diarrhea-2.ppt

7/27/2019 diarrhea-2.ppt

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HPI

Female pt. 46 ys old

C/O weakness and diarrhea for 6 days

Her usual BMs are EOD, that time she was

having 10 - 15 BMs/ day of fluid stool

Denied nausea or vomiting

Denied fever, skin rash, Bl or mucous or

other constitutional symptoms



HPI

She had history of recent travel to New York,

one week prior to developing symptoms

Pt had chicken salad lunch in a restaurant,

on that very day she started developing her

symptoms

No body else dinning with her ever had

such symptoms



PMH

Hypothyroidism ( following radio active I )

Hypercholesterolemia

Abnormal MRI of brain ( DD stroke vs MS )

Abdominal hystrectomy ( fibroid uterus )

C section x 2



Meds

Paxil 20mg po QD

ASA 81mg po QD

Synthroid 0.125mg po QD

Premarin 1.25mg po QD

Zocor 20mg po QDNo recent Abx use

NKDA (no known drug allergy)



Social Hx

Negative for alcohol or tobacco use

Lives with family

Works as an accountant



Family Hx

Negative for DM, CAD, HTN

No history of cancer

No history of colon polyps or ulcerative

colitis



Phys Exam

BP T RR PR

84/60 98.2 16 84

HEENT: Unremarkable

Neck: No lymphadenopathy or thyroid

enlargement

Heart: RRR, no murmurs or gallop detected

Lungs: CTAs



Phys Exam

Abdomen: Soft, mild diffuse tenderness

without organomegally. No abdominal skin

rash

Extrem: No E,C,C. +ve PP

Neuro: AAO, no focal deficits or CN palsies

Rectal: No masses, normal tone of anal

sphicter with Guiac - ve heme stools



Labs

Hgb Hct RBCs WBCs Plat

14.2 43 4.99 6.0 211

Na K Cl Co2 BUN Cr Gluc

133 3.0 100 24 13 0.6 111

Urinalysis: Unremarkable

T4 TSH

8.5 5.84



Course

Pt continued on IVFs with close monitoring

of I/Os and was given metamucil 2tsp TID

Stool cultures grew Gm - ve pathogens

Pt started on Ciprofloxacin 400mg IV Q 12hs

Subcultures grew salmonella sero group D

Flex sigmoidoscopy: Erythema and edema

of colon compatible with salmonella colitis

Abx D/Cd after one day, diarrhea resolved



Definitions

Increase in daily stool weight above 200gm

Increase in frequency, fluidity or amount

Differentiate from incontinence and IBS

Acute lasts less than 7 - 14 days

Chronic lasts more than 2 - 3 weeks



Acute Diarrhea

INFLAMMATORY

Fever & bloody with

Leukocytes, volume<1L/ 24 hr secondary to

colonic damage

Shigella, Salmonella,

Amebiasis, C.diff, E coli0157:H7 toxin,

Ischemia, UC, Crohn’s,

Cytomegalovirus

Non-INFLAMMATORY

Watery with N/V,

volume >1L/ 24hr secondary to small

intestine disease

Norwalk & Rota virus,

entrotoxins as Giardia,Staph aureus, Cholera,

E coli, Bile acid,

Laxatives, Malabsorpt



Evaluation

Most pt with acute diarrhea respond in 5-7

d for rehydration and antidiarrheal agents

Isolation rate of pathogen from stool < 3%

Stool leukocytes is inexpensive test to

differentiate inflammatory vs non-

inflammatory types

Sigmoidoscopy indicated for Proctitis,

C diff, UC, Ischemic colitis



Management

Inflammatory

Antidiarrheal agents are

avoided Moderate to severe

cases; start empiric

Abx: Ciprofloxacin,

TMP-SMA,

Erythromycin

Always treat: C diff,

Amebiasis, Enteric

fever, Shigella, STDs

Non-inflammatory

Rehydration is most

important Loperamide offers

relief, Anticholinergic

contraindicated for

megacolon

Always treat: Cholera,

Giardiasis, Traveler ’s

diarrhea



Salmonella food poisoning

Contaminated poultry especially egg yolk

Incubation : 8- 48 Hrs

Diarrhea, low temp. Bacteria grow on

surface with little invasion

No Abx unless immune compromised

Pt remains as carrier for up to 2 months



Enteric fever

Caused by Salmonella typhi, incubation 2 w

Fever, bradycardia, altered behavior,

constipation followed by diarrhea

2nd week: Rose spots on abdomen & thorax,

Spleenomegally and Lymphadenopathy

Rx: Chloramphenicol, Ciprofloxacin,

Ampicillin



Traveler’s diarrhea

E coli produces heat labile entrotoxin and

heat stable, causes 40 - 75%

Diarrhea lasts 3- 5 days

Other pathogens - Shigella, Salmonella,

Rotavirus, Giardia

Rx: Ciprofloxacin, TMP- SMA, Aztreonam



Chronic Diarrhea

Persists > 2 weeks

Do stool cultures, ova and parasites

Stool collection for 48 - 72 Hrs for weight ,

fat content, lytes and osmolality

Sigmoidoscopy for visualization of mucosa

and biopsy



Osmotic Diarrhea

Stool osmotic gap (Normally <50)

Measured - Estimated (Na + K) X 2

Stool volume decreases with fasting

Common causes

• Lactose intolerance

• Sorbitol

• Laxatives

• Antacids



Secretory Diarrhea

Increased intestinal secretion or

decreased absorption with > 1 L diarrhea

Little change with fasting

Endocrine diseases

VIPoma medullary carcinoma

carcinoid Zollinger- Ellison syndrome

Bile salts Villous adenoma



Inflammatory Diarrhea

Fever , hematochezia and abdominal pain

Causes

• Ulcerative colitis

• Crohn’s disease

• Microscopic colitis

• Radiation enteritis

• Malignancy



Malabsorption

Wt loss, anemia, vitamin deficiency with

fecal fat > 7 - 10 g/24 Hs

Causes

• Tropical sprue

• Whipple’s disease

• Pancreatitis

• Bacterial overgrowth

• ( vagotomy , diabetes )



Infections

Chronic infectious agents

• Giardia

• Entamoeba histolytica

• Cyclospora

AIDS related infctions

• Cytomegalovirus

• Cryptosporidium



Motility Disorders

Charachterised by systemic disease or

prior abdominal surgery

• Diabetes Mellitus

• Hyperthyroidism

• Irritable bowel syndrome

diarrhea-2.ppt

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