disease related to GIT - Diarrhea, ibs, and malabsorption syndrome

1. DIARRHEA, IBS, AND
MALABSORPTION SYNDROME
NUR FADZLINA ZABRI
082013100006

2. DIARRHEA
Diarrhea is defined as passage of
abnormally liquid or unformed stools at
an increased frequency, stool weight
>200 g/d

4. Pathophysiology
Osmotic Diarrhea
• Absorption of water in the intestine is dependent
on adequate absorption of solutes.
i. Ingestion of a poorly absorbed substrate
ii. Malabsorption syndrome
Excessive amounts
of solutes are
retained in the
intestinal lumen
Water will not be
absorbed

5. Secretory Diarrhea
• Diarrhea occurs when secretion of water into
the intestinal lumen exceeds absorption.
Causes
• Cholera toxin
• Idiopathic bile acid malabsorptions
•Laxatives
•Plant products
•VIP

6. Inflammatory Diarrhea
• The lining of the gut becomes inflamed
• Leads to loss of fluid and electrolytes
• Caused by infections or autoimmune disease

7. ACUTE DIARRHEA
• Diarrhea that comes on suddenly and goes
away over a period of a couple of weeks.
• >90% caused by infectious agents.
• Remaining 10%
i. Medications
ii. Toxic ingestions
iii. Ischemia

8. A. Infectious Agents
• Feco-oral transmission
• Systemic manifestations
• Five high-risk groups
Reiter's syndrome
Arthritis
Urethritis
Conjuctivitis
Salmonella,
Campylobacter,
Shigella, and
Yersinia.
Hemolytic-uremic
syndrome
- High mortality rate
Enterohemorrhagic
E. coli and Shigella
Others:
Viral hepatitis
Listerosis
Toxic shock syndrome

9. • Enterotoxigenic or Enteroaggregative E.coli
• Campylobacter
• Shigella
• Giardia
Travelers
• Chicken : Salmonella, Shigella,
Campylobacter
• Undercooked hamburger : Enterohemorrhagic E. coli
• Fried rice or reheated food : Bacillus cereus
• Mayonnaise or creams : Staph.aureus/Salmonella
• Eggs : Salmonella
• Uncooked foods : Listeria
• Seafood (esp raw) : Vibrio sp, Salmonella,
Acute hepatitis A
Consumers
of certain
foods

10. • Primary immunodeficiency : IgA deficiency,
common variable hypogammaglobulinemia,
chronic granulomatous disease
• Secondary immunodeficiency : AIDS,
pharmacologic suppression
Immunodeficient
persons
• Shigella
• Giardia
• Cryptosporidium
Day care
attendees and
their family
members
• C.difficile
Institutionalized
persons

11. Clinical features

13. Pathogen Incubation Period
Bacillus cereus
Staph.aureus
1-8 hr
Clostridium perfringens 8-24 hr
Vibrio cholerae
Enterotoxigenic Escherichia coli
Klebsiella pneumoniae
Aeromonas species
8–72 h
Enteropathogenic E.coli
Enteroadherent E. coli
Giardia
1-8 days
C. difficile 1–3 d
Hemorrhagic E. coli 12–72 h
Rotavirus and norovirus 1–3 d
Salmonella
Campylobacter
Aeromonas species
Vibrio parahaemolyticus
Yersinia
12 h–11 d

14. B. Medications
• Antibiotics
• Anti hypertensives
• Antidepressants
• Antacids
• Bronchodilators
• Chemotherapeutic agents
• Cardiac antidysrhythmics
• NSAIDs
• Laxatives

15. C. Ischemic colitis
D. Toxins
i. Organophosphate insecticides
ii. Amanita and other mushrooms
iii. Arsenic
Acute lower abdominal
pain preceding watery
then bloody diarrhea
Acute inflammatory
changes in the sigmoid or
left colon while sparing
the rectum.

16. • Mild and self-limited.
• Indications for evaluation include :
Abdominal pain (severe) in patients >50 years
Antibiotic use (recent)
Bloody stools (grossly)
New Community outbreaks
Duration >48 h without improvement
Profuse diarrhea with Dehydration
Elderly (>70 years)
Fever 38.5°C (101°F)
Immunocompromised patients
Approach to patient with acute diarrhea

17. Investigations
• Microbiologic analysis of the stool :
i. Cultures for bacterial and viral pathogens.
ii. Direct inspection for ova and parasites.
iii. Immunoassays for certain
- Bacterial toxins (C. difficile)
- Viral antigens (rotavirus)
- Protozoal antigens (Giardia, E. histolytica)

18. • Flexible sigmoidoscopy with biopsies and upper
endoscopy with duodenal aspirates and biopsies
may be indicated.
• Structural examination by sigmoidoscopy,
colonoscopy or abdominal CT scanning
i. To exclude IBD
ii. Initial approach in patients with suspected
non-infectious acute diarrhea.

19. MANAGEMENT

21. • Mild case : Fluid alone
• Severe case : Oral sugar-electrolytes solutions
Fluid and
electrolyte
replacement
• Dehydrated patients, especially infants and the
elderly.IV rehydration
• Moderately severe non febrile and non bloody
diarrhea.
• To control symptoms.
• Avoided with febrile dysentery, which may be
exacerbated or prolonged by them.
Antimotility and
Antisecretory
agents

22. • Reduce severity and duration of diarrhea.
• Treat empirically without diagnostic evaluation.
Quinolone (500 mg
bid for 3–5 d)
Metronidazole
(250 mg qid for 7 d)
• If travelling to high-risk countries
• Immunocompromised
• Hemochromatosis
• IBD
Antibiotic
prophylaxis
**Antibiotic is indicated whether or not causative org is discovered in patients who are
i. Immunocompromised
ii. Have mechanical heart valve or recent vascular grafts
iii. Elderly

23. IRRITABLE BOWEL SYNDROME
Recurrent abdominal pain in association
with abnormal defecation in the
absence of a structural abnormality of
the gut

24. Pathophysiology

25. Clinical features
Stomach
bloating
Abdominal
discomfort
Colicky pain
Altered bowel habits
Constipation/diarrhea

26. Diagnosis
Features supporting a diagnosis of IBS
– Symptoms >6months
– Frequent consultations for non-gastrointestinal problem
– Stress worsens symptom
Alarm features
– Age >50 years, male
– Weight loss
– Nocturnal symptoms
– Anemia
– Colorectal bleeding
– Family history of colon cancer

27. • Rome III criteria
• Full blood count and faecal calprotectin
• Colonoscopy (>40 years age)
• Endoscopy

28. Management

29. MALABSORPTION SYNDROME
Number of disorders in which the intestine
unable to absorb certain nutrients
(micronutrients or micronutrients) into the
bloodstream

30. Coeliac disease
Tropical sprue
Lactose intolerance
Blind loop syndrome
Whipple’s syndrome
Ileal resection
Radiation enteritis
Short bowel syndrome
Abetalipoproteinemia
Protein losing enteropathy
Intestinal lymphangiectasis
Meckel’s diverticulum
Eosinophilic gastroenteritis
Cystic fibrosis
Biliary atresia
Chronic pancreatitis

31. Clinical feature
• Diarrhea (watery and voluminous)
• Bulky, pale and offensive stool
• Abdominal distension
• Borborygmi
• Cramps
• Weight loss

32. Pathophysiology
1. Intraluminal maldigestion
Deficiency of bile and pancreatic
enzyme
Inadequate solubilisation and
hydrolysis of nutrients
Fat and protein malabsorption

33. 2. Mucosal malabsorption
Damaged of small epithelium
-Diminished surface area of absorption
- Depleting brush border enzyme
activity

34. 3. ‘Post-mucosal’ lymphatic obstruction
– Prevent the uptake and transport of absorbed
lipids into lymphatic vessels
– Increased pressure in these vessels
Leakage into intestinal lumen
Protein-losing enteropathy

35. Investigations
• Routine blood test
Hematology
Microcytic anaemia – iron deficiency
Macrocytic anaemia – folate or B12
deficiency
Increased prothrombin time -vitamin
K deficiency
Biochemistry
Hypoalbuminemia
Hypocalcemia
Hypomagnesemia

37. Management
• Celiac disease
– Correcting the existing deficiencies : iron, folate,
calcium, vitamin D
– Life-long gluten-free diet
– Corticosteroids and immunosuppresive drugs
• Tropical Sprue
– Tetracycline
– Folic acid (improve symptoms)

38. • Lactose intolerance
– Dietary exclusion of lactose
• Blind loop syndrome
– Antibiotic : metronidazole, ciprofloxacin, tetracycline
– IM Vitamin B12
– Antidiarrheal drug
• Ileal resection
– Vitamin B12 supplementation
– Cholestyramine
– Aluminium hydroxide

39. REFERENCES
• KUMAR & CLARCK’S , CLINICAL MEDICINE ,
PUBLISHED BY ELSEVIER , SEVENTH EDITION ,
UK
• DAVIDSON’S PRINCIPLES AND PRACTICE OF
MEDICINE 21st EDITION