S/Sx 2 - Constipation and Diarrhea Flashcards
How may a patient define constipation?
- Infrequent stools **less than 3x week
- Hard stools
- Excessive straining
- Incomplete evacuation
What are some things that can cause constipation?
- *Inadequate fiber
- *Poor hydration
- Opiods
Other
Poor bowel habits, systemic disease, meds, *IBS - C
Compare primary vs secondary constipation
Primary - Common, “functional”, Poss Hx psychosocial
Secondary - systemic, meds, lesions… **Sudden
What do we do during PE of constipation patient? What may we find?
DRE and ABD percussion
DRE - R/O structural abnormal or impaction
Percuss - dullness to Left Quadrants
When do we need to do a further diagnostic test for constipation (ie Colonoscopy)
- Pt older 50 **
- Severe ?
- Signs of Organic disorder
- Alarm signs **
What are the alarm signs with constipation?
Hematochezia
Weight loss
Pos FOBT
Family hx of colon cancer or IBD
When doing further workup for constipation, what are our options in terms of Labs, Rads, and endoscopy?
Labs = CBC, CMP, Thyroid
Rads = ABD (will show non-specific bowel gas)
Endoscopy = Colonoscopy and flex sig
How do we treat constipation?
Diet and lifestye (excercise, fiber etc)
Change offending meds
Pharmacotherapy - Osmotic, stimulant, stool surfactant, enema
Describe the types of Osmotic laxatives, Stimulant laxatives, Stool surfactants, Enemas
1. Osmotic Mag Hydroxide Polyethelyne glycol 3350 " w/o 3350 Mag citrate
- Stim
Bisacodyl
Senna - Stool Surfactants
Ducosate - Enema
Tap water
saline
What are 2 complications of constipation
Fecal Impaction = paradoxical diarrhea –> manual disimpaction
Hemmorrhoids
When do we refer constipatio patients?
Symptoms refractory to tx Structural abnormality Obstruction Over 50 (scope) ** Alarm symptoms (scope) **
Differentiate acute vs chronic diarrhea
Acute = <2 weeks Chronic = >4 weeks
Differentiate inflamm vs non-inflamm diarrhea
Bloody vs. non - bloody
What are the diagnostic pearls of acute non-inflamm diarrhea? Is diagnostic evaluation needed?
- acute length
- water/non bloody
- mild and self limiting
- virus or non-invasive bacteria
Workup not needed unless *severe or persistant beyond **7 DAYS
What are 3 common etiologies for Acute non inf diarrhea?
Norovirus
Rotavirus
Giardia lamblia (water)
What are the diagnostic pearls for Acute Inflammatory Diarrhea? Do we need diagnostic eval?
- acute length
- blood or pus
- invasive or toxin prod. bacteria
Yes, Stool bacteria culture (O157:H7 E coli) is routinge. PRN = C Diff toxin, O and P
What are some common etiologies for Acute inflammatory diarrhea?
E coli
Shigella
Salmonella
C Diff (think ABX)
Symptoms of acute inflammatory diarrhea typically include what findings?
Diarrhea Fever LLQ cramping Urgency Tenesmus
Prompt evaluation for acute diarrhea is required when?
- Inflamm diarrhea - FEVER, 15000+ WBC, Bloody, Severe abd pain
- Profuse non inflamm
- frail old people
- Immune compromise
- ABX
- Nosocomial (3 days of hospitalization)
- Systemic illness
How do we typically treat acute diarrhea? Without meds
BRAT diet, avoid bad food
Rehydrate PO, ORS prn.
What are examples of antidiarrheals? Should we always give them? Why or why not?
Loperamide and bismuth subsalicylate. Diarrhea is the method of flushing the system. Dont give unless pt needs to continue important things.
What are the ABX’s of choice for acute diarrhea? In what cases would you consider emperic therapy? **Not traveler’s
Empiric -
Flouroquinolones - Cipro, Ofloxacin, Levofloxacin
Other - Septra (trimethoprim sulfamethoxazole) and Doxy
What is traveler’s diarrhea? How do you treat?
Diarrhea that develops during travel or w/in 10 days of return.
Flouroquinolones - Cipro, Oflox, Levo **Not for asia
Azithromycin
Rifaximin
What organisms require specific tx w/ antibiotics in acute diarrhea
Shigellosis Cholera Extraintestinal salmonellosis Listeriosis T-diarrhea Giradiasis Amebiases
When should acute diarrhea patients get admitted?
- Severe dehydration requiring IV fluids
- Bloody diarrhea that is *sever or *worsening
- Severe ABD pain **toxic colitis, IBD, Ischemia, Surgical abdomen
- Severe infection 39.5 C +, leuks, rash
- Sever or worsening if **over 70
- Hemolytic-uremic syndrome (kidney, platelets, hemolytic anemia
How do we work up Chronic Diarrhea?
- Exclude most common causes - offending meds, IBS, Lactose intolerance
- Base eval on history and S/Sx
- Labs - CBC, CMP, LFT, Thyroid, ESR, CRP, Stool - culture, leuks, lactoferrin, FOBT, O and P
- Colonoscopy w/ biopsy to r/o IBD and neoplasm
- Other = 24 hour stool for weight and fat
Chronic diarrhea warrants _________ to _______ in most cases
Referral to gastroenterologist
