diarrhea and constipation

increased stool frequency 3 or more times per day with loose/watery stools, ranging from mild self limited to severe and life threatening, with the most common cause of acute diarrhea in adults being infectious

diarrhea

diarrhea for 14 days or less

acute

diarrhea for 15-30 days

persistent

diarrhea for over 30 days

chronic

if pt has diarrhea and fever think

inflammatory

if pt has diarrhea and NO fever think

noninflammatory

acute diarrhea classifications

inflammatory and non-inflammatory

bacteria or toxin invades mucosal tissues causing tissue damage and likely systemic issues leading to diarrhea and other sx like bloody stools, fecal leukocytes, anf fever

inflammatory acute diarrhea

bacteria or toxins do not invade or lead to the break down of mucosa so you have diarrhea but NO blood or fecal leukocytes

non inflammatory diarrhea

the most common cause of “stomach flu” aka viral gasteroenteritis commonly sen on cruise ships, daycares and schools

norovirus

most common cause of nausea, vomiting, and diarrhea in the us

viral gastroenteritis

viral gasteroenteritis most likely found in infants and young kids seen in schools and daycares

rotaviruses

protozoal cause of diarrhea found in untreated water while camping, daycares and schools and can spread fast within families

giardia

protozoal cause of diarrhea found in untreated water while camping and largely an opprotunistic infection seen in immunocomp ppl

cryptosporidium

bacterial cause of diarrhea found in meats, eggs, dairy products, and other foods that require hand contact and without further cooking, onset 1-6 hrs after ingestion and will have N/V, diarrhea, and cramping

staph aureus

bacterial cause of diarrhea found in rice, leftovers, sauces, soups, gravy, and other strachy foods that have been left at room temp too long. vomiting will start 30min-6hrs later and diarrhea will start 6-15hrs after ingestion

bacillus cereus

bacterial cause of diarrhea found in beef, poultry, and gravy with onset 6-24hrs later and with diarrhea and cramping sx

clostridium perfringes

bacterial cause of diarrhea is found in undercooked ground beef, unpasterurized milk/juice and has an onset 1-10days after ingestion with diarrhea and cramping

E. coli

bacterial cause of diarrhea from fecal contamination of food and water, that will have profuse, watery diarrhea and “rice water stools”

vibrio cholerae

viral cause of diarrhea more common in immunocomp pts that we should check for in any immunocomp pts w diarrhea

cytomegalovirus

protozoal cause of diarrhea that is a parasite from untreated water

entamoeba hystolytica

a bacterial cytotoxin cause of diarrhea from contaminated oysters or shellfish with an onset 2-24hrs after ingestion

vibrio parahaemolyticus

a bacterial cytotoxin cause of diarrhea that is an opprotunistic infection when normal colon flora has been reduced seen in pts w recent antibiotic usage

clostridium difficile

a bacterial cause of diarrhea that comes from undercooked ground beef, onset 2-24hrs, and has antibiosis, massive toxin load that can lead to sepsis and death

e. coli 0157:H5

a bacterial cause of diarrhea that invades the mucosa and is found in sandwhiches, salads, and raw foods in contact w an infected person

shigella

a bacterial cause of diarrhea that invades the mucosa from undercooked poultry, unpasteurized milk, or contaminated water and can cause guillen barr syndrome

campylobacter jejuni

a bacterial cause of diarrhea that invades the mucosa and is from undercooked poultry or eggs, unpasteurized milk or juice, cheeses, contaminated veggies, snakes, turtles, frogs, lizards, and baby birds

salmonella

a bacterial cause of diarrhea that invades the mucosa from undercooked pork

yersinia enterocolitica

a bacterial cause of diarrhea that invades the mucosa from lunch meats, hotdogs, soft cheeses, causes fever, stiff neck, confusion, and vomiting, and meningitis like sx

listeria

if your patient with acute diarrhea is over 70yo, immunocomp, and/or has signs of severe illness (temp over 38.5C, abdominal pain, bloody diarrhea, 6+ stools in 24hrs, dehydration) what do we do

send stool for fecal leukocytes or NAAT → if pos get culture to confirm

c diff testing if recently hospitalized or on abx

ova and parasite testing if theyve had diarrhea for over 10days, traveled to an endemic region, theres a community water-born outbreak, HIV infection or at risk for HIV

if your patient with acute diarrhea is NOT over 70yo, immunocomp, and does NOT have signs of severe illness (temp over 38.5C, abdominal pain, bloody diarrhea, 6+ stools in 24hrs, dehydration) what do we do

symptomatic therapy (pedialyte or just water+sugar+salt),

bismuth subsalicylate or loperamide (anti-diarrheals)

acute diarrhea labs (dont need imaging unless ruling out other shit)

CBC, CMP, stool leukocytes, stool assay for C. difficile toxin, stool ova and parasite if diarrhea for over 10days, PCRs

since pt eval of acute diarrhea is focused on identifying sx of dehydration and inflammatory/invasive causes, what are the signs of dehydration we should look for

tachycardia, hypotension, orthostatic hypotension, dry mucous membranes

since pt eval of acute diarrhea is focused on identifying sx of dehydration and inflammatory/invasive causes, what are the signs of inflammation/invasive disease we should look for

fever, blood in stools, severe abdominal pain and tenderness

acute diarrhea tx for most ppl

diet and hydration (fluids w carbs and electrolytes, not too much sugar or make it worse, BRAT diet (bananas, rice, apples, toast)

antidiarrheals (loperamide, be careful bc risk of toxic megacolon and systemic illness)

probiotics

when are empiric abx indicated for acute diarrhea

fever, over 6 stools a day, bloody stool, immunocomp pts, significant clinical dehydration, over 70, comorbidities

empiric abx for acute diarrhea

azithromycin 3 days

ciprofloxacin 3-5 days

otherwise wait for labs and tailor tx to specific organism

inc stool frequency of more than 3 per day, stools over 200g per day, dec fecal consistency all occuring over 4 week period and grouped to describe composition and causative agent (either watery, bloody/pus, or fatty)

chronic diarrhea

watery diarrhea from malabsorptive conditions or meds

osmotic diarrhea

watery diarrhea form tumors or bile salts

secretory diarrhea

chronic diarrhea from inflammatory cause

bloody or pus diarrhea

chronic diarrhea from pancreatic insufficiency

fatty diarrhea

common meds that can cause watery diarrhea

cholinesterase inhibitors, SSRIs, PPIs, ARBs, NSAIDS, metformin, allopurinol, orlistat

most common cause of osmotic diarrhea with increased stool osmotic gap

malabsorption syndromes (of lactose, fructose, sorbitol, laxative abuse, or pancreatic insufficiency)

what will pts say makes their diarrhea better/worse if its osmotic watery diarrhea

gets better w fasting, worse after eating (consider in all postprandial diarrhea and ask about their diet)

characteristics of malabsorption of carbs

abdominal distention, bloating, farting due to inc gas production

how do we dx osmotic watery diarrhea (inc stool osmotic gap)

elimination trial of suspected thing you cant digest for 2-3wks or hydrogen breath test

increased intestinal secretion or decreased absorbtion resultis in high volume watery diarrhea w normal anion gap/osmotic gap that may cause dehydration adn electrolyte imbalance to develop

secretory watery diarrhea

causes of secretory diarrhea

endocrine tumors (stimulating intestinal or pancreatic secretion) or bile salt malabsorbtion (stimulating colonic secretion)

systemic causes of watery diarrhea

hyperthyroidism or DM altering motility or intestinal absorbtion

most common cause of chronic diarrhea in young adults

IBS

abnormal motility and malabsorption without pain and w no abnormal findings

functional diarrhea

causes of inflammatory (blood or pus) diarrhea

primary ulcerative colitis and crohns disease

chronic infectious causes of blood or pus diarrhea

persisting bacterial or parasitic infections (C.diff or giardia)

chronic diarrhea things to ask about

hx is important, ask when it started, is it continuous or intermittent, relationship to meals, at night or during fasting, associated incontinence etc

greasy or malodorous stool = malabsorption

blood or purulent stool = inflammatory

watery stool = secretory

associated sx (abdominal pain = IBS or inflammatory disease)

find signs of dehydration, malnutrition, underlying disease, abdominal pain, or blood on rectal exam

chronic diarrhea labs

serum: CBC, CMP, TSH, VIT A & D, INR, ESR, CRP, IgA tissue transglutaminase if they have signs of malabsorption (celiacs)

stool: cultures, ova and parasites, fecal fat (pos=malabsorption), occult blood, fecal leukocytes, stool electrolytes, fecal antigen detection test (for giardia and E. histolytica), acid fast staining, PCRs

chronic diarrhea imaging

colonoscopy w mucosal biopsy to rule out IBD and cancers

upper endoscopy for suspected small intestinal malabsorption conditions

chronic diarrhea tx

antidiarrheal agents: loperamide (imodium), codeine and deodorized tincture of opium (dont use chronically or get addicted), clonidine (alpha-2 adrenergic agonist stops intestinal electrolyte secretion) octreotide (stimulates intestinal fluid and electrolyte absorption, stops intestinal fluid secretion, used for secretory diarrhea)

only do abx if you think its infectious or pt is high risk

diarrhea beginning 2-10days into travel from change in climate, sanitation standards, and social conditions

travelers diarrhea

most common causes of travelers diarrhea

e. coli, shigella (inflammatory), campylobacter (inflammatory)

travelers diarrhea sx

up to 7-10 stools per day, abdominal cramping, nausea, maybe vomiting

travelers diarrhea tx

normally self limited w resolution in 1-5days, 10% have sx 1wk+, 2% have sx 1mo+, mostly benign and resolves on its own even though its bacterial

mild: hydrate, bismuth subsalicylate (pepto bismol), loperamide

indications for abx in travelers diarrhea

high fever, bloody stools, worsening abdominal pain

abx tx for travelers diarrhea

ciprofloxacin or azithromycin, rehydrate

key factors required for normal elimination of stool

colonic mobility, water, fiber, intact and properly functioning anal sphincters and pelvic floor musculature

normally an involuntary and voluntary process assisted by relaxation, deep breathing, and good posture

how can straining or inc pressure during shitting lead to death

vasovagal drop in BP followed by rebounding BP, aneurysm rupture, death

infrequent bowel movements or difficult passage of stools with less than 3 bowel movements per week, more common in women and often idiopathic but can become a big problem infants and elderly (can cause aneurysm and encopresis)

constipation

variant of constipation that can result in soiling of clothing when impacted stool collects in the colon/rectum, creating an overflow of liquid stool that leaks out, most often due to voluntary retention of stool (stress or emotional issues), more in kids over 4 or after potty training and is frustrating for parents and embarrasing for kids and they just need patience and positive reinforcement

encopresis

causes of secondary constipation

complication of another disorder or adverse effect of meds

neurological disorders, myopathies, electrolyte abnormalities, OPIATES (GIVE ALL PTS PRESCRIBED THESE STOOL SOFTENERS)

colon lesions/cancers obstructing passage

cause of primary constipation

primary slow colon transit (avg input-output time is 35hrs but can be up to 72hrs), often idiopathic and more in women

defecatory disorders (impaired coordination of musculature during defecation, with impaired relaxation or paradoxical contraction of the anal sphincter and pelvic floor muscles)

most common cause of constipation

inadequate fiber or fluid intake, poor bowel habits

systemic disease causes of constipation

endocrine: hypothyroidism, hyperparathyroidism, DM

metabolic: hypokalemia, hypercalcemia, uremia

neurologic: MS, spinal cord injury, stroke, dementia, parkinsons, hirschsprung disease

med causes of constipation

OPIOIDS, anticholinergics, diuretics, CCB, psych meds

structural abnormality causes of constipation

anorectal: rectal prolapse, structure, fissure

colonic mass or obstruction

pelvic floor dyssynergia (lack of coordination, aka anismus)

slow colonic transit causes of constipation

idiopathic, neurologic, eating disorders, preg

constipation sx

nausea, maybe vomiting, bloated feeling, intermittent abdominal cramping, “wave like” spasms, worse post-prandial, possible bowel incontinence of water from “overflow”

mild abdominal tenderness, hyperactive bowel sounds progressing to hypoactive or absent if constipation progresses into ileus

maybe: distended abdomen, palpable mass, often on left side of abdomen, RECTAL EXAM REQUIRED to check for impacted stool

red flag constipation sx

age over 50 w new onset, reports of blood from rectum or in stools, weight loss, fam hx of colon cancer or IBD

signs of systemic disease, severe abdominal tenderness, guarding, rebound tenderness, grossly bloody digital rectal exam, +FOBT, or +fecal immunochemical test

constipation dx

not needed unless its secondary or red flags present

labs: CBC, CMP, TSH, FOBT, Fecal immunochemical test (do if sx persistent despite conservative tx)

imaging: colonoscopy or flexible sigmoidoscopy (colonoscopy is dx of choice for red flags), abdominal xray can show large stool burden, CT w contrast (dx of choice for undifferentiated abdominal pain w constipation

constipation specialized tests

anal maometry w balloon expulsion (tests internal pressure and coordination of musculature)

defecography (barium paste put in asshole, x ray used to see shape and position of rectum during defecation)

radiopaque markers (encapsulated markers are swallowed to determine transit time by xray)

dietary and lifestyle change tx for constipation

Address psychosocial issues and create normal
toilet habits with regular schedule, proper
positioning, and abdominal pressure

High-fiber diet, exercise, d/c offending
medication, and increase in fluid intake

Trial of fiber supplements recommended as first-
line treatment

fiber laxative thats cheap but may cause gas and bloating

bran powder

fiber laxative that may cause gas and bloating

psyllium (metamucil)

fiber laxative that causes less gas and bloating

methylcellulose

fiber laxative that doesnt cause gas and comes in pill form

calcium polycarbophil

fiber laxative thats tasteless, non-gritty and causes less gas

guargum

constipation tx category w minimal side effects and good if straining is required to shit

stool softeners (docusate sodium, only marginal benefits or mineral oil which can cause pneumonia if aspirated)

constipation tx category that inc secretion of fluids into colon via large indigestable molecules in the meds, used for non responders to fiber and stool softeners,

osmotic laxatives:

magnesium hydroxide (aka milk of magnesia and epsom salts)

lactulose (can cause cramping, bloating, gas)

polyethelene glycol (aka mirilax, causes less bloating than lactulose and is good for chronic constipation)

constipation tx used for incomplete response to osmotic laxatives, can be used as a rescue med or taken at scheduled intervals but using regularly long term causes dependency. irritates the bowels causeing colonic fluid secreiton adn colon contractions, bloating and abdominal cramps are common ADR. dont use any of these daily, they all cause cramping

stimulant laxative:

bisacodyl/bisacodyl suppository, cascara, senna

constipation tx that inc intestinal chloride secretion, resulting in inc fluid within colon and faster colon transit, expesive and last line

lubiprostone (expensive, causes nausea, NO PREG PTS, good for chronic constipation)

linaclotide (expensive, NOT FOR KIDS)

constipation tx that is fast acting and often works in 15-60min and often used in conjunction w digital disimpaction

enemas:

tap water, sodium phosphate (used for acute constipation or to induce BM before medical procedure), mineral oil (soften and lubricate impaction and aid disimpaction)

constipation tx that inc fluid absorbtion and slows/inhibits colon peristalsis, but you have to use a slective Mu-opioid receptor one that doesnt affect outside GI tract. can reverse GI tract ADRs of opioids w/o affecting pain or causing withdrawl

opioid receptor antagonists

impaction of stool in the rectal vault is an obstruction, may cause diarrhea from overflow around obstruction, and MUST be disimpacted w digit and maybe enema before oral meds can start

fecal impaction

constipation complications

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