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Revision Cards > Week 101 - Diarrhoea > Flashcards

Week 101 - Diarrhoea Flashcards

1
Q

What is considered a slow capillary refill time?

A

> 2seconds

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2
Q

What are the signs of moderate dehydration?

A
  • Irritability

* Thirst

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3
Q

What are the signs of severe dehydration?

A
  • Lethargy

* Unable to drink

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4
Q

What is the definition of diarrhoea?

A

3 or more loose/watery stools within 24 hours.

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5
Q

What are the four causes of diarrhoea?

A

1) Infective
2) Inflammatory
3) Steatorrhoea
4) Functional

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6
Q

What is infective diarrhoea?

A

This is diarrhoea caused by an infective agent. It typically has sudden onset and comes with associated fever and cramp-like abdominal pain.

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7
Q

What is Inflammatory diarrhoea?

A

This is diarrhoea caused by an inflammatory condition such as IBD. Often occurs with a blood stained stool.

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8
Q

What is steatorrhoea?

A

This is pale, offensive floating stool. It often coincides with weight loss and appetite loss.
• Giardiasis and Coeliac disease.

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9
Q

What is functional diarrhoea?

A

Small volume and often semi-formed.

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10
Q

What are the two main mechanisms of diarrhoea?

A

Osmotic and Secretory

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11
Q

What is osmotic diarrhoea?

A
  • This is where there are large amounts of hypertonic substances in the lumen which may be due to substances that can’t be digested, general malabsorption.
  • Moderate volume
  • Stops on fasting
  • High osmolality of stool
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12
Q

What is secretory diarrhoea?

A
  • Active secretion of fluid and electrolytes from gut wall which may be due to irritants and hormones.
  • High volume
  • Continues on fasting (Still secreting)
  • Normal osmolality of stool
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13
Q

Which mechanism of diarrhoea is halted by fasting?

A

Osmotic

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14
Q

Which mechanism of diarrhoea produces high volume of stools?

A

Secretory

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15
Q

Which mechanism of diarrhoea produces stools with a high osmolality?

A

Osmotic

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16
Q

What are the initial investigations for diarrhoea?

A

Stool sample - Osmolality, microbiology, culture and sensitivity.

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17
Q

What investigation may be needed for persistent diarrhoea?

A

Sigmoidoscopy and rectal biopsy.

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18
Q

What is the initial stage of treatment for diarrhoea?

A

Assess fluid status and rehydrate if required.

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19
Q

Once fluid status is assessed and managed how should acute diarrhoea be managed?

A
  • Treat cause - Antibiotics/ stop drugs causing.
  • Treat diarrhoea - Loperamide - Opioid agonist, decreases motility and increase anal sphincter tone.
  • (Infective diarrhoea is often self-limiting so let it run it’s course)
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20
Q

101 Diarrhoea: What are the three steps of treatment for acute diarrhoea?

A

1) Replace fluids.
2) Address the underlying cause.
3) Stop Diarrhoea.

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21
Q

101 Diarrhoea: Describe (briefly) how oral rehydration solutions work?

A

They are composed of glucose and sodium, which get actively pumped into the cell, this causes water to follow and the glucose and sodium are then excreted.

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22
Q

101 Diarrhoea: What is the main drug used to stop acute diarrhoea? What class is it?

A

Loperamide, anti-motility drug.

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23
Q

101 Diarrhoea: What is the mechanism of Loperamide?

A

It is an opioid receptor agonist which causes decreased motility of the bowel and increases the tone of the anal sphincter.

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24
Q

101 Diarrhoea: What is the role of Racecadotril and what is it’s mechanism?

A

Treatment of acute diarrhoea. Inhibits enkephalinase, therefore prolonging the life of enkephalins, which are opioid receptor agonists, causing decreased motility of the bowel.

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25
Q

101 Diarrhoea: How long would you expect a skin pinch on a child abdomens to revert back to normal shape in a healthy child?

A

Immediate, 1s=slow, ≥2s = very slow.

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26
Q

101 Diarrhoea: In what part of the bowel does the majority of fluid resorption take place?

A

Jejenum

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27
Q

101 Diarrhoea: By which part of the bowel is the absorption of <95% of macronutrients completed by?

A

Distal jejenum

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28
Q

101 Diarrhoea: Which part of the bowel has specialised transport mechanisms for bile acids and Vitamin B12-IF?

A

Distal Ileum

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29
Q

101 Diarrhoea: What role does the colon play in nutrient absorption?

A

Carbohydrate digestion and absorption, enzymes produced by colonic bacteria break the carbohydrates into short-chain fatty acids which can then be absorbed.

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30
Q

101 Diarrhoea: Diseases affecting which part of the bowel will result in greater amount of diarrhoea?

A

Small intestine (predominantly jejunum) since this is responsible for water resorption. If the colon receives more than 4L water a day, then diarrhoea will result.

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31
Q

101 Diarrhoea: What is the osmotic gap?

A

This is the difference between the osmolality of the colon contents and bodily fluids.

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32
Q

101 Diarrhoea: What is the osmotic gap in secretory diarrhoea? What accounts for this difference?

A

Around 10 mOsm/kg, electrolyte resorption is lower so sodium, potassium and their counter-ions account for most of the osmotic gap.

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33
Q

101 Diarrhoea: What is the osmotic gap in osmotic diarrhoea? What accounts for the difference?

A

Mostly carbohydrates and magnesium ions.

34
Q

101 Diarrhoea: If the osmotic gap is greater than 50mOsm/kg, what is the likely cause?

A

An ingested substance that cannot be easily absorbed.

35
Q

101 Diarrhoea: What is the usual osmolality of plasma?

A

290mOsm/kg

36
Q

101 Diarrhoea: What is the WHO definition of diarrhoea?

A

Loose or watery stools (that take the form of the container they are in), ≥3 times in a 24 hour period.

37
Q

101 Diarrhoea: What is dysentery?

A

Small volume, bloody, mucoid stools and abdominal pain.

38
Q

101 Diarrhoea: What are the two main types of diarrhoea?

A

Secretory and Osmotic.

39
Q

101 Diarrhoea: What is the stool volume, and response to fasting of osmotic diarrhoea?

A

Moderately increased.

Stops in response to fasting.

40
Q

101 Diarrhoea: What is the stool volume, and response to fasting of secretory diarrhoea?

A

Very large.

No response to fasting.

41
Q

101 Diarrhoea: Aside from osmotic and secretory diarrhoea, what is the third type of diarrhoea?

A

Inflammatory

42
Q

101 Diarrhoea: What are the main causes of inflammatory diarrhoea?

A

Infection.
Food sensitivity.
Auto-immune disease.

43
Q

101 Diarrhoea: What is the common cause of increased intestinal fluid secretion? Give an example.

A

Infection.

Rotavirus, ETEC, Cholera.

44
Q

101 Diarrhoea: Give some causes and examples of diarrhoea caused by an osmotically active substance.

A
  • Malabsorption: CHO/protein - Lactose intolerance

* Rapid gut transit - IBS, Toddlers Diarrhoea, Stimulant laxative.

45
Q

101 Diarrhoea: Give some causes of steatorrhea and give examples.

A

• Malabsorption: Fat - Pancreatic disease, Coeliac Disease

46
Q

101 Diarrhoea: Give some causes and examples of inflammatory diarrhoea.

A
  • IBD - Crohns, UC
  • Dysentery - Shigella, campylobacter
  • Other - Radiation enteritis.
47
Q

101 Diarrhoea: What are the main consequences of secretory diarrhoea?

A
  • Fluid loss leading to dehydration.

* Electrolyte loss leading to disordered physiology.

48
Q

101 Diarrhoea: What are the consequences of osmotic dehydration?

A

• Loss of nutrients leading to malnutrition.

49
Q

101 Diarrhoea: A 28yr old woman, episodes of abdominal bloating and watery diarrhoea lasting 1-2 days for the last 6 months, no blood or mucus.

A

IBS (spastic colon/ functional diarrhoea).

50
Q

101 Diarrhoea: What is the treatment for IBS?

A

Reassurance, anti-spasmodics, anti-diarrhoeal medication.

51
Q

101 Diarrhoea: UK toddler, with watery diarrhoea more than 10x in 24hrs, some fever and vomitting, other children at playgroup have also been suffering. Likely diagnosis?

A

Rotavirus.

52
Q

101 Diarrhoea: What is rotavirus? What is the treatment?

A

RNA virus, with multiple mechanisms causing diarrhoea.

The virus is self-limiting within 4-5 days, so only oral rehydration is needed.

53
Q

101 Diarrhoea: 19 year old student just back from
India with Pale, foul-smelling, greasy stools that float +
difficult to flush. x 3-5/day for 3 weeks, May be “explosive”,
Lost a lot of weight – “two clothes sizes”,Feels generally unwell, nauseous and very tired. Likely diagnosis?

A

Giardiasis.

54
Q

101 Diarrhoea: What is giardiasis, how is it treated and diagnosed?

A

Caused by giardia parasite, that causes steatorrhoea.

It is diagnosed by microscopy of three stool samples.

Treated by metronidazole.

55
Q

101 Diarrhoea: A 40yr old lady has acute onset diarrhoea at a conference in bulgaria. She has had two-days of frequent and loose stools, has been unable to leave bathroom. Is very thirsty. Likely diagnosis?

A

Travellers Diarrhoea

56
Q

101 Diarrhoea: Which organism is the common cause of travellers diarrhoea? What is the treatment?

A

ETEC - Enterotoxigenic Escherichia coli.

Usually self-limiting, but severe.

57
Q

101 Diarrhoea: What is c-diff?

A
  • Gram positive bascillus.
  • Highly infectious - requires barrier nursing.
  • Wide spectrum - from self-limiting to severe colitis.
  • Treated with metronidazole / vancomycin +/- faecal enema.
58
Q

101 Diarrhoea: What are the signs of over-rehydration?

A
  • Increasing HR
  • Respiratory Distress
  • Crackles in lung fields
  • Hepatomegaly
  • Oedema
59
Q

101 Diarrhoea: How should fluid management differ in those with hypernatraemic shock?

A
  • Fluid replacement should be over a 48hr period not 24hrs.

* Also slowly replace serum Na+.

60
Q

101 Diarrhoea: What are the signs of SAM? (severe acute malnutrition)

A
  • Loss of subcutaneous fat and muscle wasting.
  • Angular stomatitis.
  • Smooth tongue.
  • Conjunctival and palmar pallor.
  • Hyper/hypo- pigmentation.
61
Q

101 Diarrhoea: What are the problems with assessing a child with diarrhoea, who also has SAM?

A
  • The clinical signs of shock and dehydration become unreliable.
  • If fluids are replaced parenterally it can cause severe deterioration.
  • In SAM the Na/K pump is broken resulting in a high body concentration of Na+.
62
Q

101 Diarrhoea: How should fluid management be performed in a patient with SAM (severe acute malnutrition)?

A
  • Oral fluids

* Reduced concentrations of Na+

63
Q

101 Diarrhoea: What are the red flags for dehydration to develop into shock? (There are six)

A
  • Appears to be unwell or deteriorating.
  • Altered responsiveness.
  • Sunken eyes.
  • Tachycardia.
  • Tachypnoea
  • Reduced skin turgor.
64
Q

101 Diarrhoea: What is dysentery?

A

• Small volume, bloody, mucoid stools, abdominal pain.

65
Q

101 Diarrhoea: What is the WHO definition of diarrhoea?

A

Three or more loose or watery stools in a 24-hour period.

66
Q

101 Diarrhoea: What is a type 1 and type 7 stool on the Bristol chart?

A
  • Type 1 - Rabbit Droppings

* Type 7 - Gravy

67
Q

101 Diarrhoea: What are the two main types of diarrhoea?

A

Osmotic and secretory

68
Q

101 Diarrhoea: Describe osmotic diarrhoea. (In terms of volume, response to fasting, osmolality and ion gap)

A
  • Moderately increased.
  • Diarrhoea will cease in response to fasting.
  • Osmolality is normal to increased.
  • Ion gap is ≥100 mOsm/kg
69
Q

101 Diarrhoea: Describe secretory diarrhoea. (In terms of volume, response to fasting, osmolality and ion gap)

A
  • Very large volume.
  • Diarrhoea continues despite fasting.
  • Osmolality is normal.
  • Ion gap is ≤100 mOsm/kg
70
Q

101 Diarrhoea: Inflammatory diarrhoea is the third main type (after secretory and osmotic), what are the main causes of it?

A
  • Infection
  • Auto-immune (IBD)
  • Food sensitivity (Coeliac, CMP)
71
Q

101 Diarrhoea: Give 3 examples of pathology that leads to infective diarrhoea.

A
  • Cholera
  • Rotavirus
  • ETEC
72
Q

101 Diarrhoea: How does Rotavirus typically present, how is it diagnosed, what is the management?

A
  • Typically a toddler with sudden onset watery, diarrhoea, no blood. - Comes in batches (Children at playgroup etc)
  • RNA virus diagnosed with stool virology.
  • Management is oral rehydration fluids (Self-limiting after 4-5 days)
73
Q

101 Diarrhoea: Gap student back from India with pale, foul-smelling, greasy stools that float. What is the diagnosis and management?

A
  • Giardiasis (A parasite that can infect your bowels and cause osmotic diarrhoea).
  • Diagnosis is through microscopy of 3 stool specimens.
  • Management is Tinidazole or metronidazole.
74
Q

101 Diarrhoea: What pathogen is responsible for traveller’s diarrhoea?

A
  • ETEC - Enterotoxigenic Escherichia coli

* Attaches the the mucosa and produces toxins, severe but usually self limiting.

75
Q

101 Diarrhoea: What is the management for Clostridium difficile?

A
  • Barrier nursing
  • Metronidazole/vancomycin
  • Faecal enema.
76
Q

101 Diarrhoea: What do oral rehydration solutions contain?

A
  • Water
  • Sodium Chloride 90mmol/L
  • Glucose 60mmol/L
  • Osmolality of 240 mOsm/L
77
Q

101 Diarrhoea: What should the dose of ORS be?

A

200ml after each loose motion.

78
Q

101 Diarrhoea: Which adverse drug reactions can cause diarrhoea?

A
  • Antibiotics - Altering gut flora and increasing gut motility.
  • NSAIDs - Irritation and inflammation of the gut.
  • Digoxin - Causes imbalance of ions in gut.
  • Orlistat - Fat in the gut.
  • Magnesium - Osmotic effect.
79
Q

101 Diarrhoea: What drug is used to stop diarrhoea? What is it’s mechanism of action?

A

Loperamide
• Opioid receptor agonist
• Decreases motility of gut and increases the tone of the anal sphincter leading to increased transit time.

80
Q

101 Diarrhoea: What is the dose of loperamide? What are the side effects?

A
  • 4mg initially, then 2mg further with each loose stool.

* Side-effects include abdominal cramps & bloating.

81
Q

101 Diarrhoea: One of the complications of loperamide is that it may cause constipation in some patients. Which medication may be used instead which has a reduced risk of causing constipation?

A
  • Racecadotril
  • Inhibits enkephalinase thereby prolonging the action of enkephalins.
  • This reduces hyper-secretion without affecting transit time.

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