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Tintinalli Section 9 - Gastrointestinal Emergencies > S09C76 - Diarrhea > Flashcards

S09C76 - Diarrhea Flashcards

1
Q

Dfn diarrhea:

A
  • > 3 BM/d exceeding 200g
  • 4 mechanisms: incr secretion, decr absorption, incr osmotic load, abn intestinal motility
  • 85% infectious, 15% non-infectious
  • acute : 3w
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2
Q

Intestional function

A

-usually lose

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3
Q

Acute diarrhea

A
  • either infxs, ischemic, intoxication of inflm

- most caused by norovirus or rotavirus and most occur in winter

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4
Q

Diarrhea + paresthesias + reverse temperature sensation:

A

ciguatera

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5
Q

IBD extraintestinal manifestations

A

-oral ulcers, erythema nodosum, episcleritis, anal fissures

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6
Q

Reiter syndrome linked to:

A
  • salmonella
  • shigella
  • campylobacter
  • yersinia
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7
Q

Wright stain

A
  • detects fecal leukocytes

- Sn 52-82%, 83% Sp for presence of bacterial pathogen

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8
Q

Bacterial Stool culture

A
  • expensive
  • dx yield is 1.5%-5.6%
  • should be performed in: some children, toxic/dehydrated/febrile pts, diarrhea >3d, pts with blood or pus in stool, immunocompromised pt
  • systemic illness/fever/blood stool should be tested for salmonella, shigellla, campylobacter, shiga toxin producing e. coli, amoebic infxn
  • many labs only culture for salmonella, shieglla, c. jejuni, therefore if something else suspected this should be communicated to the lab
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9
Q

O+P

A
  • should be done on travelers, those with diarrhea >7d
  • may need multiple samples to get a positive result
  • direct immunofluorescence staining can improve sensitivity for detecting giardia and cryptosporidium
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10
Q

C. diff Toxin assay

A
  • 10% flase neg rate

- takes 24h

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11
Q

General tx for diarrhea

A
  • caffeine-free glucose containing beverage, eg. gatorade
  • 30-50ml/kg over 4h for mild dehydration
  • 100cc/kg over next 4h for moderate dehydration
  • avoid caffeine (stimulates gastric motility), sorbitol, lactose (to allow villi enough time to produce enzymes required)
  • BRAT diet
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12
Q

Noninfectious diarrhea

A
  • almost all true diarrheal emergencies are non-infxs:

- GIB, adrenal insufficiency, thyroid storm, toxins, acute radiation syndrome, mesenteric ischemia

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13
Q

Acute infxs and traveller’s diarrhea

A
  • south asia: c. jejuni, shigella, salmonella
  • bloody stool w/o WBC is common in shiga toxin-producing E.coli (e. coli O157:H7) and e. hystolytica
  • hikers with diarrhea >7d should be tested for protozoans (e. histolytica antigen, g intestinalis antigen, cryptosporidium parvum antigen – enzyme immunoassay)
  • severe pain, fever, bloody stool should be tested for salmonella, shigella, jejuni, e coli O157:H7, assay for shig toxin and microscopy or antigen testing for e histolytica
  • prevention, bottled/boiled water for teeth brushing and preparing food and formula
  • vaccine for rotavirus
  • tx: ciprofloxacin 500mg once or BID x3d decreases course by 24h for shigella, e. coli
  • tx with flagyl 750mg TID for giardia/histolytica
  • loperamide can be used if non-bloody or non IBD or non c-diff –** do not use in children b/c of risk of HUS
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14
Q

C diff epidemiology

A
  • illness ranges from mild diarrhea to pseudomembranous enterocolitis (yellow laques of exudate over necrotic mucosa)
  • spore-forming obligate anaerobic bacillus
  • secretes 2 toxins: A and B
  • toxin A = enterotoxin
  • toxin B = cytotoxin
  • relapses occur in 10-25% of pts
  • complications: arthritis, visceral abscesses, cellulitis, nec fasc, osteomyelitis, prosthetic device infxn
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15
Q

C diff pathophys

A
  • hospitalized pts are colonized with c. diff in 1- 25% of cases
  • recent hospitalization should flag a pt for c diff
  • linear relationship with length of stay and colonization
  • broad-spectrum Abx are a risk factor (clinda, cephalosporins, amp/amox, fluoroquinolones) as well as PPI
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16
Q

Dx c diff

A
  • stool is more likely to have fecal leukocytes than benign forms of diarrhea
  • may have profuse diarrhea 20-30x per day
  • toxic megacolon in 1-3% of cases with pseudomembranous colitis
  • usually begins 7-10d after administration of Abx but can occur several wks after Abx have been d/c
  • dx: c diff toxin in stool and colonoscopy
  • toxin detected with ELISA, latex agllutination, PCR (most labs use ELISA)
  • ELISA has Sn of 63-94% and Sp of 75-100%
  • stool Cx for is 100% Sn but not necessarily very specific
  • colonoscopy = yellow plaques, often R colon
17
Q

Tx c diff

A
  • mild: d/c offending Abx
  • mod/severe: flagyl 500mg PO QID x10-14d
  • severe: vanco 125-250mg PO WID x10c
  • colectomy may be required (WBC >20, lactate >5, >75yo, immunosuppression, shock, toxic megacolon, perforation) for fulminant colitis
18
Q

Crohn Dz: pathology

A
  • chronic granulomatous inflammatory dz
  • mouth to anus, often ileum, 20% of cases only colon involved, 30% only small bowel
  • involves all layers of bowel wall with extension into lymph nodes
  • skip lesions, discontinuous
  • deep ulcers, fissures, fistulas, abscesses, cobblestone muscosa
19
Q

Crohn Dz: presentation

A
  • pain, anorexia, diarrhea, wt loss
  • 1/3 of pts develop perianal fissures, fistulas, abscesses, rectal prolapse
  • may present with sx of obstruction, obstipation, intra-abdo abcess with fever, palpable mass
  • extraintestinal: arthritis, uveitis, liver dz, erythema nodosum, pyoderma gangrenosum, episcleritis, uveitis
20
Q

Crohn Dz: Dx

A
  • CT is very helpful

- colonoscopy detects early lesions and defines extent of colonic involvement

21
Q

Crohn Dz: DDx

A
  • lymphoma
  • ileocecal amebiasis
  • sarcoidosis
  • deep chronic mycotic infections
  • GI TB
  • kaposi sarcoma
  • campylobacter enteritis
  • yersinia ileocolitis
22
Q

Crohn Dz: extraintestinal manifestations

A 
Arthritic: peripheral arthritis, ank spon, sacroiliitis
Ocular: episcleritis, uveitis
Derm: EN, PG
Hepatobiliary: cholelithiasis, fatty liver, pericholangitis, cholangiocarcinoma, pancreatitis
Vascular: thromboembolic dz
-malnutrition
-chronic anemia
-nephrolithiasis
23
Q

Crohn Dz: Tx

A

-4 classes: symptomatic agents, anti-inflammatories, Abx and immunomodulators

-sulfasalazine 3-5g/d for mild/mod crohn
SE: n/v/d, anorexia, arthralgias, h/a, male infertility
-5-ASA, pentasa, asacol

Symptomatic mgmt:

  • glucocorticoids (40-60mg OD)
  • loperamide for diarrhea

Immuno-suppressive:

  • azathioprine - helps heal fistulas (SE: leukopenia, fever, hepatitis, pancreatitis)
  • MTX

Abx:

  • cipro induces remission
  • flagyl goo for perianal dz and fistulas
  • rifaximin

Biologics:

  • infliximab (remicade)
  • humira (adalimumab)(more effective than remicade)
24
Q

Crohn’s complications:

A
  • abscess - think of retroperitoneal abscess in a pt with IBD and hip or back pain and difficulty ambulating
  • fissure
  • fistula - suspect if change in BM frequency, pain, wt loss
  • obstruction - due to edema and also due to stricture formation, distal small bowel most common
  • toxic megacolon - can be assoc with massive bleeding
  • malnutrition
  • malignancy (3x higher than general popn)
25
Q

Crohn’s dispo

A
  • hospitalize if fulminant colitis, peritonitis, obstruction , hemorrhage , severe dehydration, fluid/lyte imbalance
  • surgery for obstruction, hemorrhage, perforation, abscess, fistula, toxic megacolon, perianal dz
26
Q

Ulcerative colitis: pathology

A
  • more severe distally, rectum nearly always involved
  • involves mucosa and submucosa
  • micro: crypt abscesses, epithelial necrosis, mucosal ulceration
27
Q

UC: clinical picture

A

-mild:

28
Q

UC: dx

A
  • leukocytosis
  • anemia
  • thrombocytosis
  • decreased serum albumin
  • abnormal liver functions studies
  • abdo CT
  • antineutrophil cytoplasmic antibody
  • anti-saccharomycis cerevisiae antibodies
  • in the ED the dx is clinical: cramps, diarrhea, mucoid stool, negative O+P and c+s, confirmed with colonoscopy
29
Q

UC: DDx

A

-infxs colitis, crohn, ischemic colitis, radiation colitis, toxic colitis, pseudomembranous colitis

30
Q

UC: ED Tx (same as for crohn)

A
  • restore fluid and lytes
  • NPO
  • NG for obstruction, ileus, suspected toxic mega.
  • parenteral narcotics for pain
  • Abx (cipro and flagyl)
  • look for complications (obstruction, perf, TM, hemorrhage, abscess, fistula)
31
Q

UC; maintenance tx

A
  • mesalamine suppositories or enemas
  • topical steroids or glucocorticoids (induce remission)
  • pentasa, asa
  • glucocorticoids plus immunomodulators for refractory cases (infliximab only)
  • antidiarrheals not used and may precipitate toxic mega.
32
Q

UC: complications

A
  • hemorrhage

- TM: occurs in more advanced UC

Tintinalli Section 9 - Gastrointestinal Emergencies (17 decks)

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