The document discusses the clinical features, pathology, microbiology, and emergency department (ED) management of acute diarrheal diseases. It covers the major causes of diarrhea including viruses, bacteria, and protozoa. In the ED, management involves assessing hydration status, providing rehydration with oral or IV fluids, and considering antibiotics for likely bacterial infections. The role of the ED physician is to exclude serious illness, ensure stability, begin diagnostic evaluation if needed, and provide referral for further care.
The genus Shigella exclusively infects human intestine.
Shigella dysenteriae is the causative agent of bacillary dysentery or shigellosis in humans.
It is a diarrheal illness which is characterized by frequent passage of blood stained mucopurulent stools.
The four important species of the genus Shigella are:
Shigella dysenteriae
Shigella flexneri
Shigella sonnei
Shigella boydii.
The genus Shigella exclusively infects human intestine.
Shigella dysenteriae is the causative agent of bacillary dysentery or shigellosis in humans.
It is a diarrheal illness which is characterized by frequent passage of blood stained mucopurulent stools.
The four important species of the genus Shigella are:
Shigella dysenteriae
Shigella flexneri
Shigella sonnei
Shigella boydii.
casoni test is an immediate hypersensitivity skin test previously used in the diagnosis of hydatid disease.
Intradermal injection of 0.2ml of hydatid fluid collected from animal/human cyst which is sterilized by seitz filtration OR membrane filtration.
equal volume of saline(control) injected on the other forearm and observation made for next 30 min and after 1 to 2 days.
As a precaution anaphylactic tray must be kept ready before carrying out the test.(Type 1 hypersensitivity reaction)
Interpretation: Sensitive patients develop large wheal measuring 5 cm or more with formation of pseudopodia like projection within 30 minutes occuring at injection site, considered positive result.(immediate hypersensitivity) .
No reaction in the control arm.
Disadvantage: It has low sensitivity (60-80%)
and gives false positive results in cross reactive cestode infections.
It is no longer used nowadays and replaced largely by the serological tests.
Less reliable than imaging technique.
Shigellosis = inflammation of intestines (especially the colon) with accompanying severe abdominal cramps, tenesmus and frequent, low-volume stools containing blood, mucus and fecal leukocytes.
General discription about E coli.. Classification scheme of E coli. Pathogenecity of E coli. Pathological characters of E coli. slide contains animations and may not support in mobile.. Use laptop for full view
casoni test is an immediate hypersensitivity skin test previously used in the diagnosis of hydatid disease.
Intradermal injection of 0.2ml of hydatid fluid collected from animal/human cyst which is sterilized by seitz filtration OR membrane filtration.
equal volume of saline(control) injected on the other forearm and observation made for next 30 min and after 1 to 2 days.
As a precaution anaphylactic tray must be kept ready before carrying out the test.(Type 1 hypersensitivity reaction)
Interpretation: Sensitive patients develop large wheal measuring 5 cm or more with formation of pseudopodia like projection within 30 minutes occuring at injection site, considered positive result.(immediate hypersensitivity) .
No reaction in the control arm.
Disadvantage: It has low sensitivity (60-80%)
and gives false positive results in cross reactive cestode infections.
It is no longer used nowadays and replaced largely by the serological tests.
Less reliable than imaging technique.
Shigellosis = inflammation of intestines (especially the colon) with accompanying severe abdominal cramps, tenesmus and frequent, low-volume stools containing blood, mucus and fecal leukocytes.
General discription about E coli.. Classification scheme of E coli. Pathogenecity of E coli. Pathological characters of E coli. slide contains animations and may not support in mobile.. Use laptop for full view
Diarrhea is an increased frequency and decreased consistency of fecal discharge as compared with an individual’s normal bowel pattern.
It is often a symptom of a systemic disease.
Acute diarrhea is commonly defined as shorter than 14 days’ duration.
Persistent diarrhea as longer than 14 days’ duration.
Chronic diarrhea as longer than 30 days’ duration.
Most cases of acute diarrhea are caused by infections with viruses, bacteria, or protozoa, and are generally self-limited.
Diarrhea- easy ppt for Nurses
definition of Diarrhea
types of Diarrhea
risk factors of Diarrhea
Clinical manifestations of Diarrhea
Assessment & Diagnostic tests of Diarrhea
Management of Diarrhea
Medical management
Nursing Management
The Use Of PEFR in Asthmatics at UHWI: A Clinical Audit: Dr Peter Soltau et al.Dr. Peter Andre Soltau
This is a clinical audit presentation which evaluated the usage of PEFR in asthmatic patients presenting to the Accident & Emergency Division of the University Hospital Of West Indies.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
Diarrhoea by Dr Peter Soltau 2014
1. The clinical features,
pathology, microbiology
and ER management of
acute diarrheal diseases,
including HIV-related
gastrointestinal infections
Dr. Peter Andre Soltau
2. Background / Incidence
• The W.H.O reports > 3 million episodes of diarrhea annually and
estimates > 2.2 million diarrheal deaths occur mainly in children,
especially in low- and middle-income countries
• Diarrheal diseases represent one of the five leading causes of death
worldwide
• Commonly called the "nuisance disease"
3. Definitions
• Acute primary diarrhea defined as 3 or more loose/
watery/ diarrheal stools in a 24-hour period
• Duration:
• Acute < 14 days
• Persistent > 14 days
• Chronic > 30 days
• Dysentery - frequent passage of small volume stools
assoc. blood, mucus, abdominal cramping and tenesmus
4. Severe Diarrhea - 4 or more stools per day for 3 or
more days associated with [abdominal
symptoms(cramps, nausea, vomiting, tenesmus) or
systemic symptom (fever, malaise, dehydration)].
6. Secretory diarrhea
• Due to abnormal electrolyte transport across the intestinal
epithelial cells
• Increased secretion and/or decreased absorption result
• The diarrhea is not related to the intestinal contents and
therefore typically does not stop with fasting.
• Infection (e.g., cholera) is the most common cause of
secretory diarrhea
• The fluid losses can be enormous.
7.
8. Osmotic diarrhea
• The presence of nonabsorbable solute exerts an osmotic
pressure effect across the intestinal mucosa, resulting in
excessive water output
• Stops during fasting
• The offending molecule is usually a carbohydrate or divalent
ion.
• Common examples include mannitol or sorbitol, epson salt
(MgSO4) and some antacids (MgOH2).
9. Malabsorption
• Inability to absorb certain carbohydrates is the most common
deficit, but it can result virtually from any type of
malabsorption.
• E.g. lactose intolerance: a deficiency in the brush border
enzyme lactase.
10. Etiology
• Infectious:
• Viruses
• Norovirus, rotavirus, adenoviruses, astrovirus, and others
• Bacteria
• Salmonella, campylobacter, shigella, enterotoxigenic E. coli, C. difficile,
vibrio species and others
• Protozoa
• Cryptosporidium, giardia l., cyclospora, entamoeba h., and others
12. Pathology - Infectious
• Pathogenic organisms must be swallowed, they must
survive the acid in the stomach, intestinal immunity,
motility, mucus, and the resident micro flora, then
colonize the small bowel and stick to the enterocytes.
They then produce their harmful effects by one of
several mechanisms
13.
14. Viral Pathogens
• Invade & destroy the small intestinal mucosa villous epithelium
• Loss of mature absorptive cells
• Regeneration of poorly differentiated intestinal epithelial cells
• Impaired salt and water absorption
• Carbohydrate malabsorption leading to osmotic diarrhea
15. Bacterial Pathogens
• Invasive:
• Adhere to mucosal cells followed by invasion and multiplication,
initiating an acute mucosal inflammatory reaction, leading to
ulceration and synthesis of a variety of secretagogues. esp. in large
intestine
• E.g. Shigella, Salmonella, Yersinia enterocolitica, campylobacter
jejuni, vibrio parahemolyticus
• Cytotoxic:
• Elaboration of cytotoxins which can either inhibit protein synthesis
or induce secretion of inflammatory mediators causing cell death
and hence decrease the intestinal absorptive surface area
• E.g. Shigella, E.coli, clostridium difficile
16. Bacterial Pathogens
• Toxigenic
• Colonize the small intestines and secrete enterotoxins which bind
mucosal receptors and increase an intracellular mediator altering
salt and water transport (mucosal integrity is unchanged)
• E.g. Shigella, E.coli, Yersinia E., Vibrio cholerae
• Adherent:
• Colonize and adhere to intestinal surface of small and large
intestine, indenting the surface and flattening the microvilli,
thereby decreasing the surface area
• E.g. E. coli
17. Microbiology
• Laboratory testing:
• Routine testing for specific pathogens is not recommended
• Reserve laboratory testing and stool cultures for select
circumstances.
• Criteria vary but often include bloody diarrhea, weight loss,
diarrhea leading to dehydration, fever, neurologic
involvement, sudden onset of severe abdominal pain,
persistent (> 7 days) diarrhea, or possible community-acquired
diarrhea, traveler’s diarrhea, or nosocomial diarrhea
19. ED Management
History Of Present Illness
• Type and volume of stools:
• Associated symptoms: nausea, vomiting, abdominal pain, fever, and tenesmus
•
•
•
•
•
Character and location of any abdominal pain
Duration of symptoms
Weight loss
Indicators of dehydration
Epidemiological risk factors
• Recent diet, ingestion of seafood, raw or undercooked meat, eggs, or milk
products
• Recent foreign travel
• Lake or stream swimming
• Visits to a farm
• Ill contacts,
• Group living arrangements (e.g., nursing home, college dormitory) or day
care attendance
20. • Past Medical History
• Comorbidities
• Immunosuppression
• Crohn’s disease or ulcerative colitis
• Medications
• prescription, over-the-counter, and herbal preparations
• laxatives, antibiotics, magnesium- or calcium-containing antacids.
• alpha-glucosidase inhibitors (e.g., acarbose, miglitol)
• Artificial sweeteners containing sorbitol or mannitol
• Enteral tube feedings
21. • Social History
• Occupational history (veterinarian, food handler, or
day care center or nursing home employee)
• Sexual preference
• Inquire about alcohol and drug use
22. Indications for diagnostic
evaluation
• Profuse watery diarrhea with signs of hypovolemia
• Passage of many small volume stools containing blood and
mucus
• Bloody diarrhea
• Temperature ≥38.5ºC (101.3ºF)
• Passage of ≥6 unformed stools per 24 hours or a duration of
illness >48 hours
• Severe abdominal pain
• Recent use of antibiotics or hospitalized patients
• Diarrhea in the elderly (≥70 years of age) or the
immunocompromised
23. Tests
• Blood Tests
• CBC: unnecessary in most
• Chem Path: unnecessary in most
• Fecal Leukocyte/Lactoferrin Testing:
• Community-acquired or traveler’s diarrhea, nosocomial
diarrhea, and diarrhea persisting more than seven days
have been suggested
24. • Stool Culture
• the yield on routinely obtained stool cultures is low (1 -5%)
• Indicated :
•
•
•
•
•
history of bloody stools (grossly bloody or heme-positive stools)
stools containing leukocytes or lactoferrin;
immunocompromised patients; fever higher than 38.5°C (101.3°F);
systemic illness or an illness that is clinically severe or persistent;
patients with severe abdominal pain.
• Stool testing for Parasites
• diarrhea lasting more than 14 days
• immunocompromised
• not responded to antimicrobial therapy
26. HIV/ AIDS
• Prone to diarrheal Illnesses, in developing world up to 100%
• Increased risk due to:
• Develop enteric infections from a variety of unusual viral,
parasitic, protozoal, and bacterial organisms
• Malignancies (lymphoma/Kaposi's sarcoma)
• Multiple course of antibiotics – antibiotic associated diarrhea
• Stool culture should be done, along with C. difficile toxin and
ova and parasite
• If negative consider endscopic investigation
27.
28. Treatment
• Rapidly assess hydration status, risk factors for likely bacterial
pathogen, and need for symptomatic relief
• Rehydration - IV VS ORT
• Diarrhea relief include loperamide, diphenoxylate, and
bismuth subsalicylate
29. Oral rehydration Therapy
• Directed at preventing or treating dehydration, replacing
ongoing fluid loss, and meeting nutritional needs
• Correct fluid deficit over 4 hours
• 50 – 100mls of ORS/ kg
• Aim for 30mls of ORS/kg per hour
• Pedialyte, Lytren, and Rehydrolyte
30. IV Fluids
• Indicated for severe dehydration, hemodynamic instability,
altered mental status
• 20 ml/kg bolus in children
31. Controversial Treatments
• Probiotics – microorganisms used to colonize the
intestine and treat or prevent diarrhea, found to reduce
duration on average 0.7 days, and frequency by 1.6 per
day
• Zinc – RCT suggests a reduction in duration and severity
of acute and persistent diarrhea, however more likely to
vomit
• Ramoplanin – a new antibiotic in Phase II development
for C. difficile associated diarrhea
32. Role of Antibiotics
• Empiric antibiotics should be considered for patients:
•
•
•
•
with acute dysentery
moderate-to-severe traveler’s diarrhea
Diarrhea lasting longer than two and a half days
fever greater than 38.5°C (101.3°F) plus either leukocyte-, lactoferrin, or hem occult-positive stools
• Fluoroquinolones for adults and trimethoprimsulfamethoxazole
(TMP-SMX) for children are reasonable
33. Disposition / Follow Up
• Decision relies heavily on physician judgment
• Most commonly – clinically stable, benign exam and low risk for
complications – safely discharged with follow up
• Moderate or severe dehydration, intractable or bilious vomiting,
surgical cause of vomiting, neurological abnormalities, large
ongoing losses, poor social support are candidates for admission
• Special consideration for patients with diagnostic dilemma,
extremes of age, immunocompromised, or multiple or severe
comorbidities
• Discharge instructions are mandatory both verbal and written
34. Transmission Prevention
• Good hand washing hygiene
• Travel Precautions
• Immunization - Rotavirus vaccines
• Patient & family education
35. Summary
• The role of the emergency physician is to exclude serious
illness, ensure patient stability, begin an investigation to
exclude infectious causes of diarrhea, and provide timely
referral for further evaluation
• This diagnostic evaluation usually exceeds the scope of most
ED capabilities
• If there is a doubt about the diagnosis, ED observation and
repeated examinations can be helpful.
• Patients warranting a greater level of concern are the very
young, the elderly, immunocompromised individuals, those
with major comorbidities, and those with unusual or atypical
presentations
Editor's Notes
Tenesmus -ineffectual and painful straining at stool, feeling of incomplete emptying
Bacterial causes are responsible for most cases of severe diarrhea. This was illustrated in a study of 173 healthy adults with severe (defined as ≥4 fluid stools per day for more than three days) acute community-acquired diarrhea; a bacterial pathogen was identified in 87 percent of cases
Secretory diarrhea is caused by these chain of events.Two types of bacteria produce diarrhea in a similar way, Vibrio cholerae and enterotoxigenic Escherichia coli(ETEC). After adhering (sticking) to the wall of the bowel, a toxin enters the enterocytes and stimulates an enzyme called adenylatecyclase (see Figure 2). This causes a chain of reactions which releases energy and results in the secretion of sodium and chloride ions (electrolytes) - accompanied by water - into the lumen of the bowel.Once a cell has been stimulated in this way it will continue to secrete fluid and electrolyte for the rest of its short life. With thousands and even millions of enterocytes all secreting uncontrollably, the bowel cannot reabsorb all the fluid and the result is watery diarrhea. This 'secretory diarrhea' can cause dehydration, circulatory collapse and death.
In such cases, a moderate quantity of lactose is consumed (usually as milk), but the intestinal epithelium is deficient in lactase, and lactose cannot be effectively hydrolyzed into glucose and galactose for absorption. The osmotically-active lactose is retained in the intestinal lumen, where it "holds" water. To add insult to injury, the unabsorbed lactose passes into the large intestine where it is fermented by colonic bacteria, resulting in production of excessive gas.
•VIRUS DIARRHOEA (e.g. Rotavirus)Effect on villus structure and functionEnzyme damageSignificant effect on digestion and absorptionSecretion-absorption imbalance
Invasive diarrheaOther pathogens produce diarrhea in a different way. The Shigella bacteria not only colonise the surface of the small bowel but they also penetrate and invade the mucous membrane. Many enterocytes are destroyed, blood vessels may rupture, the white cells of the patient's defense mechanism die and are excreted as pus along with blood and tissue fluid. The result is dysentery diarrhea. Other invasive germs include the food-poisoning Salmonellae bacteria. These cause less local damage but penetrate blood vessels causing bacteremia - circulation of pathogens in the bloodstream - and generalized illness with fever and vomiting.The rotavirus is also a common cause of acute diarrhea in small children. The organisms penetrate the small bowel in patches, killing many enterocytes and in this way reducing the surface for absorption. They may also have some secretory mechanism since they often produce a watery diarrhea.
When vomitingis a prominent feature of the patient’s symptoms,viruses are the more likely etiologic agents.12,37 Fevergreater than 38.5°C (101.3°F) is usually associated withintestinal inflammation due to invasive bacteria (e.g.: Pain iscommon in patients with mesenteric ischemia, inflammatorybowel disease, and irritable bowel syndrome.22Symptom duration can helpnarrow the differential diagnosis. Viral gastroenteritisusually lasts 12-60 hours.2 Thus, it is less likely thatdiarrhea lasting more than a couple of days or so isviral. Diarrhea lasting greater than two weeks often hasa different etiology (see Table 3) than diarrhea that hasbeen present for less than two weeks.37Determine whether the patient has lostweight. Patients with diarrhea may have weight lossbecause of both increased output and reduced intake.Substantial weight loss is more likely due to ischemia,neoplasm, or malabsorptive syndromes.22 Weight lossmay be an indicator of dehydration in children.Asking about urine output,dizziness, thirst, and syncope—as well as askingfamily members or prehospital personnel about alteredmental status—is useful in assessing the patient’svolume status.
A chemistry panel may reveal an electrolyteimbalance or the degree of dehydration in systemically illpatients, or in those with severe or persistent diarrhea. Inpatients with bloody diarrhea, obtain a CBC and plateletcount to exclude hemolytic uremic syndrome. (Hemolyticuremic syndrome is discussed in further detail in the sectionon pediatric patients later in this article.) Eosinophilia on theleukocyte differential can point to food allergy, collagenvasculardiseases, neoplasm, parasitic infections, or eosinophilicgastroenteritis or colitis.22 Such diagnostic testingshould be reserved for select cases in which clinical orepidemiologic factors or disease severity suggest theirneed.5 Unfortunately, the literature does not provide clearcutindications for such testing.
Immunocompromized PatientsPatients with HIV/AIDS are especially prone to diarrhealillnesses. About half of North American AIDS patients willdevelop diarrhea at some point in their illness. The incidenceof diarrhea in AIDS patients throughout the develop-ing world approaches 100%.65While HIV/AIDS patients are at risk for all of thediarrheal ailments that afflict the immunocompetentpopulation, they can develop enteric infections from avariety of unusual viral, parasitic, protozoal, and bacterialorganisms. Malignancies affecting the gastrointestinal tract,such as lymphoma and Kaposi’s sarcoma, may producediarrhea, as can many antiretroviral medications.65,66 Finally,many AIDS patients receive multiple or sustained courses ofantibiotics, predisposing them to C. difficile-associateddiarrhea.66 Therefore, it is important to maintain a broaddifferential diagnosis, consider a more aggressive diagnosticstrategy, involve consultants early when appropriate, andconsider hospitalization to improve diagnostic certaintythrough a combination of testing, observation, and consultantinvolvement. (See also the January 2002 issue ofEmergency Medicine Practice, “HIV-Related Illnesses: TheChallenge Of ED Management.”)Because certain symptoms may suggest particularorganisms (see Table 5), the approach to the HIV/AIDSpatient with diarrhea begins with the history. Definitivediagnosis, however, is likely to result from either microbiologicalstudies or endoscopy.65,66 Begin by assessing thepatient’s immune status. Ask about specific exposures(sexual practices, travel history, and medications includingrecent antibiotics). Inquire also about the stool characteristics(bloody, mucoid, watery) and all associated symptoms(e.g., fever, vomiting, abdominal pain or cramping, tenesmus,bloating, weight loss).65,66 What may seem like an acutebout of diarrhea may actually represent the beginning ofchronic symptoms. Routine laboratory tests should beordered based on the clinical situation.65 Many authoritiesrecommend that in AIDS patients, a stool culture should bedone, along with C. difficile toxin and ova and parasitetesting.66 If these studies are negative, referral to a gastroenterologistfor endoscopic investigations could be the nextstep in the patient’s evaluation.65,66 In the AIDS patient withchronic diarrhea and a negative microbiological work-up forinfectious agents, authorities are divided on the bestapproach. Some advocate symptomatic care, some a courseof empiric antibiotics, and still others suggest endoscopy disease stage guide these decisions.17 Endoscopy oftenproduces a definitive diagnosis in AIDS patients withchronic diarrhea and negative stool studies.67ED treatment options include rehydration, antimotilityagents, and empiric antibiotics, as discussed earlier in thisarticle. Consultation or referral to the patient’s primary careprovider or infectious disease specialist regarding antibiotictherapy or changes in antiretroviral therapy are advisable.
afebrile and have non-bloodydiarrhea as well as most patients with chronic diarrheaassociated with inflammatory bowel disease may benefitfrom the use of antimotility agents.28 Antimotility agentsshould generally be avoided in patients with high fever,sepsis, immunocompromise, bloody diarrhea, or suspectedinflammatory diarrhea because of delayed clearance ofenteric pathogens, prolonged fever, and toxic megacolon
Controversies/Cutting EdgeProbioticsProbiotics are microorganisms that some have used in a variety of settings and clinical circumstances to colonize the intestine to prevent or treat diarrhea. One recent meta-analysis of probiotic use in children hospitalized with acute gastroenteritis found that probiotics are a useful adjuvant along with rehydration therapy in acute gastroenteritis.73 Another meta-analysis of oral Lactobacillus (the most-studied probiotic) treatment of children with acute infectious diarrhea found that diarrhea duration was reduced an average of 0.7 days, and stool frequency decreased by an average of 1.6 per day.74 A third recent meta-analysis of probiotics for antibiotic-associated diarrhea found that diarrhea occurred in 23% of patients not receiving a probiotic agent and in 13% of patients receiving a probiotic.75 This meta-analysis involved children and adults.While probiotics are not standard therapy for adults or children with diarrhea in the United States, they are available over-the-counter in a variety of retail outlets, and patients may ask about their utility in diarrheal illnesses.ZincIn 2000, a pooled analysis of randomized, controlled trials of zinc therapy in children under 5 years of age with diarrhea concluded that zinc supplementation reduces the duration and severity of acute and persistent diarrhea.76 A more recent randomized, controlled clinical trial studied the effects of zinc administration in children with diarrhea. This study was done in Nepalese children 6-35 months of age with acute diarrhea. Findings were that zinc supplementation substantially reduced diarrhea duration and that those in the zinc group were more likely to vomit than those in the placebo group.77 It should be noted that the studies referenced above were conducted primarily in the developing world, where zinc deficiency in children is prevalent. In the United States, zinc administration to children with diarrheal illnesses is not a part of standard therapy. Ramoplanin For C. difficile-Associated Diarrhea A new antibiotic, ramoplanin, is currently in Phase II development for C. difficile-associated diarrhea. This antibiotic also has activity against vancomycinresistant Enterococcus species and other enteric organisms.78 Ramoplanin is an oral agent and is not systemically absorbed.79