Vomiting, Diarrhea, and Constipation: A Comprehensive Review

Vomiting, Diarrhea, Constipation

Normal GI Function

  • Stomach
    • Mechanical breakdown of food.
    • Absorption of fatty acids and alcohol.
  • Small Intestine
    • Absorbs most nutrients: vitamins, minerals, sugars.
  • Large Intestine
    • Absorbs sodium, potassium, water, acids, gases, undigested starch, and vitamins synthesized by bacteria.

Vomiting

  • Nausea and vomiting are symptoms of an underlying disease process.
  • Many causes:
    • Gastrointestinal
    • Infectious
    • Metabolic
    • Cardiac
    • GU (Genitourinary)
    • Medication-related
    • Neurological
    • Psychological
Vomiting - Gastrointestinal
  • Gastroenteritis
    • Typically viral.
    • Often accompanied by diarrhea.
  • Pancreatitis
    • Potential causes: alcohol, gallstones, HIV, medications.
  • Appendicitis
    • Typically associated with peri-umbilical and right lower quadrant (RLQ) pain.
  • Ulcer
  • Diabetic Gastroparesis
  • Intestinal Obstruction
Vomiting - Infectious
  • Food Poisoning
    • Staphylococcal toxin
    • B. cereus (Bacillus cereus) - "Chinese Restaurant Syndrome"
      • Incubation period: 0.5-5 hours.
      • Pre-formed heat-stable toxin; also has a different emetic toxin.
Vomiting - Metabolic
  • Ketosis
    • Diabetic
    • Alcoholic
  • Thyroid Storm
  • Hyperparathyroidism
Vomiting - Cardiac
  • AMI (Acute Myocardial Infarction)
    • 43% of transmural MIs reported vomiting before analgesic administration.
    • Complicates the evaluation of chest/abdominal pain.
Vomiting - GU (Genitourinary)
  • Pregnancy
    • Normal.
    • Hyperemesis Gravidarum
      • Consider previous history, multiple gestation, or molar pregnancy.
  • Renal Colic
  • Pyelonephritis
  • Testicular or Ovarian Torsion
Vomiting - Medication/Drugs
  • Many medications list nausea and vomiting as side effects.
    • Chemotherapy
    • HIV Meds
    • Colchicine
  • Most important consideration = Toxicity
    • Digoxin
    • Iron
    • Carbon Monoxide
    • Mushrooms
Vomiting - Neurological
  • Migraine
  • Meningitis
  • Concussion
  • Subdural Hematoma
  • Epidural Hematoma
  • Subarachnoid Hemorrhage
  • Vestibular Disease
Vomiting - Psychological
  • Bulimia
    • Finger damage (scars on dorsum of fingers/hand).
    • Dental damage.

Vomiting Evaluation

  • Determine the amount and duration of vomiting.
  • Determine the type of emesis:
    • Food/liquid
    • Bilious
    • Feculent
    • "Coffee Ground" or Blood
  • Assess hydration status:
    • Vital Signs/Orthostatics
    • Mucous Membranes
    • Skin Turgor
    • Urine Output
    • Weight Change
  • Lab/Electrolyte Abnormalities
    • Metabolic Alkalosis
    • Hypochloremia
    • Hypokalemia
    • Elevated BUN:Cr

Vomiting Treatment

  • Medicine (Anti-Emetics)
    • Metoclopramide (Reglan®): Dopamine receptor antagonist/prokinetic.
    • Ondansetron (ZofranⓇ): 5 HT-3 Serotonin receptor antagonist.
    • Droperidol: Dopamine receptor antagonist.
    • Promethazine: H1 receptor antagonist.
Vomiting Key Points
  • Rule out life-threatening causes first
    • Surgical/traumatic causes
    • Infectious causes in "sick" patients
    • Consider myocardial ischemia
  • Assess hydration status
  • Always check UCG (urine chorionic gonadotropin) in women of child-bearing years to rule out pregnancy
  • Consider toxic causes

Diarrhea

  • Acute: < 2 Weeks
    • Infection
    • Antibiotics
    • Stress/Anxiety
  • Chronic: > 2 Weeks
    • Infections
    • Irritable Bowel Syndrome
    • Laxative abuse
Acute Diarrhea
  • Osmotic
    • Due to osmotically active substance in the intestine.
  • Secretory
    • Epithelial cells' ion transport processes are turned into a state of active secretion.
    • The most common cause of acute-onset secretory diarrhea is a bacterial infection of the gut.
Infectious Causes of Acute Diarrhea
  • Bacteria
    • Campylobacter jejuni - 6-8% of cases
    • Salmonella - 3-7% of cases
    • E Coli - 3-5% of cases
    • Shigella - 0-3% of cases
    • Yenterocolitica - 1-2% of cases
    • C difficile - 0-2% of cases
    • Vibrio parahaemolyticus - 0-1% of cases
    • V cholerae - Unknown
    • Aeromonas hydrophila - 0-2% of cases
  • Viruses
    • Rotavirus - 25-40% of cases
    • Calicivirus - 1-20% of cases
    • Norovirus- 10% of cases
    • Astrovirus - 4-9% of cases
    • Enteric-type adenovirus - 2-4% of cases
  • Parasites
    • Cryptosporidium - 1-3% of cases
    • Giamblia - 1-3% of cases
Travel History and Diarrhea
  • Travel history may indicate a cause for diarrhea
    • Travelers' diarrhea is the most common illness affecting travelers
    • Each year 20%-50% of international travelers are affected
    • Enterotoxigenic E. coli is the leading cause of travelers' diarrhea
    • Rotavirus and Shigella, Salmonella, and Campylobacter organisms are prevalent worldwide and need to be considered regardless of specific travel history
    • Risk of contracting diarrhea while traveling is highest for persons traveling to Africa, Central and South America and Eastern European countries
Organisms - Viral
  • Norovirus (Norwalk like Virus)
    • Diarrhea
    • Vomiting (more so in children)
    • Usually lasts 2 days
Organisms - Bacterial

  • Salmonella

  • Shigella (dysentery)

    • Bloody, mucousy diarrhea
    • Fever
    • Cramps

  • E. Coli

    • Enterotoxigenic
      • Toxin producing, most common.
    • Enteroinvasive/Enterohemorrhagic
      • O157:H7
      • Produces toxin similar to Shigella
      • May lead to Hemolytic Uremic Syndrome.

  • Campylobacter (jejuni)

    • Secretory diarrhea from enterotoxin.
    • May be bloody and clinically indistinguishable from Shigella or E. coli infection.

  • Yersinia enterocolitica

    • Bloody Diarrhea
    • Abdominal Pain
    • Fever

  • Crytosporidium

  • Giardia lamblia

  • Entamoeba histolytical

    • A parasite that is prevalent Mexico, India, Africa, and Central and South America
    • Produces small stools that contain blood and mucus. If the condition becomes chronic, it can resemble inflammatory bowel disease (IBD)
    • Important to distinguish the two since corticosteroids used to treat IBD can have dangerous effects in people carrying the parasite.

Diarrhea Evaluation

  • Obtain Good History
    • Volume
    • Frequency
    • Blood
      • Amount
      • Type
    • Fever
    • Travel History
    • Employment History (Daycare Worker, Food Worker)
    • Sick Contacts
    • Recent Antibiotic Use
    • Immunocompromised
    • Home Treatment
  • Physical Exam
    • Assess for Dehydration
    • Abdominal Exam
      • Tenderness
      • Distention
    • Rectal Exam
  • Diagnosis
    • Stool Guiaic and Fecal Leukocytes
      • Sensitivity and specificity variably reported in literature
    • Stool Culture
      • Routine not recommended
      • Sick and non-responding patients
      • Immunocompromised
      • Patients with Inflammatory bowel disease
      • Food Handlers
      • Patients with Comorbidities
    • Stool O&P Exam
      • Persistent symptoms (Giardia/Cryptosporidium/Entamoeba histolytica)
      • Travel to endemic areas (Russia Nepal, mountainous areas)??? (Giardia/Cryptosporidium/Cyclospora)
      • Daycare workers (Giardia/Cryptosporidium)
      • Community waterbourne outbreak
      • Bloody diarrhea with little or no leukocytes (Amebiasis)
    • C. diff Toxin
    • Thyroid function tests (TFTs)

Chronic Diarrhea

  • Diarrhea that lasts more than 2-4 weeks
Infectious Causes
  • Parasites (e.g., Cryptosporidium, Cyclospora, Entamoeba, Giardia, Cryptoisospora, microsporidia)
  • Bacteria Toxins (e.g., Campylobacter, Clostridium difficile, E. coli, Salmonella, Shigella, cholera)
  • Viruses (e.g., norovirus, rotavirus)
Non-Infectious Causes
  • Disorders of the Pancreas
    • Chronic pancreatitis
    • Pancreatic enzyme deficiencies
    • Cystic fibrosis
      Intestinal Disorders
    • Crohn's Disease
    • Ulcerative Colitis
    • Irritable Bowel Syndrome
  • Medications
    • Antibiotics
    • Laxatives
  • Intolerance to certain foods and food additives
    • Soy protein
    • Cow's milk
    • Sorbitol
    • Fructose
    • Olestra
  • Hyperthyroidism
  • Previous surgery or radiation of the abdomen or gastrointestinal tract
  • Tumors
  • Altered immune function
    • Immunoglobulin deficiencies
    • AIDS
  • Hereditary disorders
    • Cystic fibrosis
    • Enzyme deficiencies

Diarrhea Treatment

  • Oral Rehydration

    • WHO ORS
    • "Gatorade"

  • Antibiotics

    • Moderate to severe travelers' diarrhea
    • > 8 stools/day
    • Volume depletion
    • > 1 week
    • Immunocompromised

  • Antibiotics

    • Ciprofloxacin 500mg BID.
    • Levofloxacin 500mg Daily
    • Azithromycin 500mg PO daily for 3 days.
    • Metronidazole 500mg PO TID

  • Anti-Motility Agents

    • Loperamide
    • Bismuth subsalicylate
    • Diphenoxylate
    • Paregoric (Camphorated Tincture of Opium)
    • Avoid if:
      • Fever
      • Bloody diarrhea
      • EHEC (Enterohemorrhagic E. coli)
        • Hemolytic Uremic Syndrome

Constipation

  • Constipation can be defined as < 3 bowel movements/week
  • Patients consider constipation to include hard or small volumes of stool or the need to push harder than usual
  • Acute
  • Chronic
  • All ages are affected
  • Newborns/infants have special conditions
  • The prevalence of constipation increases exponentially in adults older than 65 years
    • Dietary Alterations
    • Decreases in muscle tone and exercise
    • Medications
    • Dehydration
    • Colonic Dysmotility
  • Bowel Obstruction
  • Colonic/Rectal Tumor
  • Spinal Cord Injury
    • Cauda Equina Syndrome
    • Herniated Disk
    • Metastatic Disease
    • Spinal Stenosis
  • Medications
    • Opiates
    • Iron Compounds
    • Calcium Channel Blockers (i.e., Verapamil)
    • Amitriptyline
    • Aluminum or calcium containing antacids

Causes of Constipation

  • Habit
    • Resisting the urge to go ("Holding It") can lead to loss of urge and subsequent constipation.
  • Painful Conditions
    • Hemorrhoids
    • Anal Fissures
    • Perianal/Perirectal Abscess

Constipation History

  • Determine patient's baseline defecation pattern
  • Onset of symptoms
  • Exact symptoms
  • Patients Diet and Exercise Status
    • Water Intake/Diet
    • Coffee/Alcohol Use (Decreases and Dehydrates)
    • Exercise (Improves Motility)
  • Home treatment and response

Laxatives

  • Bulking Agents
    • Psyllium
    • Methylcellulose
    • Calcium Polycarbophil
  • Saline
    • Milk of Magnesia
  • Osmotic Agents
    • Lactulose
      • Osmotic effect of undigested disaccharide HO\eqslantO_{OH}
      • Creates acidic colonic environment
      • Promotes conversion of Ammonia to Ammonium
    • Sorbitol
    • Polyethylene Glycol (PEG)
  • Diphenylmethane
    • Bisacodyl (DulcolaxⓇ)
    • Phenophthalein (Ex-Lax®)
  • Emolients
    • Mineral Oil
    • Glycerine Suppositories
    • ?Castor Oil

Stool Softeners

  • Docusate sodium (Colace)
    • Lowers surface tension of stool and allows more water in
    • Not as effective as an acute laxative, better for ongoing maintenance

Other Constipation Treatments

  • Lubiprostone (AmitizaⓇ)
    • Locally acting chloride channel activator
    • Chronic idiopathic constipation or IBS with constipation
  • Biofeedback
  • Relaxation Exercises
  • Intrasphincteric Botulinum Toxin

Laxative Abuse

  • Hypokalemia
  • Melanosis coli
  • Colonic Denervation and Atony