Diarrhea

Differentiate between acute, persistent, and chronic diarrhea

-Acute: ≤ 14 days in duration -Persistent diarrhea: 15-29 days in duration -Chronic: ≥ 30 days in duration

Disposition of acute diarrhea patient

-Admit the toxic patient and any patient who cannot comply with oral rehydration -Be conservative in admitting those at extremes of age -Most patients with diarrhea can be safely discharged home with 48 - 72 hour follow up with their PCP

Diarrhea Patient education

-Avoid caffeine, which stimulates gastric motility -Avoid sorbitol-containing chewing gum or raw fruits, which can worsen osmotic diarrhea -Avoid lactose until the colonic villi are able to recover and produce the necessary digestive enzymes -Encourage patients to attempt early solid food intake, because eating expedites the recovery from diarrheal illnesses

When are antimotility agents not used? What education should be provided to a patient taking them?

-Avoided in dysentery -Caution patients to stay very hydrated, pooling of fluids in the intestine can occur (antimotility=stop peristalsis)

What is the most likely cause of traveler's diarrhea

-Enterotoxigenic E. coli (ETEC) is the pathogen most likely to cause travelers diarrhea

Presentation of large bowel diarrhea

-Frequent, regular-small volume, and often painful bowel movements -Fever and bloody or mucoid stools are common, and RBCs and inflammatory cells can be seen routinely on stool microscopy

Lab evaluation of diarrhea

-If substantial volume depletion: BMP to screen for electrolyte abnormalities or renal dysfunction -CBC: does not reliably distinguish bacterial etiologies of diarrhea from others -Blood cultures: in patients with high fevers and systemically ill patients -Pregnancy Test: in all females 8-80 yo with GI symptoms -Stool Guiac Testing: for evaluation of blood presence

Etiologies of non-infectious diarrhea

-Osmotic Diarrhea (like after eating HARIBO Sugar-free gummy bears:) -Intestinal Obstruction -Toxic Ingestions -Inflammatory Bowel Disease -Drug Withdrawal- e.g. opioid withdrawal -Cholinergic Toxicity - e.g. organophosphate poisoning

What is the most likely cause of hiker's diarrhea

-Rural hiking and camping increases the patient's risk for Giardia, particularly if water-purification procedures were not strictly followed

When are empiric antibiotics used for diarrhea treatment

-Severe disease (fever, 6+ stools/day, volume depletion requiring hospitalization) -Suggestive of Bacterial Infection (bloody, mucoid stools) -High risk host (>70 yo, cardiac dz, immunocompromised)

How is ova and parasite evaluation done when working up diarrhea: - when should you suspect parasitic infection - why do ova and parasite tests lack sensitivity? - direct immunofluroescense staining improves sensitivity for what?

-Suspect parasitic infection in travelers exposed to untreated water and those presenting with diarrhea for more than 7 days -Stool tests for ova and parasites lack sensitivity, because shedding of the parasitic organisms is intermittent --> Multiple samples may need to be collected for a positive result -Direct immunofluorescence staining improves the sensitivity for detecting Giardia and Cryptosporidium

Presentation of small bowel diarrhea

-Typically watery, large volume, and associated with abdominal cramping, bloating, and gas -Weight loss can occur if diarrhea becomes persistent -Fever is rarely a significant symptom and occult blood or inflammatory cells in the stool are rarely identified

CDC Recommendation for Prevention of spreading Diarrhea

-Wash your hands thoroughly with soap and water -Handle and prepare food safely -When you are sick, do not prepare food or care for others -Clean and disinfect surfaces -Wash laundry thoroughly

Risk factors for acute diarrhea

1. Recent travel to endemic area 2. Food associated illness -Raw meat, poultry, fish, seafood, milk, rice 3. Wilderness travel, drink mountain streams -Consider Giardia, Entamoeba histolytica, Cryptosporidium 4. Daycare Exposure -Consider Rotavirus, Cryptosporidium, Giardia, Shigella 5. High Risk Sexual Behavior -Fecal oral route: Shigella, Salmonella, Campylobacter, Protozoa 6. Recent Antibiotic Use or Recent Hospitalizations -Consider Clostridium difficile 7. Immunosuppression (HIV, Chemo, Long-term Steroids)

What antimotility agents are used for treatment of diarrhea? What cautions should be used with each drug?

1st line: Loperamide (Imodium) -Can be used cautiously in non bloody afebrile diarrhea 2nd line: dephenoxylate (Lomotil) -Can cause central opiate/cholinergic side effects 3rd line: Bismuth subsalicylate (Pepto-Bismol) -Potential for salicylate toxicity (avoid with ASA use, pregnancy, children)

Prevention of Rotavirus diarrhea

2 Rotavirus vaccines are available in the US -Rota-Teq- given in 3 doses (2, 4 & 6 months) -Rotarix- given in 2 doses (2 & 4 months) The availability of the rotavirus vaccine has resulted in norovirus becoming the most common viral pathogen to cause diarrhea in the United States

Where do absorption and secretion occur in the intestine

Absorption occurs through the villi 1.Passively with the transport of sodium 2.Actively with the absorption of glucose Secretion occurs through the crypts

Use of ABX treatment for diarrhea caused by E. coli 0157:H7

Antibiotics Contraindicated: Treatment with antibiotics can result in hemolytic uremic syndrome (HUS) Shiga toxin-producing E coli HUS is the MCC of pediatric HUS: ~90%

How is C. diff diagnosed in diarrhea patient

C diff toxin assay: Unfortunately, this assay has a 10% false-negative rate, and the turnaround time on the test approaches 24 hours

What is the most likely cause of antibiotic related diarrhea?

C. difficil

Etiologies of chronic diarrhea

Chronic Fatty Diarrhea due to Malabsorption Chronic Inflammatory Diarrhea: Infectious or IBD Chronic Watery Diarrhea: -Secretory Diarrhea, Large volume stools ?1L/day and not better over night or with fasting -Osmotic Diarrhea -Drug-Induced Diarrhea -Functional Chronic Diarrhea (diagnosis of exclusion): Small Volume Stools (<350 ml/day) and better over night and with fasting

Prevention of traveler's diarrhea

Counseling families about the proper selection and preparation of food and beverages consumed while traveling -Encourage the use of boiled, bottled, and carbonated water for drinking, brushing teeth, and preparing food and infant formula

Why are ABX not recommended for treatment of acute diarrhea in adults?

Cuz its usually viral and the side effects really aren't worth it since it won't even be helpful

Define hemolytic uremic syndrome (HUS)

Defined as simultaneous occurrence of: microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury

Differentiate between gastroenteritis and diarrhea

Gastroenteritis: Inflammation of the GI tract, usually dx of exclusion - Typically: Emesis followed by diarrhea - MC viral, but can be bacterial Diarrhea: 3+ loose stools a day -MC viral, can also be bacterial or protozoan

what imaging can be used for patients with diarrhea

In patients with significant peritoneal signs or ileus, Abd CT w/wo contrast -This can evaluate for bowel perforation, abscess, colitis, toxic megacolon, or intestinal obstruction

Pathophysiology of diarrhea

Ischemia, inflammation & enterotoxins block the intestinal villa from reabsorbing sodium resulting in decreased fluid absorption -As a result, diarrhea occurs because of diminished intestinal villi absorption and unopposed crypt secretion

What history is needed for diarrhea presentation

Length of Symptoms? Quantify episodes/day? > 3 bouts/24 hours meets definition of diarrhea > 6 bouts/24 hours increases concern Character -Bloody or melanic? -Associated with certain food? -Exposures? (turtles, poultry, petting zoo's, travel, daycare occupation) -Does it resolve or persist with fasting? -Size of stools? -Recent Antibiotic use? Travel history (Outside U.S. or to rural areas)? Med changes?

Physical exam for work-up of diarrhea

Main focus of exam: looking for complications of diarrhea Volume depletion- dry mucous membranes, diminished skin turgor, sunken fontanelles, postural or frank ↓ BP, tachycardia, poor capillary refill, altered mentation Abdominal exam- for distension, ttp, rebound or guarding -If benign abdomen despite severe pain, consider Mesenteric Ischemia -Bowel sounds: hyperactive typical with diarrhea, if hypoactive, consider bowel obstruction Rectal exam- eval for impaction and guaiac testing

What drugs are likely to cause diarrhea

Many drugs affect gastrointestinal function: -Erythromycin accelerates gastric emptying -Clavulanate stimulates small bowel motility -Other drugs that cause diarrhea are laxatives, sorbitol, lactose, NSAIDS, and cholinergics

ABX treatment of C diff

Metronidazole (Flagyl) or PO vancomycin

Hydration treatments for patients with diarrhea

Mild to moderate dehydration: Oral rehydration -Water, E-lyte options, Pedialyte® and Gatorade® Moderate to severe dehydration: IV hydration

Define diarrhea

Passage of loose or watery stools, typically 3+ times in a 24-hour period. -It reflects increased water content of the stool, whether due to impaired water absorption and/or active water secretion by the bowel.

what probiotics are used for diarrhea treatment?

Probiotics are safe and beneficial when used alongside rehydration therapy -Lactobacillus GG -Saccharomyces boulardii

What will stool culture and sensitivity for diarrhea identify

Salmonella, Campylobacter, and Shigella (3 MCCs of bacterial diarrhea in the US States) -Additional Pathogens will require communication with the laboratory to identify additional pathogens: Yersina, E. coli 0157:H7, Vibrio, etc....

How much fluid is absorbed vs lost in the stool in the intestine normally?

Small intestine secretes and reabsorbs 10 L/day -Fluid not absorbed by the small intestine then enters the colon, where fluid is absorbed at an even higher rate -The colon can make up for a decrease in small intestinal absorption Under normal conditions, very little fluid (<100 mL) is lost in the stool each day

History in chronic diarrhea

Stool Characteristics -Watery -Blood or mucous: inflammatory -Foul, greasy: fat malabsorption issue Age -Younger: IBD -Older: Colon CA Timing: -Alternating with Constipation: IBS -Intermittent: Diverticulitis -Persistent: meds, IBD

Diagnostic workup for diarrhea

Workup is expensive and does not alter management in most US cases of diarrhea. H&P most important. Lab eval It is reasonable to continue expectant management for several days without microbiologic stool testing

What antibiotics can be used for severe/bacterial diarrhea

Zithromax or Cipro - get C&S to narrow treatment

Define invasive diarrhea

dysentery, is defined as diarrhea with visible blood or mucus, in contrast to watery diarrhea. Dysentery is commonly associated with fever and abdominal pain.

Treatment of infectious diarrhea

hydration, antimotility agents, and avoidance of agents that worsen diarrhea

MCC of acute diarrhea (<14 days)

infections: self-limited -Viruses: norovirus (MC), adenoviruses, astrovirus, rotavirus -Bacteria: Salmonella, Campylobacter, Shigella, enterotoxic Ecoli, Clostridioides -Protozoa: Cryptosporidium, Giardia, Entamoeba Non-infectious causes MC in longer lasting more chronic diarrhea

When is microbiologic stool testing indicated for patients with diarrhea

only indicated in patients with the following features: -Passage of >6 unformed stools per 24 hours -> 1 week of symptoms -Severe abdominal pain -Need for hospitalization for dehydration -Dysentery (Bloody diarrhea, Fever, Abd Pain, Tenesmus) -High Risk Patients: > 70 yo, < 12 mo old, Pregnancy, Immunocompromised state