case: acute infectious diarrhea

1. INTRODUCTION TO
CLINICAL MEDICINE
GROUP 1
Banzuela, Alvie Marie
Barba, Louie Andrew
Barce, Cathryn Marie
Battung, Andrea Rose
Bejer, Kaye Diane
Gaminde, Evander Turallo
Llanza, Christine Sarah
Vibar, Angelo Carlo

2. CASE 4
2
A 19-year-old woman is brought into the emergency department (ED)
complaining of abdominal pain and diarrhea of 3-day duration. She has
also been nauseous and has not been able to drink much liquid. Five days
ago she returned from a camping trip in New Mexico, but did not drink from
natural streams. She denies fever, but states that she has had some chills.
Her stools have been watery, brown, and profuse. The patient denies health
problems.

3. CHIEF COMPLAINT:
ABDOMINAL PAIN AND DIARRHEA
3

4. 1.
HISTORY OF
PRESENT ILLNESS

5. HPI
• Five days ago she returned from a camping trip
in New Mexico
• Then has the following complaints:
- Abdominal pain and diarrhea of 3-day
duration
- Tachycardic
- Hypotensive
- Watery, brown, and profuse stool
- Nausea
- Pale in appearance
- Dry mucous membranes
- Chills
- Leukocyte count of 16,000 cells/u/L
5

6. 2.
PAST MEDICAL
HISTORY

7. “
The patient has no known
illness.
7

8. 3.
REVIEW OF
SYSTEMS

9. 9
General (-) weight loss, (-) fatigue, (-) loss of appetite, (-) fever, (+) chills
Cutaneous (-) rashes, (-) pruritus, (-) skin changes
Respiratory (-) DOB, (-) cough, (-) wheezes, (-) crackles
Cardiovascular (-) chest pain, (+) tachycardia, (-) cyanosis, (-) murmur, (-) palpitation
Gastrointestinal (+) abdominal pain, (-) vomiting, (+) nausea, (+) diarrhea, (-) melena, (-) hematochezia
Genitourinary (-) dysuria, (-) hematuria, (-) frequency, (-) incontinence
Neurologic (-) seizure, (-) loss of consciousness, (-) convulsions
Musculoskeletal (-) joint pain, (-) swelling of joints, (-) stiffness
Endocrine (-) abnormal growth, (-) goiter
Hematologic (+) pallor on palms and soles, (-) easy fatigability

10. 4.
PHYSICAL
EXAMINATION

11. General survey: conscious, coherent, afebrile, thin, dry mucous membranes
Vital signs:
• BP: 90/60 mmHg
• HR: 110 bpm
• Temperature: 37.2 °C
Skin: Pale and warm. No jaundice. No visible skin lesions.
HEENT: Normocephalic
Chest/Lungs: SCE, clear breath sounds
Heart: Adynamic precordium, Tachycardic
Abdomen: abdominal pain with diffuse tenderness, (-) guarding, hyperactive
bowel sounds, (-) masses,
Rectal: (-) tenderness or masses
11

12. 5.
DIFFERENTIAL
DIAGNOSIS

13. 13
SALIENT FEATURES
 19-year-old healthy woman
 3-day history of abdominal pain, nausea, and non-bloody, watery,
profuse diarrhea.
 Five days ago, she was on a camping trip in New Mexico but did not drink
from natural streams.
 Dry mucous membranes
 Tachycardic
 Hypotension
 Hyperactive bowel sounds
 Diffuse mild tenderness without peritoneal signs
 Leukocyte count: 16,000 cells/μL
 Pregnancy test: Negative

14. 14
SALIENT FEATURES ACUTE INFECTIOUS
DIARRHEA
ACUTE
GASTROENTERITIS
CELIAC DISEASE INFLAMMATORY
BOWEL DISEASE
19 y/o + + + +
Female + + + +
Chills + - - -
Abdominal pain x 3 days + + + ( > 4 weeks) + (>4 weeks)
Nausea x 3days + - + +
Non-bloody stool + + - -
Watery stool for 3 days + + + ( > 4 weeks) + (>4 weeks)
Profuse diarrhea x 3 days + +/- +/- (> 4 weeks) +/- (>4 weeks)
With travel history to New Mexico + +/- - -
Dry mucous membranes + + +/- +/-
Tachycardic + + +/- +/-
Hypotension + + +/- +/-
Hyperactive bowel sounds + + +/- +/-
Diffuse mild tenderness without
peritoneal signs
+ + + +
Leukocyte count- 16,000 cells/uL + + + +
(-) pregnancy test + + + +

15. 6.
IMPRESSION

16. “
Acute Volume Depletion
and Moderate Dehydration
2o Acute Infectious
Diarrhea
16

17. 7.
ETIOLOGY OF THE
DISEASE

18. o When fluid loss is < 5% of ECF volume (mild volume depletion), the only
sign may be diminished skin turgor (best assessed at the upper torso).
o When ECF volume has diminished by 5 to 10% (moderate volume
depletion), orthostatic tachycardia, hypotension, or both are usually, but
not always, present. Also, orthostatic changes can occur in patients
without ECF volume depletion, particularly patients deconditioned or
bedridden. Skin turgor may decrease further.
o When fluid loss is > 10% of ECF volume (severe volume depletion), signs
of shock (eg, tachypnea, tachycardia, hypotension, confusion, poor
capillary refill) can occur.
18

19. o Diarrhea is loosely defined as passage of abnormally
liquid or unformed stools at an increased frequency
o CLASSIFICATION:
 Acute: <2 weeks
 Persistent: 2-4 weeks
 Chronic: >4 weeks
19

20. Diarrhea of duration less than 2
weeks (<2 weeks)
• Causes:
• Infectious agents: most common
cause of acute diarrhea
• 90% of cases of acute
diarrhea often accompanied
by vomiting, fever and
abdominal pain
• Other causes – the remaining 10%
• Medications, Toxic ingestions,
Ischemia , Other conditions 20

21. What can be the cause?
• Most are acquired by fecal-oral transmission
→ Ingestion of food or water contaminated with pathogens from
human or animal feces
• In the immunocompetent person, the resident fecal microflora,
containing >500 taxonomically distinct species
→ Rarely the source of diarrhea
• Disturbances of flora by antibiotics can lead to diarrhea
21

22. 22

23. TRAVELERS
• Nearly 40% of tourists to
endemic regions of Latin
America, Africa and Asia
develop so-called
traveler’s diarrhea
→ (enterotoxigenic or
enteroaggregative E.coli)
→ as well as to
Campylobacter, Shigella,
Aeromonas, Norovirus,
Coronavirus, and Salmonella
CONSUMERS OF
CERTAIN FOODS
• Diarrhea closely
following food
consumption such as:
• From
undercooked
hamburger
(Enterohemorrh
agic E. coli)
• Salmonella
from eggs
• Vibrio species,
Salmonella
from seafood
IMMUNODEFICIENT
PERSONS
• AIDS patients: Common
enteric pathogens often
cause a more severe
and protracted
diarrheal illness
• Persons with
hemochromatosis:
• Prone to invasive
enteric infections
with Vibrio
species and
Yersinia infections
• Should avoid raw
23

24. • Of the several million people who travel from temperate
industrialized countries to tropical regions of Asia, Africa, and
Central and South America each year, 20–50% experience a
sudden onset of abdominal cramps, anorexia, and watery
diarrhea; thus traveler’s diarrhea is the most common travel-
related infectious illness.
• The time of onset is usually 3 days to 2 weeks after the traveler’s
arrival in a resource-poor area; most cases begin within the first
3–5 days.
• The illness is generally self-limited, lasting 1–5 days. The high
rate of diarrhea among travelers to underdeveloped areas is
related to the ingestion of contaminated food or water.
24

25. 25

26. “
26

27. 27
The epithelium of the digestive tube is protected from insult by a number of
mechanisms constituting the gastrointestinal barrier, but it can be breached.
Disruption of the epithelium of the intestine due to microbial or viral
pathogens is a very common cause of diarrhea in all species.
Destruction of the epithelium results not only in exudation of serum
and blood into the lumen but often is associated with widespread
destruction of absorptive epithelium.
In such cases, absorption of water occurs very inefficiently,
resulting to diarrhea.

28. 8.
MANIFESTATIONS
OF THE DISEASE

29. 29
 Abdominal pain (+)
 Nausea (+) and vomiting
 Fever (-) and chills (+)
 Watery stool (+)
 Signs and symptoms of dehydration (the most important and most
common complication of acute diarrhea)
 Abdominal tenderness (+)
 Altered mental status (caused by infection [e.g., with Salmonella
spp] or dehydration).

30. 30
Dry mucous membranes (dry mouth)
Decreased skin turgor
Increased thirst
Altered mental status
Dizziness, lightheadedness
Headache
Hypotension
Tachycardia
Weakness, fatigue
Presyncope or syncope
Decreased urine output, concentrated urine (deep yellow or amber
color)

31. 31

32. 32
Various syndromes may occasionally overlap:
1. Acute gastroenteritis (the most frequent manifestation): Starts with vomiting,
which is followed by the development of nonbloody diarrhea without pus and
mucus. Patients are at risk of significant dehydration.
2. Bloody diarrhea (dysentery): The dominant clinical features are diarrhea with
fresh blood in stools and abdominal cramping. It may be caused by Shigella spp
or Salmonella spp, enteroinvasive E coli (EIEC), or amebiasis.
3. Dysentery syndrome: Frequent small-volume bowel movements containing
fresh blood or pus and large quantities of mucus, painful and unproductive
urge to defecate, and severe abdominal cramping.
4. Typhoid syndrome (enteric fever): The dominant features are high-grade fever
(39-40 degrees Celsius), headache, abdominal pain, and relative bradycardia
(pulse <100 beats/min with a fever >39 degrees Celsius), which may be
accompanied by diarrhea or constipation.

33. 9.
DIAGNOSTIC
PROCEDURES

34. DIAGNOSTIC
TEST DONE:
HEMOCCULT with
NEGATIVE RESULT

35. 35
to detect
bacterial or
viral
pathogens
STOOL
CULTURES
to detect
presence of
pus, ova and
parasites
FECALYS
IS
for certain bacterial
toxins (C. difficile),
viral antigens
(rotavirus), and
protozoal antigens
(Giardia, E.
histolytica).
IMMUNOAS
SAYS

36. 10.
TREATMENT

37. • Rehydration – electrolyte replacement if necessary
• Symptomatic relief
• Intravenous hydration in patients with severe symptoms is
recommended
• Antidiarrheal medication - OTC drugs: Loperamide (Imodium) and
Bismuth subsalicylate (pepto-bismol)
• Bismuth subsalicylate should not be taken in immune-compromised
individuals because of the risk of bismuth encephalopathy
• Antibiotics can only treat diarrhea due to bacterial infections. If the
cause is a certain medication, switching to another drug might help.
37

38. 38
Clinical algorithm for
the approach to patients
with community-
acquired infectious
diarrhea.

39. “
39

40. Chronic complications may
follow the resolution of an
acute diarrheal episode. The
clinician should inquire about
prior diarrheal illness if the
conditions listed are
observed.
40

41. References:
1. Harrison’s Principle of Internal Medicine,
20th Edition
2.
https://empendium.com/mcmtextbook/chapte
r/B31.II.4.24.1.

42. THANK YOU FOR YOUR ATTENTION