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- 1. Diagnosis & Treatment Of Diarrheal Diseases
- 2. Diarrheal diseases represent one of the 5 leading causes of death worldwide and are a particular concern for children younger than 5 years old When clinicians care for adults with diarrhea, 2 important decision points When to perform stool testing whether to initiate empiric antimicrobial therapy Most cases of acute diarrhea in adults are of infectious etiology Most cases resolve with symptomatic treatment alone
- 3. Definitions Passage of loose or watery stools, at least 3 times in a 24-hour period Whether due to impaired water absorption And/or active water secretion by the bowel
- 4. Definitions according to the duration of symptoms Acute Diarrhea lasting <2 weeks Persistent diarrhea Diarrhea continuing for >2 - <4 weeks Chronic or recurrent Diarrhea lasting >4 weeks
- 5. Definitions Invasive diarrhea, or dysentery Diarrhea with visible blood or mucus, in contrast to watery diarrhea Dysentery is commonly associated with fever and abdominal pain
- 7. Definition Abnormal loose stool (consistency), changes in stool frequency, urgency and continence Lasting < 2 weeks Acute diarrhea is one of the most commonly reported illnesses, 2nd only to respiratory infections It is the leading cause of mortality in children <4 years old Often mild & Often associated with abdominal cramping, bloating & gas However, can lead to severe dehydration & electrolyte loss Worldwide
- 8. Causes acute diarrhea Viral Travel Drugs Bacterial Dietery Contamination Acute, watery diarrhea Acute, bloody diarrhea Antibiotics and magnesium Coffee, tea, colas, dietetic foods Gums or mints that contain poorly absorbable sugars Traveler's diarrhea Fresh fruit with E.coli 0157:H7 or chemicals
- 9. as the course of the diarrhea persists and becomes chronic Most cases of acute diarrhea are due to infections and are self-limited Most cases of acute infectious diarrhea are viral Protozoa are less commonly as etiologic agents of acute diarrheal illness ETIOLOGY Noninfectious etiologies become more common
- 10. EVALUATION Most adults with acute diarrhea do not present to medical care because of the mild or transient nature of the symptoms Evaluation is required for with persistent fever, bloody diarrhea, severe abdominal pain, symptoms of volume depletion (eg, dark or scant urine, symptoms of orthostasis), or a history of IBD Hospitalization may be necessary, in particular with comorbidities (eg, Hx of immunosuppression, treatment for malignancy, Hx of transplantation, advanced HIV infection or significant vascular or cardiovascular disease)
- 11. Clinician meets acute viral GE in 3 setting 1st 2nd 3rd Sporadic GE in infants Sporadic GE in adults Epidemic GE frequently caused by rotavirus Caused by calici-, rota-, astro-, adeno- viruses Occurs in semi-closed communities eg, families, institutions, ships, camps Or as classic food-,water- borne pathogens Mostly caused by caliciviruses
- 12. From asymptomatic infection To severe dehydration and death Viral GE typically presents with Short prodrome of mild fever & vomiting Followed by 1-4 days of non-bloody watery diarrhea Self-limited Never protracted, A viral cause should be suspected when Absent warning signs of bacterial infection high fever bloody diarrhea severe abd pain >6 stools /24 h) Alternative diagnosis is excluded by Hx (eg, travel, sexual practices, antibiotic use) Clinical spectrum of acute viral GE ranges
- 13. Acute Bacterial GE Range from mild to severe Usually manifests with Vomiting, diarrhea, & abdominal discomfort Usually is self-limited But, can lead to a protracted course The most common complication is dehydration
- 14. Small Bowel or large Bowel diarrhea Appearance Watery Mucus and/or blood Volume Large Small Associated with Abdominal cramping, bloating, and gases Painful bowel movements Blood Possibly heme +ve but Never gross blood Possibly grossly bloody pH Possibly <5.5 >5.5 Stool WBC count <5/HPF Possibly >10/HPF Serum WBC count Normal Possible leukocytosis
- 15. Small Bowel or large Bowel Organisms Preformed toxins Bacillus species Staphylococcus aureus Invasive bacteria E coli and Shigella, Salmonella, Campylobacter, Yersinia, Aeromonas and Plesiomonas Toxic bacteria E coli, cholera, C perfringens, Listeria Toxic bacteria Clostridium difficile Viral Rota-, Adeno-, Calici-, Astro- Norwalk — Parasitic Giardia Cryptosporidium Parasitic Entameba species
- 16. Particular foods associated with bacterial food poisoning • Salmonella, Campylobacter, Listeria, Staph Dairy • Salmonella, Campylobacter, C perfringens, Aeromonas, Staph Meats • Salmonella Eggs • Campylobacter Poultry • Aeromonas, Plesiomonas, Vibrio • Astrovirus and Calicivirus Seafood • Aeromonas and C perfringens Vegetables • Bacillus species Fried rice • Staphylococcus species Custards, mayonnaise
- 17. • Dogs or cats: Campylobacter • Turtles: Salmonella Animals • Major reservoir for many organisms that cause diarrhea. Water • Associated with outbreaks of Shigella Swimming pools • Associated with Aeromonas Marine environment • Enterotoxigenic E coli is the leading cause Traveler's diarrhea Other organisms associated with travel Aeromonas Giardia Plesiomonas Salmonella Shigella Entamoeba Clostridium Cholerae Yersinia Plesiomonas C perfringens
- 18. Preexisting medical conditions predispose to infections with particular organisms C difficile Hospitalization with antibiotic use Plesiomonas Liver diseases or malignancy Salmonella Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especially sickle cell disease), immunosuppression, malaria Rotavirus Hospitalization Giardia Agammaglobulinemia, chronic pancreatitis, achlorhydria, and cystic fibrosis Cryptosporidia Immunocompromised
- 19. Inflammatory signs associated with large bowel infection (fever, bloody or mucoid stools) suggest Invasive bacteria (eg, Salmonella, Shigella, or Campylobacter), enteric viruses (eg, CMV or adenovirus), E histolytica, or a cytotoxic organism such as C. difficile Visibly bloody acute diarrhea is relatively uncommon and raises the possibility of enterohemorrhagic E. coli (EHEC) (eg, E. coli O157:H7) Bloody diarrhea can also reflect noninfectious etiologies such as IBD or ischemic colitis
- 20. What tests are needed to diagnose acute diarrhea? Most episodes of acute diarrhea resolve quickly With no antibiotic therapy Just with simple dietary modifications Persistent diarrhea that does not respond to empiric treatment Stool cultures or parasite exams & rarely fecal calprotectin Imaging typically not necessary in acute diarrhea However, with signs or ileus, abdominal CT to identify complications e.g. bowel perforation, abscess, fulminant colitis, toxic megacolon, or intestinal obstruction Therefore, with mild acute diarrhea No required lab for evaluation
- 21. Hx of duration of symptoms Frequency and characteristics of the stool Associated symptoms Elicit evidence of dehydration (eg, dark yellow or scant urine, decreased skin turgor, orthostatic hypotension) Food history occupational exposure, travel, pets recent antibiotic use Management of acute diarrhea starts with History?
- 22. Dietary recommendations for acute diarrhea • Plenty of fluid and salt (may be oral rehydration solutions) Avoid dehydration: • May be difficult to digest in the presence of diarrheal disease (due to secondary lactose malabsorption, which is common following infectious enteritis and may last for several weeks to months) Avoid dairy products (except yogurt) for 24-48 hrs • begin with Soups and broth, boiled vegetables and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt and crackers and bananas. Foods with high fat content should be avoided On refeeding
- 23. Dietary recommendations for acute diarrhea • Bananas • Rice • Applesauce • Toast BRAT diet (Has been recommended for years) Generally, as the patient tolerates solid food, go forward with diet as adequate nutrition is important to facilitate enterocyte renewal
- 24. Empiric antibiotic therapy Azithromycin or a fluoroquinolone are suggested Azithromycin is preferred if suspected to be at risk for a fluoroquinolone-resistant pathogen Can be given as a single 1 g dose or as 500 mg once daily for 3 days Ciprofloxacin (a single 750 mg dose or 500 mg twice daily for 3-5 days) Levofloxacin (a single 500 mg dose or repeated once daily for 3-5 days) For selected patients with more symptomatic disease or with risk for more severe disease, is appropriate
- 25. Symptomatic therapy Antimotility agents and/or Probiotics can be used As it may mask the amount of fluid lost, since fluid may pool in the intestine Thus, fluids should be used aggressively when antimotility agents are employed Furthermore, it can prolong the duration of fever, diarrhea, and excretion of the organism
- 26. Dose initially 2 tablets (4 mg), then 2 mg after each unformed stool for ≤2 days, with a maximum of 16 mg/day 30 mL or 2 tablets every 30 minutes for 8 doses), although it is less effective and there is the potential for salicylate toxicity (especially in those who take aspirin) Two tablets (4 mg) 4 times daily for ≤2 days Effective option works by reducing the amount of fluid and salts secreted into the intestine, this makes the stools less watery Symptomatic therapy Antimotility agents and/or Probiotics Loperamide (Imodium) Bismuth salicylate (Pepto-Bismol Diphenoxylate (Lomotil) Racecadotril (Hidrasec) Probiotics can also be used as alternative therapy
- 28. Definition To most lay people Increase in stool frequency, fluidity, or urgency, with rapid evacuation Clinically Same definition but add with an increased stool weight (> 200 g/day) AGA suggests that chronic diarrhea should be defined as ≥ 3 loose or watery stools daily lasting for ≥ 4 weeks Chronic diarrhea affects ~ 3-7% of the population & can decrease QOL
- 29. Chronic or recurrent diarrhea is most commonly due to IBS Functional diarrhea IBD Chronic infections (particularly in immunocompromised bacterial, mycobacterial, & parasitic infection Factitious diarrhea Acute diarrhea may persist chronically Major Causes of Chronic Diarrhea are listed in texts Common disorders associated with malabsorption Lactose intolerance Chronic pancreatitis Celiac disease SIBO syndrome Malabsorption syndrome
- 30. C. difficile Aeromonas Plesiomonas Campylobacter Giardia Amebae Cryptosporidium Whipple's disease Cyclospora Should be considered with specific risk factors such as Travel, HIV infection, use of antibiotics, and consumption of potentially contaminated drinking water Chronic infections
- 31. Other causes of chronic diarrhea caused by or resulting from a presumed infection • Develops in 30% of patients following documented acute bacterial enteric infections Post-infectious IBS • In small bowel in immunosuppression Candida albicans • Protozoan that lives in the digestive tract and are harmless or even helpful, sometimes cause chronic diarrhea abdominal pain and vomiting Blastocystis hominis
- 32. Other causes of chronic diarrhea caused by, or resulting from a presumed infection • Epidemic form of secretory diarrhea associated with patchy lymphocytic colonic inflammation can persist for up to 3 years. • An infectious agent is suspected but not identified yet Brainerd diarrhea • Multidrug-resistant gram-ve bacillus opportunistic pathogen, particularly among hospitalized patients. • S. maltophilia infections have been associated with high morbidity and mortality in severely immunocompromised and debilitated individuals Stenotrophomonas maltophilia (Xanthomonas)
- 33. Optimal diagnostic strategies have not been established However, a specific diagnosis can be achieved in >90% of patients
- 34. •Because IBS is one of the most common causes of chronic diarrhea •It is useful to begin evaluation of symptoms and signs of the diarrhea as Either functional (IBS-diarrhea predominant) Or organic (related to an identifiable bowel pathology)
- 35. Organic disease can be predicted with 90% certainty if at least 3 of the following clinical/lab parameters are present Sudden onset Daily occurrence Large volume diarrhea, daily stool volume > 400 g Bloody stools Nocturnal diarrhea Greasy stools Weight loss of > 5 kg Anemia
- 36. Red flags Or Alarm features in patients with chronic diarrhea Rectal bleeding or melena Nocturnal pain or diarrhea Progressive abdominal pain Unexplained weight loss, fever, or other systemic symptoms Lab abnormalities (iron deficiency anemia, elevated CRP or fecal calprotectin) Family history of IBD or CRC
- 37. Consistency or frequency of stools, the presence of urgency or fecal soiling Stool characteristics (eg, greasy stools that float & malodorous (malabsorption), visible blood may (suggest IBD) Duration of symptoms, nature of onset (sudden or gradual) Weight loss Fecal incontinence ( may be confused with diarrhea) History
- 38. Occurrence of diarrhea during fasting or at night (suggesting a secretory diarrhea) Family history of IBD Large volume diarrhea is more likely due to small bowel Small volume diarrhea is more likely colonic Presence of bloody diarrhea favors a colonic vs small bowel disorder Presence of systemic symptoms such as fevers, joint pains, mouth ulcers, eye redness History
- 39. All medications (including over-the-counter drugs and supplements A relevant dietary (including possible use of sorbitol-containing products and use of alcohol). Association of stress and depression with onset and severity of the diarrhea Sexual history (anal intercourse) History of recurrent bacterial infections (eg, sinusitis, pneumonia), which may indicate a primary Ig deficiency History
- 40. A stool specimen should be obtained for: Direct visual examination (for oil, blood, and mucus) WBCs (Fecal leukocytes are not a good test for inflammatory diarrhea) Occult blood Near infrared reflectance analysis Fecal Elastase alpha-1 antitrypsin clearance Ova and parasites Electrolytes and osmolality (to determine osmotic gap) pH (< 5.3 suggests carbohydrate malabsorption) Fecal calprotectin & fecal lactoferrin
- 41. Watery diarrhea The water content of chronic diarrhea can be caused by secretory or osmotic processes, or both However, the clinical utility of these categories and their diagnostic markers is limited because some diarrheal diseases involve both processes Secretory diarrhea Usually associated with large volumes of watery stools and persists during fasting. (So, it is helpful to assess the effects of fasting on stool output) Pure secretory diarrheas are uncommon (occurs in 80% of patients with carcinoid syndrome) Stools may be up to >30/day, are typically watery, non-bloody, and can be explosive and with abdominal cramping
- 42. Osmotic or "substrate-induced" or "diet-related" diarrhea Typically, less voluminous than secretory diarrhea (eg, <200 mL/day), and improves or resolves on fasting Presence of reducing substances or low fecal pH (ie, pH <6) suggest carbohydrate malabsorption Osmotic diarrheas are characterized by relatively low sodium concentration (<70 mEq/L) and a high osmotic gap (>75 mOsm/kg) but testing stool osmolality is not routinely required Fatty diarrhea Malabsorption is often accompanied by steatorrhea and the passage of bulky malodorous pale stools However, milder forms of malabsorption may not result in any reported stool abnormality Inflammatory diarrhea Inflammatory forms of diarrhea typically present with liquid loose stools with blood Elevation in fecal calprotectin indicates inflammatory diarrhea
- 43. Osmotic or secretory diarrhea or both Stool osmotic gap = 290 - 2 ( [Na+] + [K+] ) [Na+] + [K+] are the stool sodium and potassium • Pure secretory diarrhea = osmolar gap < 50 • Pure osmotic diarrhea = osmolar gap > 125 • Mixed osmotic & secretory = osmotic gap between 50 & 125 [290 mOsm/kg is normal osmolality of blood and stool] If fasting is impossible or impractical The stool specimen should be fresh & free of urine and the serum osmolality should be checked and compared with the stool value Fasting test Measurement of osmotic gap 24- to 48-h fast should temporarily eliminate osmotic diarrhea, while secretory diarrhea should continue
- 44. Carcinoid syndrome Secretory diarrhea occurs in 80% of patients (often the most debilitating component of the syndrome) Stools may vary from few to >30/day Stools are typically watery and non-bloody, and can be explosive and accompanied by abdominal cramping The abdominal cramps may be a consequence of mesenteric fibrosis or intestinal blockage by the primary tumor The diarrhea is usually unrelated to flushing episodes
- 45. Functional diarrhea vs IBS-D A number of related FGIDs are described to include: Functional diarrhea IBS-D predominant IBS-M (mixed) Functional bloating functional dyspepsia According to a consensus of experts these disorders Represent a continuum Rather than being independent entities Continuous sequence in which adjacent elements are not noticeably different from each other, although the extremes are quite distinct Example of a continuum is a range of temperatures from freezing to boiling Continuum
- 46. IBS-D vs Functional diarrhea IBS-D predominant patients complain of LQ cramping pain associated with altered bowel habits (D, C, alternating D/C) Diarrhea is usually frequent loose stools of small to moderate volume Stools generally occur during waking hours, most often in the morning or after meals Some bowel movements are preceded by urgency and may be followed by a feeling of incomplete evacuation or tenesmus Incontinence of liquid stool may occur occasionally ~ ½ of all patients with IBS complain of mucus discharge with stools Symptoms of IBS often correlate with episodes of psychologic stress Patients usually are young adults, but the prevalence is similar in older adults Post-infectious IBS can occur following recovery from bacterial infections
- 47. Functional diarrhea Characterized by recurrent similar stool changes of passage of loose or watery stools Without prominent pain Patients with functional diarrhea should not meet criteria for IBS Functional diarrhea vs IBS-D
- 48. Inflammatory bowel disease Diarrhea, abdominal pain, weight loss, and fever are the typical manifestations for most patients with ileitis, ileocolitis, or Crohn colitis. Patients can have symptoms for many years prior to diagnosis. Although occult GI blood loss is common in CD, gross bleeding is much less frequent than in UC (except for Crohn colitis) Gradual onset of symptoms, sometimes preceded by a self-limited episode of rectal bleeding for weeks or months earlier Still uncommon & occurs in all ages Two main histologic subtypes with similar clinical presentation Lymphocytic colitis Collagenous colitis Patients usually have intermittent watery stools, between 4-9 /day CD UC Microscopic colitis
- 49. The classic manifestations of malabsorption are Chronic diarrhea Unintentio nal weight loss Unexplaine d nutrient deficiencie s The majority of patients with malabsorption have relatively mild Gl symptoms, which often mimic more common disorders such as IBS 49 Fatty diarrhea Despite adequate food intake And Or In some cases, flatulence, abdominal distension, and borborygmi may be the only complaints suggesting malabsorption; other patients may be asymptomatic
- 50. Post-cholecystectomy diarrhea (choleretic diarrhea) The incidence has ranged from as low as 2% to as high as 50% Resolve or significantly improve over the course of weeks to months • Diarrhea is related to excessive bile acids entering the colon. In the absence of a GB, bile drains directly & continuously into the small bowel, which may overcome the terminal ileum's reabsorptive capacity Mechanism • Respond to bile-acid binding resins such as cholestyramine powder (start at a dose of 2 g once daily up to 4 g daily) – some patients prefer pill formulations (eg, colestipol) Tx
- 51. CBC and differential ESR & CRP have limited utility in differentiating IBS & IBD TSH -- fT3 -- fT4 Serum electrolytes Total protein and albumin Stool occult blood Celiac serologies Serum electrolytes with severe diarrhea, or concern for dehydration Stool test for giardia Fecal leukocytes is not an accurate test for inflammatory diarrhea Fecal calprotectin or fecal lactoferrin If fecal calprotectin & fecal lactoferrin are normal, diagnosis of IBD is unlikely Minimum lab evaluation in most patients should include Other lab tests should include Reserve lab testing for hormone secreting tumors (eg, fasting serum gastrin, calcitonin, somatostatin, vasoactive intestinal polypeptide, 24-hour urine 5-HIAA) for patients where no other etiology if found
- 52. In addition Most patients require some form of endoscopic evaluation and mucosal biopsy (either ileo-colonoscopy or sometimes upper endoscopy), depending upon the clinical setting
- 53. Upper GI endoscopy for small bowel biopsy and possibly for a duodenal aspirate for checking for Giardia Crohn's disease Celiac disease Intestinal lymphoma Eosinophilic gastroenteritis Whipple's disease Various infections. Colonoscopy or flexible sigmoidoscopy with biopsies Direct mucosal examination + Biopsies May demonstrate • Inflammation (colitis) • Ulceration • Polyps • Masses • Melanosis coli (due to the use of anthracene-containing laxatives)
- 54. Bowel imaging Plain abdominal films in the supine and upright position can provide evidence of bowel distention or air-fluid levels suggesting a motility disease, megacolon, or partial mechanical obstruction Small-bowel enema (enteroclysis) More detailed imaging is provided by abdominal CT or MRI Barium enema is seldom used in the evaluation of diarrhea and largely replaced by endoscopy and biopsy Patients with abdominal pain in addition to chronic diarrhea often require imaging
- 56. MANAGEMENT Empiric therapy — Empiric therapy may be appropriate when comorbidities limit diagnostic evaluation or when a diagnosis is strongly suspected. Examples include: • Empiric antibiotics for suspected SIBO. • Lactose restriction with suspected lactose intolerance. • Cholestyramine for bile acid diarrhea in a patient who develops diarrhea following limited (<100 cm) ileal resection, abdominal radiation therapy, or post-cholecystectomy diarrhea. It is reasonable to start patients on a low dose (eg, 2 g once or twice daily) and titrate as needed. Patients often prefer pill formulations (ie, colestipol) over the powder (ie, cholestyramine). Symptomatic therapy — including loperamide, anticholinergics, and intraluminal adsorbents (such as clays, activated charcoal, bismuth, fiber, bile acid binding resins)
- 58. فيتبقى 30 مليون ا يمكنهم لعمل منهم 40 مليون وشباب أطفال ماي يدرسون زالوا منهم 30 السن وكبار عجائز مليون
- 59. فيتبقى 10 للعمل مليون منهم 8 وسياسيين حكوميين مليون منهم 12 والجيش بالعسكرية مليون
- 60. منهم 7 و مليون 550 ومعاق بالمستشفيات مرضى ألف ومقعدون ين فيتبقى 950 ألف للعمل
- 62. وأنت أنا م
- 63. وأنت م تركتم ال عمل وقاعد ين ت م سمعوا حاضرة بشتغل اللي بس أنا يعني
- 64. كده أظن أنا الراحة أستحق بل أجـــــــازة الغ اليوم محاضرة وتعتبر يه ( أجازة يوم أول )