Diarrhea and Constipation

Diarrhea

An increase in stool frequency (more than 3x a day) or loose/watery stools that can be self-limited to severe (most likely infectious)

14 days or less

Acute diarrhea is classified by

14-30 days

Persistent diarrhea is classified by

more than 30 days

Chronic diarrhea is classified by

Inflammatory

Which type of acute diarrhea am I describing - bacteria/toxin invades mucosal tissues causing damage and likely systemic illness characterized by bloody stools, fecal leukocytes, and fevers

Non-inflammatory

Which type of acute diarrhea am I describing - bacteria/toxins do not invade or lead to the breakdown of the mucosa (no blood or fecal leukocytes)

Norovirus, rotavirus

Types of viral gastroenteritis

Norovirus

The most common cause of the stomach bug that is common on cruise ships, daycares, and schools

Rotavirus

Which type of viral gastroenteritis is most likely found in infant and young kids (daycare, school)

giardia, cryptosporidium

Types of protozoal noninflammatory acute diarrhea

Giardia

Which type of protozoal noninflammatory acute diarrhea is commonly associated with untreated water when camping, daycares or schools - spreads quickly (NO blood or leukocytes)

Cryptosporidium

Which type of protozoal noninflammatory acute diarrhea is commonly associated with untreated water when camping, and is largely an opportunistic infection affecting immunosuppressed individuals (think HIV)

Bacillus cereus, clostridium perfinges, staph aureus

Types of bacterial non-inflammatory acute diarrhea that have PREFORMED ENTEROTOXINS

Staph aureus

20 y/o male presents to the ED for abdominal pain and cramping. He also reports N/V/D, he states that this started 1-6 hours after eating his meat, eggs, and dairy → what type of bacteria are you thinking?

Bacillus Cereus

What type of bacterial non-inflammatory acute diarrhea is associated with rice, leftovers, sauces, soups, and gravies that were left out of the fridge too long → onset 30min - 6hr (emetic) OR 6-15 hours (diarrheal)

Clostridium perfringes

What type of bacterial non-inflammatory acute diarrhea is associated with beef, poultry, and gravy → onset of diarrhea and cramping w/in 6-24 hours

E.coli, vibrio cholerae

Types of bacterial non-inflammatory acute diarrhea that produce enterotoxins

E. coli

What type of bacterial non-inflammatory acute diarrhea is associated with undercooked ground beef, unpasteurized milk/juice, contaminated water → onset of diarrhea and cramping within 1-10 days

Vibrio Cholerae

What type of bacterial non-inflammatory acute diarrhea is associated with fecal contamination → onset of profuse, “rice-water” stools within 3 hours-5 days

CMV, entamoeba hystolytica (protozoa), vibrio parahaemolyticus (cytotoxin producing), C.diff (cytotoxin producing), E.Coli 0157:H5, Shigella (mucosal invasion), Campylobacter jejuni (mucosal invasion), Salmonella (mucosal invasion), Yersinia enterocolitica (mucosal invasion), Listeria (mucosal invasion)

Types of inflammatory acute diarrhea

CMV

Which type of inflammatory acute diarrhea is more common in immunocompromised patients

entamoeba hystolytica

Which type of inflammatory acute diarrhea is due to a parasite from untreated water

Vibrio parahaemolyticus

Which type of inflammatory acute diarrhea is associated with contaminated oysters or shellfish → onset of 2-24 hours

Clostridium difficile

Which type of inflammatory acute diarrhea is an opportunistic infection associated with antibiotic use (clindamycin)

E.coli 0157:H5

Which type of inflammatory acute diarrhea is associated with undercooked ground beef → onset is 2-24 hours (toxin can lead to sepsis or death)

Shigella

Which type of inflammatory acute diarrhea is associated with sandwiches, salads and raw foods that made contact with an infected person?

Campylobacter jejuni

Which type of inflammatory acute diarrhea is associated with undercooked poultry, unpasteurized milk, and contaminated water → can lead to Guillain Barre Syndrome

Salmonella

Which type of inflammatory acute diarrhea is associated with undercooked poultry or eggs, unpasteurized milk or juice, cheeses, contaminated veggies, and contact with reptiles and amphibians?

Yersinia enterocolitica

Which type of inflammatory acute diarrhea is associated with undercooked pork

Listeria

Which type of inflammatory acute diarrhea is associated with lunch meats, hot dog, soft cheeses → presents with fever, stiff neck, confusion, vomiting

CBC, CMP, Stool (leukocytes, cultures, assay for C.diff, ova/parasite if longer than 10 days, PCR)

20 y/o male presents to the ED for abdominal pain and cramping. He also reports N/V/D, he states that this started 1-6 hours after eating his meat, eggs, and dairy. What diagnostics do you want?

tachycardia, hypotension, orthostatic hypotension, dry mucous membranes

Signs of dehydration to watch out for in diarrhea

Fluids, antidiarrheal medications (loperamide - only mild-moderate disease, risk of toxic megacolon), probiotics

20 y/o male presents to the ED for abdominal pain and cramping. He also reports N/V/D, he states that this started 1-6 hours after eating his meat, eggs, and dairy. Labs are negative. What is your treatment plan?

Fever, 6+ stools/day, bloody stools, immunocompromised peeps, significant dehydration, 70+ y/o

Empiric abx for acute diarrhea should be considered IF → otherwise wait for labs

Azithromycin, ciprofloxacin

Which empiric abx should you pick for acute diarrhea

Chronic diarrhea

Increased stool frequency of more than 3/day, stool weighing more than 200 g/day, and decreased fecal consistency occuring over a 4 week period

Watery (osmotic, secretory), bloody/pus (inflammatory), fatty (pancreatic insufficiency)

Classifications of chronic diarrhea

Cholinesterase inhibitors, SSRIs, PPIs, ARBs, NSAIDs, metformin, allopurinol, orlistat

Common medications that can cause watery diarrhea

Malabsorption syndromes (most common - presents abdominal distention, bloating, and flatulence)

What may cause osmotic (increased osmol gap) watery stools

Endocrine tumors (stimulate intestinal or pancreatic secretion), bile salt malabsorption (stimulating colonic secretion)

What may cause secretory (normal osmol gap) watery stools

hyperthyroidism, DM

What systemic diseases may cause watery stools

IBS (most common in young adults), functional diarrhea (no abnormal findings)

What motility diseases may cause watery stools

UC, CD, Chronic C. diff or giardia

What causes blood or pus in the stools in inflammatory chronic diarrhea

CBC, CMP, TSH, Vitamin D and A, INR (vitamin K), ESR, CRP, IgA-tTG (if you think celiac), Stool (culutes, ova, parasites, fecal fat, leukocytes, electrolytes, fecal antigen detection for Giardia and histolytica), PCR, colonoscopy with mucosal biopsy, upper endoscopy

45 y/o female patient presents to the clinic for diarrhea that has been going on for the last 4 weeks. She notes that she has been running to the bathroom at least 4 or 5 times a day. She notes that the odor of her stools has changes and that they are greasy. What diagnostics you want?

Loperamide, Codeine and deodorized tincture of opium, clonidine, octreotide

Treatment game plan for chronic diarrhea

Traveler’s diarrhea

Diarrhea that presents 2-10 days into travel (change in climate, sanitation, social conditions) usually due to E.coli, shigella, camplylobacter

Should resolve in 1-5 days, maintain hydration, bismuth subsalicylate, loperamide

27 y/o female presents to the clinic for diarrhea, she states that she is “running to the bathroom at least 5 time a day.” She states that she is new to the area and has been visiting her mother the last few days. She also reports abd cramping and N/V. Vitals WNL. What’s your treatment plan?

Hydration, ciprofloaxacin/azithromycin

27 y/o female presents to the clinic for diarrhea, she states that she is “running to the bathroom at least 10 time a day.” She states that she is new to the area and has been visiting her mother the last few days. She also reports abd cramping that has been getting worse and N/V. Vitals are stable with the exception of a 103.2 temp. What is your treatment plan?

colonic motility, water, fiber, intact and properly functioning anal sphincters and pelvic floor muscles

Key factors for normal elimination of stool

involuntary and voluntary (assisted by relaxation, deep breathing, and posture)

Describe the normal colonic excretion

Constipation

Infrequent bowel movements or difficult passage of stools (<3 per week) that is more common in women and is often idiopathic → BIG issue in infants and elderly

Encopresis

A variant of constipation that can result in soiling of clothing when impacted stool collects in the colon/rectum creating an overflow of liquid stools that leaks → usually due to voluntary retention (in children 4+)

Primary (not a complication); secondary (complication of another disorder)

Etiologies of constipation

slow colon transit (up to 72 hours - idiopathic, women), Defecatory disorders

Primary constipation etiologies examples

Neuological disorders, myopathies, electrolyte abnormalities, opiates, colon lesions and cancers

Secondary constipation etiologies examples

No enough fiber, poor bowel habits, hypothyroidism, hyperparathyroidism, DM, hypokalemia, hypercapnia, uremia, Neurological disorders, anticholinergics, diuretics, CCB, psych meds, rectal prolapse/stricture/fissure, colonic mass/obstruction, pelvic floor dyssynergia (anismus), IBS

Common etiologies of constipations

psychosocial issues, create normal toilet habits, high fiber diet, exercise, increase fluids, trial of fiber (1st line - bran powder, psyllium, methylcellulose, calcium polycarbophil, guargum)

35 y/o female presents to the clinic for “feeling bloated.” She also reports abdominal cramping that worsens after eating and comes in waves. On physical exam you note hyperactive bowel sounds that progress to hypoactive and mild distended abd tenderness. On DRE there is no impacted stool in the vault. What are some dietary and lifestyle changes we could recommend?

gas and bloating (methylcellulose less, calcium polycarbophil (NO GAS))

ADRs for fiber laxatives

Age over 50, reports of blood from rectum or in stools, weight loss, FHx of colon cancers or IBD, signs of systemic disease, severe abdominal tenderness, guarding, and rebound, grossly bloody DRE, FOBT+, FIT+,

Constipation red flags that are indications for labs and imaging

DRE

ALL CONSTIPATION WORK UPS INCLUDE

CBC, CMP, TSH, FIT, FOBT, Colonoscopy (#1 draft pick for red flags), sigmoidoscopy, ABD x-rays, CT with contrast (undifferentiated ABD pain with constipations)

35 y/o female presents to the clinic for “feeling bloated.” She also reports abdominal cramping that worsens after eating and comes in waves and that she’s loss 15 lbs. On physical exam you note hyperactive bowel sounds that progress to hypoactive, a palpable mass in the LLQ, and severe abd tenderness. On DRE there is no impacted stool in the vault but there is gross blood. What diagnostics do you want?

Anal manometry with balloon expulsion test, defecography, radiopaque markers

Specialized test for constipation

Stool softeners (Docusate sodium, mineral oil)

What can we use in constipation to soften the stool if straining is required to defecate

pneumonia if aspirated (mineral oil)

ADRs for Stool softeners

Osmotic laxatives (Mg Hydroxide, lactulose, PEG (chronic))

What treatment for constipation increases the secretion of fluid into the colon via large indigestible molecules in the meds → nonresponders to fiber and stool softeners

Cramping, bloating (less with PEF), gas (lactulose), PEF

ADRs for osmotic laxatives

Stimulant laxatives (bisacodyl, cascara, senna)

What treatment for constipation can be used for the incomplete response to osmotic laxative - rescue med (not for long term), bloating and cramping are common due to irritation of the bowel

cramping

ADRs for Stimulant laxatives - avoid daily use

Lubiprostone ($$$), linaclotide

What treatment for constipation increases intestinal Cl secretion resulting in increased fluid resulting in increased fluid in the colon and faster colon transit

Nausea, C/I in pregnancy, NOT for peds (linaclotide)

Side effects for Lubiprostone and linaclotide

enema (water, sodium phosphate, mineral oil)

What treatment for constipation works fast (15-60 min) and is often used with digital disimpaction

Mu-opioid receptor antagonist that doesn’t affect anything outside the GI tract

For opioid induced constipation → what are we using

Fecal impaction (MUST be disimpacted with digit before oral medications)

Impaction of stool in the rectal vault that is causing an obstruction - may cause diarrhea overflow

hemorrhoids (most common), anal fissures, rectal prolapse, laxative abuse, toxic megacolon, fecal impaction, may exacerbate cardiac and cerebral vascular disease

Constipation complications

diverticulitis, IBS, IBS, bowel obstruction, intra-abd infection, cancer

DDx of constipations