Patient Presentation: Dairrhea Flashcards
What is the difference between the symptomatic and physiologic definition of diarrhea?
- Symptomatic
- increased frerquency, fluidity or volume
- physiologic
- decreased absorption or increased secretion, or usually both causing > 200mL liquid excretion per day
Consider the input and absorption of water daily.
How much and through what avenue is water input to the GI system, and how much and though what avenue is it absorbed?
What is considered a normal amount of fecal water?
- input
- diet/saliva: 3L
- Stomach: 2L
- Bile: 1L
- Pancreas: 2L
- Bowel: 1L
- Total: 9L
- Absorption
- jejunum: 5L
- Ileum: 2-3L
- colon: 1-2L
- Total: 8.8L
- Fecal water
- normal: 100-200mL/day
- diarrhea: >200mL/day
What tool do we use to talk to patients about their stool?
What are the different types and how are they described?
Bristol Stool Chart
- Type 1
- separate hard lumps
- very constipated
- Type 2
- lumpy and sausage like
- slightly constipated
- Type 3
- A sausage shape with cracks in the surface
- normal
- Type 4
- like a smooth, soft sausage or snake
- normal
- Type 5
- soft blobs with clear-cut edges
- lacking fiber
- Type 6
- musy consistency with ragged edges
- inflammation
- Type 7
- liquid consistency with no solid pieces
- inflammation and diarrhea
Diarrhea is what percent of childhood deaths in low-income countries?
Diarrhea causes how many deaths/year worldwide?
How many cases of diarrhea require hospitalization in the US each year?
How may deaths are cause by diarrhea in the US each year?
What percent of the US population has chronic diarrhea?
- percent childhood deaths low-income countries
- 18%
- serious problem
- deaths/year worldwide
- 2 million
- How many cases of diarrhea require hospitalization in the US each year?
- 250,000
- How may deaths are cause by diarrhea in the US each year?
- 3,000-6,000
- What percent of the US population has chronic diarrhea?
- 1%
How would you classify/work up diarrhea?
- Diarrhea vs. Not Diarrhea
- Acute vs. Chronic
- infectious vs. non-infectious
- osmotic vs. secretory
- inflammatory state vs. non-inflammatory
- large intestine vs. small intestine
- drugs?
- large intestine vs. small intestine
- inflammatory state vs. non-inflammatory
- osmotic vs. secretory
- infectious vs. non-infectious
- Acute vs. Chronic
If you determine it is not diarrhea, what are common causes it could it be?
- Pseudo-diarrhea (weigh stool for 24 hrs)
- passage of stool totally <200 g/day
- frequent passage small volumes of stool
- rectal urgency adn accompanies or proctitis
- Fecal incontinence
- involuntary discharge of rectal contents and is most often caued by neuromuscular disorders or structural ano-rectal problems
- can be liquid– then look at how much are they excreting/day
- Overflow diarrhea
- occur nursing home patients due to fecal impaction
- water that is overflowing around the impaction, so having loose stool but still constipated
- can be from anyone who is constipated
How do you determine acute vs. chronic diarrhea?
What are the most common causes acute diarrhea?
Common causes chronic diarrhea?
- acute
- less than 2 weeks duration
- 90% – infectious agents
- think blood? septic? disturbance in vital signs? white count elevated? fecal white count?
- 10% – think patient history
- medications
- toxic ingestions
- ischemia (inadequate blood supply)
- surgery, elderly
- food allergies
- > 4 weeks in duration
- rarely secondary to infectious process
- inflammatory processes, IBS
What symptoms woudl indicate infectious vs. noninfectious diarrhea?
- infectious
- fever
- blood
- pus
- epidemic
- travel (bacterial in visisted country adn parasitic after return)
- norovirus
- less liekly infectious
- afebrile
- non-bloody
- non-mucoid
- sporadic
- no travel
What 4 etilogical agents have most commonly been isolated during US military deployment?
-
ETEC
- Egypt (57%)
- South America (42%)
- Shigella
-
Campylobacter
- Thailand (39%)
- Salmonella
What is the difference between osmotic and secretory diarrhea?
What is the mechanism behind this classification?
Why would you also look at the pH of the stool?
- osmotic
- diarrhea ceases with fasting (as you eat, continually adding miliosmoles, & cant absorb, will pull in water and cause diarrhea)
- secretory
- diarrhea continues with fasting (not giving any more fuel)
- osmotic mechanism
- lumenal contents are in osmotic equilibrium at 290 mOsm/kg with othe rbody fluids. Thus, the osmotic gap 890-2([Na] +[K]) is the amound of solutes other than Na and K in stool water.
- Osmotic: if osmotic gap > 50 mOsm/kg
- only carbohydrate malabsorption will cause pH <5.6
- other osmotic AND secretory diarrheas pH > 5.6
- Osmotic: if osmotic gap > 50 mOsm/kg
- lumenal contents are in osmotic equilibrium at 290 mOsm/kg with othe rbody fluids. Thus, the osmotic gap 890-2([Na] +[K]) is the amound of solutes other than Na and K in stool water.
- secretory mechanism:
- increased Cl- and water secretion with or wthout abnormal active Na+ and water absorption
- secretory - osmotic gap < 50 mOsm/kg
What symptoms are you looking for in a patient with inflammatory diarrhea vs. non-inflammatory?
- Inflammatory
- frequent
- blood
- pus
- fever
- abdominal pain
- tenesmus
- (constant urge to need to have a bowel movement)
- fecal leukocytes
- non-inflammatory
- watery stools
- NO blood
- NO pus
- NO fever
- NO fecal leukocytes
Which etiological agents/diseases cause fecal leukocytes, and which do not?
- Fecal WBC (inflammation)
- Chron’s, ulcerative colitis
- C. difficile colitis
- shigellosis
- salmonellosis
- thyphoid fever (S. typhi)
- Invasive E. coli
- Y. enterocolitica
- V. parahemolyticus
- No fecal WBC
- Giadiasis
- Amebiasis
- Viral enteritis
- Toxigenic E. coli
- Salmonella carrier
If you do have fecal leukocytes, what is the primary culprit? Percent infected patients that display with fecal leukocytes?
What are the other causes that frequenty cause fecal leukocytes? Percent?
- Shigella (72.2% with fecal leukocytes)
- Escheria coli (65.4%)
- Campylobacter jejuni (49.1%)
- Yersinia enterocolitica (48.1%)
- Salmonella (42.1%)
Smart clinical clues for determining large intestine vs. small intestine
- large intestine
- frequent urges
- mushy
- dark colored
- rarely foul
- left lower quadrant pain
- tenesmus
- small volume
- just absorbs the last of the water
- small intestine
- light colored
- foul
- periumbilical
- right lower quadrant pain
- large volume
- does majority of absorption
What does volume tell you about the diarrhea?
<400mL?
>400mL?
- Small volume (<400 mL)
- rectal and sigmoid disease
- ulcerative colitis
- ulcerative proctitis
- pseudo-diarrhea
- rectal and sigmoid disease
- Large volume (>400mL)
- secretory -
- cholera, enterotixic EC, laxatives, Bile Acid Malabsorption
- osmotic-
- lactase deficiency, laxatives, sprue
- Dysmotility -
- post-gastrectomy syndrome, carcinoid tumor, laxatives
- altered permeabiltiy
- Sprue
- Ileal resection, chron’s disease, J-I bypass, radiation
*
- secretory -
Nearly all medications may cause diarrhea as a side effect. Which drugs are most common?
- Laxatives
- Antacids
- magnesium is a stimulant
- antibiotics
- negatively effect the microbiome
- metformin (to contorl high blood sugar)
- most common medication to cause diarrhea?
What does nocturnal diarrhea indicate?
- nocturnal
- organic issue
- inflammatory bowel disease (wake up in the middle of the night and have diarrhea)
If a child attends day care and is experience diarrhea, what are common causes?
- Giardia
- Cryptosporidium
- Shigella
What recent surgeries often caue diarrhea?
really, any surgery on the GI tract
- small intestinal diruption
- removal of terminal ileum
- cholecystectomy
- gastrectomy
If your patient experiences the following symptoms in addition to diarrhea, what etilogical agents would you consider?
Reactive arthritis
Hemolytic uremic syndrome
Vomiting/Nausea & Diarrhea < 7 hr after eating
Vomiting/Nausea & Diarrhea > 8-14 hr after eating
- Reactive arthritis
- salmonella
- shigella
- campylobacter
- yersinia
- C. difficile
- Hemolytic uremic syndrome
- E. coli
- S. typhi
- C. jejuni
- S. dysenteriae
- Vomiting/Nausea & Diarrhea < 7 hr after eating
- Preformed toxin:
- s. aureus
- B. cerus
- Anisakis
- emetic syndrome
- Preformed toxin:
- Vomiting/Nausea & Diarrhea > 8-14 hr after eating
- Toxins formed in GI tract
- C. perfringens
- B. cereus
- diarrhea syndrome
- Toxins formed in GI tract
Who should you work up for acute diarrhea?
chronic diarrhea?
- Acute
- most resolve within 24 hrs
- evaluation with dehydration (can’t drink enough water)
- common w/ cholera
- Septic?
- febrile, blood or puss in stool
- Chronic
- evlauate when symptoms have persisted for 2 weeks
What are the steps to evaluation for non-blood and bloody acute diarrhea?
Probable causes?
- Non-bloody
- most do not need evaluation
- causes (low fever, mild pain)
- infection
- Enterotoxic E. coli
- Giardia
- Cryptococcus
- Clostridium difficile
- Vibria cholera
- Norovirus
- Rotavirus
- contaminated food, water or person
- nearly any drug
- infection
- Bloody
- stool culture
- flexible sigmoidoscopy
- causes (high fever, severe pain)
- infection
- salmonella
- shigella
- Campylobacter
- E. coli
- Yersinia
- IBD (inflamatory bowel disease), vascular, ischemic
- infection
What are treatment considerations for acute infectious diarrhea?
- initiate rehydration
- oral
- epidemiologic evaluation significant diarrheal illness
- selective fecal studies
- calculate osmotic or not
- selective therapy
- avoid administering anti-motility agents with bloody diarrhea or proven infection with shiga toxin producing E. coli
- administer available vaccines
What are the 3 aims for treating chronic diarrhea?
Treatments?
- aims to
- eliminate the underlyign cause (if known)
- firm up the bowel movements
- treat any diarrhea-related complications
- treatments include
- Bismuth (Pepto-Bismol)
- High-fiber diet or fiber supplement (Bulk stool)
- Loperamide (Imodium)
- Atropine/diphenoxylate (Lomotil) - prescription
- Octreotide - severe diarrhea
