Acute
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Acute diarrhea
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?
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· < 14 days
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S/S
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· Diarrhea (watery / bloody) +/- Dehydration
· Signs of SEVERE condition:
· Bloody
· Tenderness
· Severe Pain
· Hypotension
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Dx
|
· H&P
· If recent use of Abx → C.diff
· methylene blue stool study ⊕ → inflammatory diarrhea
· 1˚ stool smear for fecal leukocytes
· C. difficile toxin
· stool culture
· ova and parasites
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Tx
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· Conservative
· oral rehydration salts
· IVF, if severe dehydration
· electrolyte replacement (Na+, K+)
· Pharmacologic (acute)
· antidiarrheal agents such as loperamide and bismuth salicylate
· most infectious causes are self-limited
· if severe diarrhea, consider IV antibiotics
· Depends on the cause:
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|
Bloody Diarrhea
|
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|
Blood
+ WBC
in stool
|
· Salmonella: poultry
· Campylobacter: most common cause, associated with GBS
· E. coli 0157:H7—hemolytic uremic syndrome (HUS)
· Shigella: second most common association with HUS
· Vibrio parahaemolyticus: shellfish and cruise ships
· Vibrio vulnificus: shellfish, history of liver disease, skin lesions
· Yersinia: high affinity for iron, hemochromatosis, blood transfusions
· Clostridium difficile: white and red cells in stool
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Dx
|
· best initial test is blood and/or fecal leukocytes
· Stool lactoferrin has greater sensitivity and specificity compared with stool leukocytes.
· The most accurate test is stool culture.
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Tx
|
depends on 👾
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Bacterial causes of Diarrhea
|
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Bacillus cereus
|
· Diarrhea, abdominal cramping
· Ingestion of preformed toxin in starchy foods such as rice
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Staph aureus
|
· Vomiting abdominal pain
· Diarrhea not typical but may occur
· Caused by preformed toxin With rapid onset of sx
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C.diff
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· Abdominal pain, watery diarrhea, possible fever
· Bloody stools UNUSUAL
· ABx exposure
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C.perfringens
|
· Brief illness With watery diarrhea, cramps & fever
· Associated with undercooked or unrefrigerated food
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Salmonella
|
· Watery diarrhea, fever, abdominal pain & vomiting
· Associated With undercooked foods. especially poultry & eggs
· Abx tx needed ONLY for severe disease or immunocompromised patients
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Vibrio vulnificus
|
· Vomiting, diarrhea & abdominal pain
· Associated with raw or undercooked shellfish
· Vibriovulnificus • May cause invasive, life-threatening disease in immunocompromised patients or those with liver disease
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E.coli
|
· Watery diarrhea, may be bloody if associated with enterohemorrhagic (Shiga-toxin producing) strain
· Associated with undercooked beef or foods contaminated with bovine feces
|
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Shigella
|
· Bloody diarrhea With fever & often bacteremia
· Associated w/ contaminated food or water, especially during travel outside the United States
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Campylobacter
|
· Abdominal pain, bloody diarrhea
· Highest incidence in children & young adults
· Associated with raw or undercooked meats
· Gullian barry syndrome
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Bloody diarrhea
|
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|
E.coli O157:H7
|
· Undercooked beef
· Complicated by HUS
|
Supportive
|
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Shigella
|
· Contaminated food or water;
· Outbreaks (daycare)
|
· Supportive
· Abx
|
|
Campylobacter
|
· raw or undercooked meat
· GBS
|
Supportive
|
|
C.Diff colitis
|
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RF
|
· Hospitalization
· Recent use of Abx
· PPI
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Path
|
· Disruption of intestinal flora → C.difficile overgrowth
· Exotoxins cause mucosal inflammation/injury
|
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S/S
|
· Watery diarrhea (most common)
· Fulminant colitis/toxic megacolon
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Dx
|
Stool PCR
|
|
Tx
|
metronidazole or vancomycin
|
|
Mild
|
Severe
|
Extra Severe
|
|
WBC <15k
|
WBC >15k
⤴️ Cr
⤵️ Albumin (<2.5)
|
Toxic megacolon
WBC >20
Lactate >2.2
|
|
Metronidazole
|
Vancomycin
if ⊕ ilieus → Add IV metronidazole
|
Surgery
|
|
Entamoeba histolytica
|
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|
RF
|
· Developing nations (travel/residence)
· Contaminated food/water
|
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S/S
|
· 90% of pt Asx
· Colitis (diarrhea, bloody stool with mucus, abdominal pain)
· Liver abscess (RUQ pain, fever)
· Complications – rupture to pleura/peritoneum
|
|
Dx
|
· Stool ova & parasites, stool antigen testing (colitis) of the liver
· E.histolytica serology (liver abscess)
· US: SINGLE CYST, Right lower lobe
|
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Tx
|
· Metronidazole & intraluminal antibiotic (eg, paromomycin)
|
|
Giardiasis
|
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|
RFs
|
· Exposure to contaminated food or water
· Fecal incontinence & crowding (eg, daycare, nursing homes)
|
|
Clx
|
Acute
· Loose, foul-smelling, fatty stools
· Abdominal cramps
· Flatulence
· Weight loss
Chronic
· Malabsorption (Lactose intolerance)
· Profound weight loss
· Vitamin deficiencies
|
|
Tx
|
Metronidazole
|
Chronic diarrhea
|
Path
|
Example
|
|
Pancreatic insufficiency
|
· Chronic pancreatitis d/t alchohol abuse,
· CF, or A.I pancreatitis
· Pancreatic cancer
|
|
Bile-salt
|
· Small bowel crohn’s
· Bacterial overgrowth
· PBC – PSC
· Surgical resection of ileum
|
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Impaired intestinal surface
|
· Celiac
· AIDS
· GIARDIASIS
|
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Other rare causes
|
· ZES
· Whipple
|
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Trace mineral deficiencies
|
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Copper
|
· Brittle hair
· Skin depigmentation
· Neurologic sx
· Sideroblastic anemia
|
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Iron
|
Microcytic Anemia
|
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Zinc
|
· Alopecia
· Pustular skin rash
· Hypogonadism
· Impaired taste
· Impaired wound healing
|
|
Chromium
|
Impaired glu control in DM
|
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Selenium
|
Thyroid dysfunction
|
Malabsorption
|
Celiac
|
|
|
features
|
· intolerance to gluten –> Ag + immune complexes –> t-cells aggregation –> loss of villi and proliferation of crypt cells
· DC-2/8 association
|
|
S/S
|
· diarrhea
· can lead to fat soluble vitamin deficiency
· iron-deficiency anemia
· failure to thrive
· growth retardation
· weight loss
· dermatitis herpitiformis
|
|
Dx
|
· 1˚ ABs –> Bx
· dx by bx: pathognomonic blunting of intestinal villi and flat mucosa with lymphocytic and plasma cell infiltration
· IgA Anti-tissue Transglutaminase Antibodies is the single best serologic test
|
|
Tx
|
· Avoid glutean
· Tx dermatitis herpitiformis w/ dapsone
|
|
📝
|
IgA def is common
|
|
Tropical Sprue
|
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|
features
|
Infxn
|
|
S/S
|
pt is caribean farmer
presents just like celiac
|
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Dx
|
Endo + Bx
|
|
Tx
|
TMP-SMX
|
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Lactose Intolerance
|
|
|
features
|
Age / Asians
|
|
S/S
|
Diarrhea, bloating, FFT?
|
|
Dx
|
Avoid Lactose –> they get better
|
|
Tx
|
Lactase
Special formula
|
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Whipple
|
|
|
features
|
Infxn
|
|
S/S
|
· Malabsorption
· Other stuff (Joint, brain, LN ⊕)
· Eyes,
· Arthritis
· Fever
· Dementia
|
|
Dx
|
Bx: organism / Mø
|
|
Tx
|
ABx:
· TMP-SMX
· Doxycycline
|
|
Specific Tx
|
|
|
Chronic pancreatitis
|
Enzyme replacement
|
|
Celiac disease
|
Avoid gluten-containing food
|
|
Whipple disease
|
Ceftriaxone, trimethoprim/sulfamethoxazole
|
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Tropical sprue
|
Trimethoprim/sulfamethoxazole, tetracycline
|
Fast HY Review 