diarrhea

diarrhea

acute

- <2 weeks

-MCC: infectious

persistant

- 2-4 weeks

chronic

- >4 weeks

-mild: <3 stool a day

-moderate: >4 stools with local sx

-severe: >4 stoll with systemic sx

diarrhea classification

secretory diarrhea

-increase in secretion or inhibition of absorption

-large volume without inflammation

inflammatory diarrhea

-typically, bloody with fever

-invasive organisms

osmotic

-excess water drawn into bowel lumen

-malabsorption, maldigestion

diarrhea hx and sx

-OLDCARDS

-frequency of stool

-description

-recent travel

-sick contracts

-tolerating PO intake

-recent abx use

-vitals, general appearance, cardiopulm, GI exam

diarrhea dx

-stool culture

-fecal lactoferrin and stool leukocyte stains: WBC in still signify inflammation

-ova and parasite testing: eggs or parasites in stool

-NAAT: presence of bacteria

-toxic assay: presence of toxins

testing is recommended when

-diarrhea and fever, bloody stool, severe cramping, sepsis, immunocompromised

diarrhea tx

Loperamide

-most effect OTC

-avoid in infectious diarrhea with fever or blood

Bismuth subsalicylate

-darkens stool, tongue

-avoid in children and aspirin allergy

-good for patients with travelers diarrhea

Diphenoxylate/Atropine

-for severe acute diarrhea unresponsive to OTC, chronic diarrhea

-causes drowsiness, dry mouth, respiratory depression, anticholinergic toxicity

viral gastroenteritis

-most infectious diarrheal illness are caused by norovirus or rotaviruses

Norovirus

-12-48 incubation period

-contaminated food/water, person to person, common in closed setting

Sx: sudden onset of vomiting, watery diarrhea, abdominal cramping

-1-2 days

Dx: clinical

Tx: supportive care (BRAT diet)

Rotavirus

-2 day incubation

-fecal oral, most common cause in infants

Sx: rapid onset of dehydration in young children, watery diarrhea, vomiting, fever

-5-8 days

Dx: fecal EIA testing

Tx: supportive

bacterial diarrhea

invasive

-invade the intestinal mucosa, penetrate and multiply within intestinal epithelial cells > inflammation and death

-BLOODY

-shigella

-salmonella

-campylobacter jejuni

-E coli

-yersinia enterocolitica

non-invasive

-remain in intestinal lumen

-secretary or secondary

-WATERY

enterotoxigenic E. Coli diarrhea

-non-invasive

-travelers diarrhea

-1-3 day incubation

-contaminated food and water

Sx: watery diarrhea, abdominal cramps, nausea

-1-5 days

Dx: PCR or EIA

Tx: supportive care

-abx if severe: azithromycin or ciprofloxacin

enterohemorrhagic E. coli diarrhea

-invasive

-cause: E coli 0157:H7

-3-4 day incubation

-undercooked ground beef

Sx: sever abdominal cramping, blood diarrhea, purulent diarrhea, potenial for HUS

-5-10 days

Dx: PCR or EIA for shiga toxin

Tx: supportive care

-avoid abx

shigella

-invasive

-1-6 day incubation

-fecal oral, contaminated food/water, daycare

Sx: blood diarrhea, purulent diarrhea, abdominal cramping and pain, fever, tenesmus

-1-7 days

Tx: fluid replacement

-abx for severe: azithromycin or ciprofloxacin

salmonella

-invasive

-6-72 hour incubation

-contaminated poultry, eggs, dairy

Sx: watery diarrhea, abdominal cramps, fever, nausea

-4-7 days

-septicemia common

Tx: supportive

-abx if severe: ciprofloxacin or ceftriaxone

campylobacter

-invasive

-2-5 day incubation

-undercooked poultry, milk, contaminated water

Sx: watery or blood diarrhea, abdominal cramps

-potential for guillain barre

-2-5 days

Tx: supportive care

-abx if severe: azithromycin or ciprofloxacin

cholera

-non-invasive

-2-3 days

-contaminated water, raw or undercooked seafood, fruits and vegetables washed in bad water

Sx: profuse watery diarrhea, rapid dehydration, vomit, muscle cramps, weakness, dry mucous membrane

Dx: stool culture

Tx: aggressive rehydration IV and doxycycline

giardia

-most common intestinal parasite in US

-7-14 days

-high risk for hiker who drink unfiltered water

Sx: foul-smelling, fatty stool (steatorrhea), malaise, flatulence

Dx: PCR

Tx: tinidazole 2g PO one time dose

C. Diff infection patho

-colonizes the gut after normal flora disruption > produces toxins A and B > inflammation and diarrhea

C. Diff infection etiology

-overgrowth of toxin producing C diff in the colon

-usually occurs after abx use disrupts normal gut flora

C. Diff infection RF

-abx use

-advanced age

-prolonged hospital stay

-immunosuppression

C. Diff infection sx

-water diarrhea

-abdominal pain or cramping

-fever

-nausea

-dehydration

-complication of toxic megacolon

C. Diff infection dx

-NAAT for toxin gene

-EIA: for toxin A and B

-if severe colonoscopy: pseudomembranous colitis

C. Diff infection tx

-discontie abx

-ORAL vancomycin

-fidaxomicin is alternative

-fecal transplant is recurrent

foreign body

-18-48 mon old children most common

-most pass spontaneously

-adults: most impactions are distal

-once is passes pylorus it typically passes without issue

foreign body etiology

-accidental ingestion (most common in children)

-intentional ingestion (psychiatric)

-occupational hazards

foreign body sx

-asymptomatic

-dysphagia and odynopagia

-vomiting

-drooling

-abdominal tenderness

-perforation= fever, tachycardia, peritonitis

foreign body dx

-Xray = show right away

-CT scan

-endoscopy

foreign body tx

-depends on object ingested

-observation of stool for passage

indication for removal

-button batteries

-magnets

-sharp objects

-above diaphragm = EGD

-below diaphragm = surgery

food impaction

-meat is most common

-usually time will allow for food to pass

if 12-24 hours then IV glucagon therapy

-complete esophageal obstruction = emergent endoscopy

toxic ingestions

-common in children under 6

-most common substances: analgesics, cleaning products, cosmetics, plants

toxic ingestions etiology

-accidental ingestion

-intentional ingestion

-occupation exposure

-latrogenic

toxic ingestions sx

-detailed hx of ingestion

-nausea, vomiting, abdominal pain

-altered mental status

-respiratory distress

-seizures

toxic ingestions dx

-clinical suspicion

-toxic screens

-basic labs: CBC, electrolytes, liver, kidney function, blood gas

-ECG for cardiotoxicity

toxic ingestions tx

-stabilization

-activated charcoal within 1 hour

-antidotes for specific agents

-supportive care

-continuous cardiac monitoring

nutritional deficiencies etiology

-inadequate dietary intake

-malabsorption disorders

-increased requirement (pregnant)

-medication interfering wtih absorption

nutritional deficiencies RF

-poor nutrition or limited food variety

-chronic GI disorder

-advanced age

-pregnancy and lactation

-veganism

-bariatric surgery

vitamin A deficiency

-fat soluble

-source: fish oil, milk, eggs

-function: vision

-at risk: eldery, alcohol use, liver diease

-sx: night blindness, dry skin

vitamin D deficiency

-fat soluble

-source: milk, sunlight

-function: calcium regulation

-at risk: elderly, low sun

-sx: rickets, osteomalacia, bone pain

-toxic: kidney stones, hypercalcermia

vitamin E deficiency

-source: plant oil, wheat, asparagus, peanuts

-function: slow cell age, vascular integreity, antioxidant

-at risk: rare

-sx: hemolytics anemia, degernative nerve change

vitamin K deficiency

-source: liver, green leafy vegatable, broccoli, peas, green beans

-function: clotting

-at risk: rare

-sx: anemia, jaundice

thiamine B1 deficiency

-source: pork, grains, dried beans, peas

-function: carbohydrate, nerve function

-at risk: alcoholism, poverty

-sx: beriberi

riboflavin B2 deficiency

-source: milk, spinach, liver, grains

-function: energy

-at risk: poverty, heavy alcohol

sx: oral inflammation, eye disorder

niacin B3 deficiency

-source: bran, tuna, salmon, chicken, beef, liver, peanuts

-function: energy, fat metabolism

-at risk: poverty, heavy alcohol

-sx: dermatilits, dementia, diarrhea

-toxic: flushing

pantothenic acid B5 deficiency

-source: liver, brocolli, eggs

-function: energy, fat metabolism

-at risk: alcoholism

-sx: tingling, fatigue, headache

pyroxidine B6 deficiency

-source: animal protein, spinach, broccoli, bananas

-at risk: adolescents, alcoholism

-sx: headache, anemia, seizures, falky skin

-toxic: nerve damage

biotin B7 deficiency

-source: cheese, eggs, cauliflower, peanuts, liver

-function: glucose production, fat synthesis

-at risk: alcoholism

-sx: dermatitis, tounge pain, anemia, depression

folate B9 deficiency

-source: green leafy vegatables, orange juice, grains

-function: DNA synthesis

-at risk: alcoholism, methotraxate, pregnancy

-sx: megaloblastic anemia, glossitis, diarrhea

cobalamin B12 deficiency

-source: animal foods

-function: folate metabolism, nerve function

-at risk: elderly, vegans. bariatric

-sx: megaloblastic anemia, neuropathy

vitamin C deficiency

-source: citrus fruits, strawberry, brocolli

-function: collagen synthesis, hormone function

-at risk: alcoholism, elderly men

-sx: scurvy

-toxic: diarrhea