Diarrhea

Infections (nejm 2004:35038)

Preformed toxins ("food poisoning." <24 h): S. aureus. C. perfringens, 6. cereus Viruses: rotaviruses, noroviruses, adenovirus. CMV (immunosuppressed Pts) Noninvasive bacteria enterotoxin-producing (© fecal WBC or blood): enterotoxigenic E. coft. Vibrio cholera cytotoxin-producing (® fecal WBC and blood): £ co/i 0157:H7. C. difficile Invasive bacteria (© fecal WBC and blood): enteroinvasive E.coli (EIEC), Salmonella.

Shigella. Campylobacter. Yersinia, V. parahaemolytkus Parasites. Giardia (© fecal WBC and blood): £ histolytica (© fecal WBC. - blood) Opportunistic: Cryptosporidia, Isospora, Microsporia, Cyclospora. MAC. CMV

• Chronic: Giardia, £ histolytica, C. difT'cile, opportunistic organisms

• Clues as to etiology

Travel: £ coli, parasites (Giardia with ingestion of water from streams) Shellfish: noroviruses. Vibrio sp.; Undercooked hamburger: E. coli 0157:H7;

Poultry: Campylobacter, Salmonella Antibiotic use: C. difficile (see below)

Medications (cause T secretion, t motility. A flora, t cell death, or inflammation)

• Antibiotics, antacids, lactulose, sorbitol. chemoRx. colchicine, gold. ASA. NSAIDs

Malabsorption (. diarrhea with fasting, t osmotic gap. * fecal fat)

• Bile salt deficiency i synthesis: liver disease (cirrhosis) or cholestasis (primary biliary cirrhosis) bacterial overgrowth: deconjugation of bile salts or -I nutrient absorption ileal disease (eg. Crohn's, surgery): interruption of enterohepatic circulation

• Pancreatic insufficiency: most commonly from chronic pancreatitis

• Mucosal abnormalities

Celiac sprue: intestinal reaction to u-gliadin in gluten — loss of villi & absorptive area other s s: Fe-defic anemia, dermatitis herpetiformis (pruritic papulovesicular rash) Dx: anti-tissue transglutaminase or anti-endomysial IgA; small bowel bx treatment: gluten-free diet (Lancet 2003:362:383) Tropical sprue: affects residents of the tropics; treatment with antibiotics, folate. B12. iron Whipple's disease (nejm 2007:365:55): infxn w T. whipplei affects middle-aged white men other s s: fever, LAN. edema, arthritis, CNS As, gray-brown skin pigmentation. Al & MS. oculomasticatory myorhythmia (eye oscillations + mastication muscle contract.) treatment: PCN G + streptomycin, or 3rd-gen ceph x 10-14 d -*> Bactrim for 2:1 y

• Lactose intolerance: 10 or 2° mucosal abnormality, viral bacterial enteritis, s p resection clinical manifestations: bloating, flatulence, discomfort, diarrhea

Dx: lactose hydrogen breath test or empiric lactose-free diet treatment: lactose-free diet, use of lactaid milk and lactase enzyme tablets

• Other: Crohn's disease, eosinophilic gastroenteritis, intestinal lymphoma inflammatory (fever, hematochezia, abdominal pain)

• Inflammatory bowel disease

• Radiation enteritis, ischemic colitis, diverticulitis, neoplasia (colon cancer, lymphoma)

Secretory (normal osmotic gap. no A diarrhea after NPO, nocturnal diarrhea freq described)

• Hormonal: VIP (VIPoma.Verner-Morrison). serotonin (carcinoid), calcitonin (medullary cancer of the thyroid), gastrin (Zollinger-Ellison). glucagon, substance P. thyroxine

• Laxative abuse

• Neoplasm: carcinoma, lymphoma, villous adenoma

• Idiopathic bile salt malabsorption

• Lymphocytic colitis, collagenous colitis (often associated with meds. including NSAIDs) Motility

• Irritable bowel syndrome (10-22% of adults; nejm 2001:344.1846): Rome III criteria recurrent abd pain d mo over last 3 mos plus 2 or more of the following;. 1) improvement w defecation. 2) onset w A freq of stool. 3) onset w A in form of stool treatment (nejm 2003:349:2136): constipation — fiber; diarrhea — anti-diarrheals; pain antispasmodics

• Scleroderma (pseudo-obstruction); diabetic autonomic neuropathy, hyperthyroidism

Diarrhea workup

Figure 3-2 Workup of acute diarrhea |< 3 wta duration)

Acute diarrhea i severe dehydration, fever, duration >5 d, mucus, pus. or blood in BM, abd pain.

recent travel, or recent abx use? / I

no to all of the above yes to any of the above

Observation Rehydration as needed

Fecal leukocytes FOB

C diff toxin (esp it recent abx)

O local leukocytes O FOB

Stool O&P x3

O local leukocytes O FOB

Med-inducod Viral Enterotoxtc Bact

Pulrilnvlr rtr

Cytotoxic or Invasive Bacterial

Pseudomembranous colitis

Figure 3-3 Vtorkup of chronic diarrhea ( -3 wki duration)

Chronic diarrhea

-culpntmeds-med-induced

- © laxative screen laxative abuse -® lactose lest-► lactose intolerance

- © stool cx-infection stool osmot* gap - Osm^, (usu 290) - [2 (Na^+K^)] fecal tat fecal leukocytes. FOBT response to NPO

osmotic gap <50 e local tat, Q local leuks & FOBT no A w/lasting

[ Secretory hormone levels colonoscopy ? Rx w/ cholestyramine osmotic gap >50 © fecal fat diarrhea I w/ tasting *

| MalabsorptioaQsmotw: |

fecal leukocytes ®FOBT

Inflammatory mucosal abnl: ✓ small intest. bx flex sig, pane insuffic: secretin test. ERCP colonoscopy, or bact overarowth ✓ "C-xvlose test UGI w/ SBFT

(nijm 1WS;332.725)

Empiric treatment for acute, community-acquired, likely infectious diarrhea

• Mild: bismuth subsalicylate & loperamide prn

• Moderate-severe or fever, blood, or pus: consider empiric fluoroquinolone x 1-5 d (if no suspicion for E.coli 0157:H7 or fluoroquinolone-resistant Compyhbocter)

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  • Annika
    What is diarrhea/clinical manifestation?
    7 years ago

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