diarrhea-KP

Some Causes of Osmotic Diarrhea
• Carbohydrate malab
– – – – gluc-galact malab fructose malab disaccaridase def ingestion (poorly absorbable carbs)
• • • • lactulose sorbitol fructose fiber
– coffee, tea, cola, ETOH
• Endogenous laxatives
– bile acids, LCFA
• Bacterial Toxins
– S.aureus, C.perf +bot, B.cereus
• Hormone producing tumors
Deranged Motility
• Magnesium-Induced
– Nutritional supplemts – antacids – laxatives
• GI Lavage solutions • Laxative
– sodium citrate – sodium phophate – sodium sulfate
Secretory Diarrhea
Approach to Patients with Diarrhea
• Physical Exam
– – – – – – Presence of rashes or flushing mouth ulcers thyroid masses wheezing arthritis anal rectal examination
– infectious – noninfectious
• drugs, fecal impaction, elixir diarrhea, enteral feedings, chemotherapy or radiation therapy, runner’s diarrhea
Who Needs Evaluation?
Algorithm for Acute Diarrhea
Infectious Assess severity, duration immocompetence of host Noninfectious Eval and Rx of underlying cause
• • • • • High fever (>102F) orthostatic symptoms or presyncope bloody diarrhea severe abdominal pain immunocompromised persons
Diagnostic Tests for Acute Diarrhea
– not effective
Antibiotics in Acute Diarrheas
• Recommended
– – – – Shigellosis Cholera Traveler’s diarrhea Pseudomembranous enterocolitis – parasites – STDs
– safe and efficacious – antidiarrheal effects, antibacterial, antiinflammatory
• Loperamide
– safe in traveler’s diarrhea
• Kaolin-pectin, opiates, anticholingerics
Approach to Patients with Diarrhea
• History
– Characteristics of the onset of diarrhea should be precisely noted (congenital, abrupt, gradual) – Pattern of diarrhea should be recorded (continuous or intermittent) – Duration of the symptoms – Epidemiological factors (travel, exposure to contaminated food or water, illness in other contacts)
History
– Iatrogenic causes (medication history, surgical history, radiation history) – Factitious diarrhea (history of eating disorders, secondary gain and malingering) – Careful ROS (hyperthyroidism, diabetes mellitus, CVD, AIDS, etc)
Diarrhea
Definition
• Increased liquidity, frequency or decreased consistency of stools
Mechanisms
• • • • Osmotic Diarrhea Secretory Diarrhea Deranged Motility Exudation
• Spot Stool Sample
– Culture, Ova and Parasite, C.diff toxin, fecal leukocytes
• Blood Tests
– CBC, electrolytes, SMA 7, blood culture
• Plain X-rays • Endoscopy
Secretory Diarrhea
• Diarrhea persist during a fast • stool Na, K and the accompany anions account for the stool osmolality (small osmotic gap)
Some Causes of Secretory Diarrhea
– flex sig
Treatment for Acute Diarrhea
• Symptomatic
– fluid replacement
• Oral replacemet solutions or IV fluids
– antidiarrheals – Bismuth subsalicylate
• Laxatives
– Phenolophthalein, aloe
• Congenital • Bacterial entertoxins
– V. cholera, C.diff, Y.enterocol, toxigenic E. coli
• Medications
– diuretics
• Toxins
Erythema Nodosum
Acute Diarrhea
• Less than 2-3 weeks duration • Majority of cases are mild and self limiting • 4 million deaths world-wide per year in children under 5 years • Categories
Exudation
• Results from disruption of the intestinal mucosa from inflammation or ulceration • blood, mucus and serum proteins in gut lumen
– bacillary dysnentery – Inflammatory bowel disease
History
– Stool characteristics should be investigated (watery, bloody, fatty) – Presence of fecal incontinence – Presence of abdominal pain – Presence of weight loss – Aggravating factors (diet or stress) – Mitigating factors (alteration of diet, OTC meds) – Previous evaluations
Infectious Nosocomial Diarrheas
• Usually from C.difficile • Salmonella, Shigella, 0+P extremely rare if diarrhea develops after 3-4 days in hospital • In the immunosuppressed, viral infections are an important cause
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• Not Recommended
– E.coli 0157:H7
Antibiotics
• First Line
– Ciprofloxacin - effective against most enteric infections – Metronidazole - if symptoms suggest Giardia
• Enhanced Motility (Intestinal Hurry) decrease contact time of the stool to the absorptive surface • Abnormally slow motility may results in bacterial overgrowth and resultant diarrhea