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Lecture 2 Infections Gi Tract (2)
 

Lecture 2 Infections Gi Tract (2)

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    Lecture 2 Infections Gi Tract (2) Lecture 2 Infections Gi Tract (2) Presentation Transcript

    • Gastroenteritis, Infections of the GI Tract, and Diarrhea
    • Gastroenteritis
      • Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract.
      • The primary manifestation is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain.
      • A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation.
        • Although most definitions center on the frequency, consistency, and water content of stools
    • Gastroenteritis
      • Defined as- Inflammation of the mucous membrane of both the stomach and intestine, usually causing nausea, vomiting, and diarrhea.
      • Acute gastroenteritis usually causes profuse watery diarrhea, often c nausea and vomiting, but without localized findings.
      • Between cramps, the abdomen is completely relaxed.
    • Cause of Gastroenteritis
      • Infectious agents usually cause acute gastroenteritis.
      • These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production.
      • These mechanisms result in increased fluid secretion and/or decreased absorption.
      • This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients.
    • Infantile Gastroenteritis-
      • An endemic viral infection of young children
        • (6 mo-12 yrs)
      • is especially widespread during winter,
      • caused by strains of rotavirus ;
      • the incubation period is 2-4 days,
      • with symptoms lasting 3-5 days,
      • including abd. pain, diarrhea, fever, and vomiting.
      • Tx = Fluids (PO vs. IV)
    • Epidemic Gastroenteritis-
      • An epidemic, highly communicable but rather mild disease of sudden onset,
      • caused by the epidemic gastroenteritis virus (especially Norwalk agent),
      • with an incubation period of 16-48 hrs
      • and a duration of 1-2 days,
      • affects all age groups;
      • infection is associated with some fever, abd. cramps, nausea, vomiting, diarrhea, and headache,
    • Causes of Vomiting and Diarrhea
      • GASTROENTERITIS MNEUMONIC
      • G astrointestinal- Obstruction, Dymotility, Inflammation, Malabsorption, Lactose Intolerance, GI bleeding
      • A ppendicitis or aorta
      • S pecific diseases- Glaucoma, Torsion (ovary/testicle)
      • T rauma
      • R x (prescription)-medication side effects
      • O bstetrics and Gynecology-pregnancy, preeclampsia, Hyperemesis gravidarum
      • E ndocrine or metabolic-thyrotoxicosis, DKA, Adrenal insufficiency
      • N eurologic-Vestibular, Migraine, encephalopathy, Hydrocephalus, Increased ICP (neoplasms, subdural, epidural, or subarrachnoid hemorrhage, cerebral edema)
      • T oxicology
      • E nvironmental-Food poisoning, envenomation, high altitude, acute radiation
      • R enal-Obstructive uropathy, renal colic
      • I nfection- gastroenteritis (viral, bacterial, parasitic), pyelonephritis, pneumonia (pertussis, Legionella), PID, Meningitis, Hepatitis, colitis, HIV
      • T umors-gastrinoma, thyroid ca, villous adenoma
      • I schemia- MI, Mesenteric ischemia, ischemia colitis
      • S upratentorial- Bulemia, psychosocial stress
    • Gastroenteritis
      • Causes:
        • Viral 50-70%
          • Norwalk virus
          • Caliciviruses
          • Rotavirus
          • Adenovirus
          • Parvovirus
          • Astrovirus
        • Bacterial 15-20%
          • Salmonella, Shigella, and Campylobacter species are the top 3 leading causes of bacterial diarrhea worldwide, followed closely by Aeromonas species
        • Parasitic 10-15%
        • Others
    • Gastroenteritis
      • Acute symptoms may follow a wide variety of infectious & chemical agents
      • Ingestion may occur as a result of person to person contact, more commonly via water or food
      • The majority of food borne illnesses are caused by staphylococcus aureus from contaminated food being allowed to stand, producing endotoxins.
      • Salmonella & Clostridium follow staph poisoning as most common. They are found in meats.
    • Gastroenteritis
      • Invasive Infection : The organism enters the mucosal cells, destroys them, causing diarrhea usually with blood in the stool.
      • Enterotoxic syndromes: The organisms do not invade the mucosa, but produce enterotoxins of which act as chemical mediators causing hypersecretion of the fluid. Little damage to the tissue is done.
    • Gastroenteritis Key Symptoms
      • Viral
        • Abdominal cramps (#1)
        • Vomiting
        • Profuse watery stools
        • Myalgias
        • Fever
        • Headaches
        • Arthralgias
      • Bacterial Dysentery
        • Small volume stools
        • Fever
        • Tenesmus
        • Bloody mucoid stools
        • Suprapubic pain relieved by BM
    • Gastroenteritis (cont.)
      • Historical Information
        • History of suspicious food eaten within the last 48 hrs, eating an unusual food (special fish) in a restaurant, or preparing food in an unconventional container (copper). Or a hx of similar illness in others who ate with the patient.
    • Gastroenteritis (cont.)
      • Physical Exam Findings
        • Minimally helpful
        • Abdominal tenderness
        • Diarrhea causing dehydration
        • Fever- usually indicates organism invasion
        • Hypotension- usually indicates dehydration and electrolyte imbalance
        • Rectal Exam- “to bleed or not to bleed”
    • Gastroenteritis (cont.)
      • Laboratory:
        • Stool Culture
        • Hemoccult of stool
        • Fecal leukocytes
        • CBC; If WBC count is elevated increased likelyhood of bacterial infection.
          • (If eosinophils present r/o parasitic infection).
        • If C. Difficile is suspected request cytotoxin of stool
      • Treatment:
        • With the exception of Giardiasis, amebiasis, C. difficile, salmonellosis, & shigellosis, practically all only need fluid replacement, glucose, and electrolyte control (IV NS, pedialyte)
    • Gastroenteritis (cont.)
      • Incubation period
        • Chemical poisons : onset immediate after ingestion of food like Ciguatera or scromboid (scrombotoxin found in fish)
        • Staphylococcal food poisoning : onset within hrs after eating contaminated food
        • Salmonella & Shigella infection : onset usually within 24-48 hrs (bacillary dysentery)
        • Giardiasis infection : onset of symptoms after one week with recurrent diarrhea.
    • Gastroenteritis (cont.)
      • Incubation period (cont.)
        • Clostridium difficile: Antimicrobial use within the last 2 weeks
        • Botulism : Associated Neurological symptoms after eating canned food. Symptoms within 24 hrs.
        • A h/o homosexuality : r/o AIDS, Shigella, Campylobacter jejuni, Salmonella, protozoalike Entamoeba, cryptosproidia, candida, giardiasis, and many others
    • Gastrointestinal Infectious Disorders
      • Viral
      • Staphlococcal
      • Cholera
      • Shigellosis
      • Salmonella
      • Hemorrhagic Colitis (E. coli O157:H7)
      • Pseudomembranous Colitis (C. difficile)
      • Enterotoxigenic E. coli
    • Viral Gastroenteritis
      • N/V/D/ abd cramps
      • Norwalk -
        • common year-round
        • This is the leading cause of viral gastroenteritis in the United States
      • Caliciviruses
        • Various caliciviruses, other than Norwalk virus, are likely responsible for many outbreaks of previously unidentified viral gastroenteritis.
      • Rotavirus
        • This is the leading cause of gastroenteritis in children (> in winter), but can also be found in adults. Rotavirus may cause severe dehydration.
      • Others
        • Enterovirus, Coxsackie virus A1, echovirus, adenovirus
      • Often occur in epidemic fashion in closed environments (eg, cruise ships, schools)
      • Viral cultures rarely indicated; ELISA and PCR assays
      • Fecal Leukocytes absent
      • Self limiting; although, hospitalization and rehydration may be needed in severe cases
    • Staphylococcal Gastroenteritis
      • From foods left @ room temperature, particularly milk, cream products, and some meat and fish.
      • Within 8 hrs p eating, N/V/D/F/HA, cramps
      • Completely recovering p 24 hrs
      • h/o similar illness in others eating same food.
      • Fecal leukocytes are usually absent.
      • Laboratory studies to distinguish b/t this and viral do not change management and are usually not done.
      • Tx: fluids and electrolyte maintenance
    • Cholera
      • Vibrio Cholerae
      • Secretory Diarrhea
      • Spread by fecal contamination of water, seafood, and other products.
      • Endemic in Gulf Coast of US, Asia, Africa, Middle East.
      • Epidemics, contaminated water supplies effects all in all seasons
      • “ Rice-Water” stools, painless, non-bloody diarrhea
      • Severe Dehydration=thirst, oliguria, anuria, cramps, weakness, decrease turgor
      • Circulatory collapse= cyanosis, stupor, renal tubular necrosis, death
      • Metabolic Acidosis may be severe b/c of lost bicarbinate
      • Dx: stool cx,
        • Fecal Leukocytes (WBC’s) absent
      • Tx: Maintain fluid and electrolyte balance.
        • Tetracycline or doxycycline reduces duration of symptoms
    • Shigellosis
      • Shigella
      • Dysentery (bloody diarrhea)
      • Only need to ingest small inoculum
      • Fecal-Oral spread, and contaminated foods, also flies act as mechanical vectors
      • Epidemics occur c overcrowding and insufficient sanitation, and reinfection possible.
      • Young children- acute onset of sx: f/n/v/d/abd pain/distention
      • Within 3 days diarrhea becomes severe and bloody, often with pus, and mucus.
      • Dehydration can cause death; otherwise acute ds. resolves within several days. (Adults have milders sx)
      • Dx: stool cx, proctoscopy,
        • Fecal Leukocytes (WBC’s) PRESENT
      • Tx:
        • Fluid replacement is critical
        • Bactrim or Cipro can shorten course of severe ds
        • DO NOT GIVE ANTI-DIARRHEALS, may prolong course
    • Salmonella
      • 3 types
        • 1. Gastroenteritis is most common form of Salmonellosis
        • 2. Enteric Fever- Typhoid Fever
        • 3. Bacteremia
      • Eating foods produced from infected animals; meat, milk, poultry, eggs, and drinking contaminated water; and from fecal-oral trans.
      • Incubation period 8-48 hrs
      • Asymptomatic or symptoms develop within 2 days of eating infected food.
        • N/cramps/watery or bloody diarrhea/fever/ and sometimes vomiting
        • lasting 1-4 days
      • Dx: stool cx, Presence of fecal WBC’s variable
      • Tx:
        • supportive (IV hydration)
        • Antibiotics usually not necessary for Salmonella gastroenteritis (Bactrim, Amp, or Cipro indicated in pt’s c increased risk of mortality, Typhoid fever, or Bacteremia)
    • Hemorrhagic Colitis
      • Escherichia coli O157:H7
      • Produces a toxin that damages GI mucosa and vascular endothelial cells (vessels), other organs, particularly the kidneys.
      • Organism has bovine reservoir: unpasteurized milk and undercooked beef; Fecal-oral transmission also possible
      • S/S: Acute, severe abd cramps and watery diarrhea progresses to bloody diarrhea; low grade fever, uncomplicated lasts ~1wk; but complicated cases=high fever, hemolytic uremic syndrome (HUS) or thrombocytopenic purpura (TTP)
      • Dx: Stool cx; fecal leuks usually absent
      • Tx: Supportive (IV hydration), Abx do not help ; complications require aggressive management
    • Pseudomembranous Colitis
      • Clostridium difficile
      • Caused by antibiotic therapy which changes balance of normal intestinal flora, causing overgrowth of pathogen (most common causes clindamycin, ampicillin, and cephalosporins, although any can be cause)
      • Hospitalized pt’s on Abx at greatest risk
        • Usually within 2 wks after starting Abx, but may be as long as 6 wks after.
      • Illness often mild, but severe bloody diarrhea with abd cramps, fever, and dehydration may occur.
      • Dx: C. difficile toxin in stool is diagnostic; stool cx or sigmoidoscopy with visualization of pseudomembranes
      • Tx: D/C Abx if possible , may be sufficient
        • Metronidazole or PO vancomycin in more severe cases
    • Traveler’s Diarrhea
      • Most commonly caused by bacteria (80%), Enterotoxigenic E. coli, Shigella, Campylobacter jejuni being the most common pathogens.
      • Chronic watery diarrhea
      • Up to 10 or more loose stools per day, usually without blood or mucus.
      • Fever is rare
      • Self limiting within 1-5 days
      • Dx: stool cx for pt’s c f/dysentery, and those that don’t respond to abx
      • Tx: mostly symptomatic therapy (IV hydration)
        • If high fever, or dysentery tx c Cipro (not antidiarrheals)
      • Prevention: Prophylaxis is recommended for those with significant underlying ds.
        • Cipro
        • Pepto-bismol is effective, but may interfere with the absorption of other medications (tetracycline/doxycycline) used for malaria prophylaxis, and it also carries the same toxicity as other salicylates (Reyes Syndrome) and turns the tongue and stool black, so it is rarely used.
    • General Bacterial Overgrowth Treatment
      • Usually self limiting
      • IV hydration
      • Correct the anatomic defect when possible.
      • Empiric antibiotic trial can be used as a diagnostic and therapeutic maneuver.
      • Ciprofloxacin (or combo c Metronidazole)
        • (However often not necessary, unless dysenteric)
    • Protozoal Infection
    • Protozoal infection signs/symptoms
      • Abdominal pain
      • Wheezing or hemoptysis due to pulmonary migration of larva (lofflers syndrome)
      • Dermatitis
      • Diarrhea
      • Dysentery
      • Pruritis
      • Rectal Prolapse
      • Steatorrhea
      • Passage of parasites
      • Bowel obstruction (as found in taenia and ascarisis)
    • Protozoal Infections
      • History
        • Travel to underdeveloped areas
        • Outbreak of associated illness (Giardia, Trichinella)
        • Daycare exposure (Giardia)
        • Homosexual behavior (Giardia, Entamoebia)
        • Animal Exposure
        • Diet: uncooked foods
        • Immunocompromised
      • Physical Findings
        • Weight loss
        • Excessive gas or abdominal distention
        • Hyperperistalsis
        • Perianal infection
        • Wheezing
    • Protozoal Infections
      • Tests
        • Fecal smears (look for WBC’s, RBC’s, ova & parasites)
        • Stool Cultures
        • CBC: eosinophilia , iron deficiency
        • Graham’s Test: scotch tape test
      • Treatment
        • Donnagel
        • Kaopectate
        • Immodium
        • Bismuth Subsalicylate
        • Chemotherapeutic agents for each parasite
    • Pinworms
      • Etiology: Enterobius Vermicularis
      • Outbreaks common in schools
      • Transmission by fecal-oral ingestion
      • Key symptom is rectal pruritis
      • Nocturnal
      • Test is scotch tape test
      • Treatment: Vermox , Antiminth (one dose, then repeat in one week)
    • Giardia (Giardiasis)
      • Etiology: Giardia Lamblia
      • Transmitted: fecal-oral
      • Most common water borne infection
      • Symptoms:
        • Diarrhea
        • Abd. Pain & cramps
        • Flatus
        • Fatty, greasy, foul smelling stool (steatorrhea)
      • Test: Microscopic exam of stool for cysts (also the ELISA antigen test)
      • It is an upper GI parasite and stool examination can be negative
      • Treatment: Metronidazole (Flagyl)
    • Amebiasis
      • Etiology: Entamoeba hitolytica
      • Found in 4% of the population
      • Transmitted: fecal-oral
      • Found mostly in cecum & ascending colon, invading the mucosa. Can travel to liver, lung, brain
      • Symptoms:
        • Asymptomatic to diarrhea
        • Abd. Cramps
        • Flatus, fever, hepatitis
        • Shoulder pain due to hepatitis
    • Amebiasis (cont.)
      • Signs: range
        • No symptoms – no signs
        • Bloody diarrhea
        • Perianal ulcers
        • RUQ tenderness
        • Pulmonary (pneumonia- emphysema)
      • Test:
        • Examine stool for cyst –trophozoites
      • Treatment:
        • Metronidazole (Flagyl)
    • Ascariasis
      • Most common intestinal helminth
      • Etiology: Ascaris lumbricoides (the large intestine round worm)
      • Transmitted by contaminated food
        • Human feces as fertilizer
      • Pulmonary phase (Loffler’s syndrome)
      • Intestinal phase (eggs in stool)
      • Penetrate the intestine & invade liver, lung, heart
      • Tx: Albendazole and Pyrantel pamoate
    • Tapeworms
      • Cestodes (segmented worms)
      • Taenia solium
      • Adults live in GI tract, larvae can be found in almost any organ (neuro, muscle, eye) (cysticercosis )
      • Fish, beef, pork, dog , cats, fleas, snakes, birds, and other mammals can carry the tapeworm larva, humans can be the definitive host or the intermediate host
      • From 5mm to over 25 meters in length
    • Whipworm (Trichuriasis)
      • Humans are the only host for this whipworm and one of the most common parasitic infections in the U.S.
      • The worm lives in the cecum and appendix
      • One female produces several thousand eggs/day
      • Fecal-oral transm., uncooked veggies, & water
      • Symptoms: allergic rxns, anemia, vague GI complaints, diarrhea & abd. distention
      • Diagnosis: stool examination
      • Tx: Albendazole, Mebendazole
    • Diarrhea
    • Diarrhea
      • Diarrhea is both a symptom and a sign.
      • Symptom : Typically considered as an increased frequency or volume of stool (i.e., 3 or more liquid or semisolid stools daily for at least 2-3 consecutive days).
      • Sign : Diarrhea is formally defined as stool weight >200 g/24h.
    • Diarrhea
      • Causes of diarrhea
        • Psychogenic
        • Surgical
        • Endocrine
        • Carcinoid tumors
        • Mechanical
          • Neoplasm
          • Foreign body
        • Chemical
        • Bacterial
        • Parasitic
        • Saline Cathartics
        • Dietary
        • Allergic
        • Malabsorption
          • Tropical sprue
          • Celiac ds.
          • Whipple’s ds.
    • Diarrhea
      • Acute vs. Chronic
        • Acute Diarrhea
          • Present for less than 2 weeks & is usually due to:
            • Infectious agent (most common cause) (usually from fecal-oral)
            • Bacterial toxin
            • Drugs
          • Types of Acute Diarrhea
            • Non-inflammatory
            • Inflammatory
    • Acute Diarrhea
      • Non-inflammatory
        • Watery
        • Nonbloody
        • Abd. Cramps
        • Bloating
        • Nausea-vomiting
      • All of these suggest a small bowel enteritis that disrupts the normal absorption & secretory process of the small bowel
      • The diarrhea can be voluminous & cause electrolyte imbalance.
      • Inflammatory
        • Fever
        • Bloody diarrhea (dysentery)
      • This indicates colonic tissue damage caused by invasion of:
        • Bacteria (infectious process)
        • Toxins
      • These organisms that are different from the non-inflammatory organisms involve the colon & the diarrhea is smaller volume & associated with LLQ pain
        • Fecal Leukocytes (WBC’s) can be present
        • Pearl:Don’t give anti-diarrheals
    • Causes of acute diarrhea Non-inflammatory
      • Viral
        • Norwalk virus
        • Rotavirus
      • Protozoal
        • Giardia lamblia
        • Cryptosporidium
      • Bacterial
        • Preformed enterotoxin
          • Staphylococcus aureus
          • Bacillus cereus
          • Clostridium perfingens
      • Intra-intestinal enterotoxin production
        • E coli (enterotoxigenic)
        • Vibrio cholera
      • New Medication
        • Including Antibiotic use
          • C. difficile
            • severe cases causing pseudomembranous colitis
      • Laxative use
      • Fecal Impaction
      • Pancreatic Insufficiency
      • Malabsorption
    • Causes of acute diarrhea Inflammatory
      • Viral
        • Cytomegalovirus
      • Bacterial
        • Cytotoxin production
          • E coli (Enterohemorrhagic)
          • Vibrio parahaemolyticus
          • Clostridium difficile
        • Mucosal Invasion
          • Shigella
          • Salmonella sp.
          • Enteroinvasive E coli
          • Aeromonas
          • Yersinia enterocolitica
          • Plasmodium (Malaria)
        • Bacterial Proctitis
          • Chlamydia
          • N. gonorrhoeae
      • Protozoal
        • Entamoeba histolytica
      • Intestinal ischemia
      • Inflammatory bowel disease
      • Radiation Colitis
    • Diarrhea History
      • Onset
      • Duration
      • Severity (fever, bloody, abd. Pain)
      • Travel
      • Food ingestion
      • Exposure to sick contacts
      • Social
      • Medications
      • FH of Crohn’s ds. or UC
      • Diarrhea-constipation suggest IBS
      • Excessive flatus c diarrhea indicates CHO diarrhea which ceases c fasting
      • Nocturnal diarrhea indicates autonomic neuropathy or anal sphincter ds.
      • Large volumes indicate sm. Bowel
      • Small volumes are usually left colon c tensmus
      • Associated c arthritis consider Whipples or IBD
    • Physical Examination
      • Appearance and mental status
      • Mucous membranes and skin turgor
      • BP (hypotension)
      • Scars
      • Abdominal Exam
        • Peritoneal signs
        • Localized tenderness
        • Masses
        • Bruits-carcinoids &/or renal artery stenosis
        • Rectal exam is needed
          • Sphincter tone- Neurogenic ->DM
          • Blood on stool & appearance
    • Diagnostic Studies for Acute Diarrhea
      • Stool exam for blood or WBC’s
        • In any patient with fever, abd pain, tenesmus, dehydration, & diarrhea >3 days
      • Stool culture
        • On all those with WBC’s and blood, mucous in stool with fever, abd pain (rectal swab if no stool present)
      • Stool for Ova & Parasites
        • For severe or persistent diarrhea (if + do HIV test)
      • Blood test
        • CBC c eosinophil count, Electrolytes, calcium, glucose, blood cultures for high fevers, HIV, Vit B12 depending on symptoms and character of diarrhea
      • ELISA
        • For Giardi lamblia (ameba titers), E. coli, C. Difficile (as a cause of pseudomembranous colitis) if from day care center, or loosing weight, traveling, HIV for immunosuppresed.
    • Management issues
      • Watch for dehydration and check for electrolyte disturbances (metabolic acidosis, hypokalemia), a common and preventable cause of death in underdeveloped areas.
      • Do a rectal exam, check for occult blood in stool, and examine stool for bacteria, ova and parasites, fat content (steatorrhea), and WBC’s
      • If the cause is not obvious, a trial of NPO status is helpful to see if the diarrhea stops.
      • If the pt has a h/o antibiotic usage c in 2 wks think Clostridium difficile and test the stool for toxin. If the test is positive, treat with metronidazole (or vancomycin).
      • Remember DM (diabetic diarrhea), factitious diarrhea (secret laxative abuse), hyperthyroidism, and colorectal cancer as causes of diarrhea.
    • Treatment
      • Supportive therapy is sufficient for most patients with viral or bacterial diarrhea
      • Antibiotics may be indicated for patients with severe diarrhea and systemic symptoms (e.g., Shigella, Campylobacter, severe cases of C. difficile ).
      • Treatment of the underlying cause is required for noninfectious diarrhea.
    • Treatment for acute diarrhea
      • 1. Nonspecific Antidiarrheals
        • These are overused
        • Unnecessary in most cases of diarrhea
        • In chronic diarrhea they are not a substitute for treatment of the underlying pathology.
        • Examples-
          • Paregoric
          • Loperamide (Imodium )
          • Diphenoxylate (Lomotil ) has some atropine also
        • ** These agents may cause Toxic Megacolon with patients that have invasive infections
    • Treatment for acute diarrhea (cont.)
      • 2. Bulk forming agents
      • 3. Absorbents:
        • Kaopectate after each BM
        • Aluminum Hydroxide
      • 4. Opiod Agents: should be used cautiously in patients with asthma, COPD, prostatic hypertophy, and acute angle closure glaucoma.
        • Paregoric (tinc of opium) (after each BM)
        • Codeine
        • Diphenoxylate (a meperidine conger) Contraindicated in liver ds.
        • **Do not use if there is fever, bloody diarrhea, or any evidence of toxicity!!**
    • Treatment for acute diarrhea
      • 5. Antisecretory agents:
        • Bismuth Subsalicylate (Pepto-Bismol)
      • 6. Anticholinergics: (offer no value)
      • 7. Antimicrobial agents:
        • **Do stool cultures first
        • Ova and Parasite studies
      • 8. Somatostatin: used in severe diarrhea which is refractory to any therapy. Used in carcinoid syndrome or VIPomas. (IV or SC.)
    • Treatment for acute diarrhea
      • 9. Special Therapies:
        • Clonidine is used for withdrawal of diarrhea in patient on opiates (usually used for HTN)
        • Indocin is used for patients with radiation enteritis (a prostaglandin inhibitor)
        • Traveler’s Diarrhea (all started one week prior or 2 days post travel)
          • Pepto-Bismol
          • Tetracycline/ Doxycycline
          • Bactrim
    • Chronic Diarrhea
      • Diarrhea >2-3 weeks, and usually progressively debilitating
      • The goal for chronic diarrhea is to make the dx quickly
      • 80% diagnosed by H&P
    • Mechanisms of Chronic Diarrhea
      • 1. Osmotic load : increase in amounts of poorly absorbable osmotic active solutes in the gut of the lumen.
        • Examples:
          • #1 Lactose intolerance
          • #2 Milk of magnesia
          • Infectious gastroenteritis
          • Lactulose
      • 2. Excessive secretion ( secretory ): increase CL & H2O w/o sodium resorption:
        • Examples:
          • Zollinger Ellison syndrome
          • Seratonins (carcinoid)
          • Staph toxin
    • Mechanisms of Chronic Diarrhea (cont.)
      • 3. Exudation of protein ( Inflammatory )
        • Idiopathic (Crohn’s ds.)
        • Infectious (Shigella, Salmonella, Campylobacter)
        • Ischemic
        • Vasculitis (blood & mucous in stool)
      • 4. Altered intestinal Motility (Irritable bowel syndrome)
    • Screening test for chronic diarrhea
      • Blood
        • CBC
        • Sedimentation rate
        • Albumin
        • Electrolytes
        • Prothrombin time (malabsorption)
        • Alkaline phosphatase
        • Serum Iron (Fe)
        • Folate & Vitamin B12 (c diarrhea and alt. Mental status)
        • Carotene
      • Stool
        • Appearance of stool
        • Occult blood test
        • Ova-Parasites
        • Stool fat
      • Proctoscopy with biopsy
    • Treatment for chronic diarrhea
      • Paregoric
      • Imodium
      • Lobitol
      • Metamucil
      • Kaopectate
      • Amphigel
      • **Note in infectious diarrhea  slowing motility can cause Toxic Megacolon  death from necrosis of bowel.
    • Diarrhea Types
      • Secretory
        • Bowel secretes fluid b/c of bacterial toxins
        • Large volume watery stools
          • Danger of dehydration
        • Persists with fasting
        • Cholera
        • Some strains of E coli
        • Ileal resection (bile acids)
        • Carcinoid
        • VIP secreting tumors (pancreatic islet cell tumor)
      • Osmotic
        • Non absorbable solutes remain in the bowel, where they retain water
        • Bulky, greasy stools
        • Improves with fasting
        • Lactase deficiency
        • Pancreatic insufficiency
        • Short bowel syndrome
      • Inflammatory
        • Frequent but small stools
        • Blood and/or pus
        • Inflammatory bowel ds
        • Irradiation
        • Shigella, amebiasis
      • Dysmotility
        • Diarrhea alternating with constipation
        • Irritable bowel syndrome
        • Diabetes mellitus
    • Chronic Diarrhea Classification
      • Inflammatory - Inflammatory bowel ds., radiation colitis
      • Systemic - any illness can cause diarrhea as a systemic symptom (hyperthyroid, zollinger-ellison, flu)
      • Osmotic - nonabsorbable solutes remain in the bowel, where they retain water (e.g. lactose or other sugar intolerances). When the person stops eating the offending substances NPO, the diarrhea stops.
      • Secretory - bowel secretes fluid b/c of bacterial toxins (cholera, some strains of E coli), VIPoma (pancreatic islet cell tumor), or bile acids (p ileal resection). Diarrhea continues with NPO status.
      • Malabsoption - (e.g., celiac sprue, Crohn’s ds.) In pt’s c celiac sprue, look for dermatitis herpetiformis, and stop gluten in the diet. Diarrhea stops c NPO.
      • Exudative - inflammation in bowel mucosa causes seepage of fluid; classically from inflammatory bowel ds. or cancer
      • Altered Intestinal Motility- after bowel resection or medications that interfere with bowel function
      • Factitious - secret laxative abuse (often by medical personnel)
    • Chronic Diarrhea
      • Chronic diarrhea or recurrent diarrhea should be based on etiology & pathophysiology of the disease process.
      • When there is difficulty in making the diagnosis an empiric trial of diet restriction is necessary.
        • Lactose
        • Gluten (protein in breads)
        • Reduction of long chain fatty acids
      • Use of pancreatic enzymes
      • Metronidazole
      • When all else fails use opiates
    • Pearls/ Review
      • Antidiarrheals often unnecessary (opiods: loperamide) b/c they may actually prolong Salmonella or Shigella infection!
      • If chronic or patient very ill (fever, bloody diarrhea): get stool exam for WBC’s, O&P’s, stool cx, C. difficile toxin and LFT’s.
    • Pearls (cont.)
      • AID’s patients: diarrhea is often due to Cryptosporidium, Isospora or CMV
      • Diarrhea of any cause may lead to transient lactase deficiency (advise patient to avoid milk)
      • Bismuth subsalicylate (Pepto-Bismol) may prevent infection with enterotoxin producing E. coli. Great for travelers to exotic countries.
    • Pearls
      • Diarrhea in elderly patients can indicate an obstruction or fecal impaction.
      • Acute Diarrhea: Lg amts. of stool  Small bowel Sm amts. of stool  Lg bowel
      • Gastroenteritis symptoms  #1. abd. pain #2. diameter
      • Celiac sprue  Gluten sensative enteropathy  proximal small bowel
    • Pearls
      • In >90% of cases, acute diarrhea is mild and self-limiting, and diagnostic investigation is unnecessary.
      • Prompt sigmoidoscopy for severe proctitis (tenesmus, discharge, rectal pain) or suspected C. difficile colitis, ulcerative colitis, or ischemic colitis
      • When traveling 4 “P’s”, Pepto-bismol, and eat only peeled, packaged, and piping hot foods.
    • Review
      • Infectious: noninflammatory (nonbloody)
      • Viruses: Norwalk virus, rotavirus, adenoviruses, astrovirus, coronavirus
      • Preformed toxin (food poisoning): Staphylococcus aureus , Bacillus cereus , Clostridium perfringens
      • Toxin production: enterotoxigenic E. coli , Vibrio cholerae , Vibrio parahaemolyticus
      • Protozoa: Giardia lamblia , Cryptosporidium , Cyclospora , Isospora
    • Review
      • Infectious: invasive or inflammatory
      • Shigella , Salmonella , Campylobacter , enteroinvasive E. coli , E. coli O157:H7, Yersinia enterocolitica , Clostridium difficile (e.g., pseudomembranous colitis), Entamoeba histolytica , Neisseria gonorrhoeae , Listeria monocytogenes
    • Pearl
      • Bloody Diarrhea DDx
      • Shigella ,
      • Salmonella ,
      • Campylobacter ,
      • enteroinvasive E. coli , ( E. coli O157:H7),
      • Yersinia enterocolitica ,