?

Answer 70

-Vibrio and Yersinia infections Avoid Raw Fish