diarrhea -working definition is: three or more loose or watery stools per day or definite decrease...
TRANSCRIPT
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Approach to Diarrhea
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Acute Diarrhea
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Diarrhea -working definition is: three or more loose or watery stools per day or definite decrease in consistency and increase
in frequency based upon an individual baseline
Acute — ≤14 days in duration Persistent diarrhea — more than 14 days in duration
Chronic — more than 30 days in duration
Definitions
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One of the five leading causes of death worldwide
Most cases of acute diarrhea are due to infections with viruses and bacteria and are self-limited.
Noninfectious etiologies become more common as the course of the diarrhea persists and becomes chronic.
Noninfectious causes of diarrhea include : drugs, food allergies, primary gastrointestinal diseases such as
inflammatory bowel disease, and other disease states such as thyrotoxicosis and
the carcinoid syndrome.
Introduction
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Most cases of acute infectious gastroenteritis are probably viral,
In contrast, bacterial causes are responsible for most cases of severe diarrhea
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careful history Duration of symptoms Frequency and characteristics of the stool Complete past medical history (identify
immunocompromised host) Important to ask about recent antibiotic use A food history may also provide clues to a
diagnosis: Within 6 hr Staphylococcus aureus or
Bacillus cereus Within 8 to 16 hr Clostridium perfringens More than 16 hr viral or bacterial infection
( enterotoxigenic or enterohemorrhagic E. coli).
DIAGNOSTIC APPROACH
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Physical examination:
fever, which suggests infection with : invasive bacteria (Salmonella, Shigella,
Campylobacter) Enteric viruses, or Cytotoxic organism such as Clostridium
difficile or Entamoeba histolytica
Evidence of extracellular volume depletion (eg, decreased skin turgor, orthostatic hypotension
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E.coli O157:H7 (Most common)
Less common bacterial causes : Shigella, Campylobacter, Salmonella species
Bloody diarrhea
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Sensitivity and specificity ranging from 20 to 90 percent
Because of these concerns about test performance, the role of testing for fecal leukocytes has been questioned .
However, the presence of occult blood and fecal leukocytes supports the diagnosis of a bacterial cause of diarrhea
Uptoate: we perform this examination in addition to
obtaining a bacterial culture in high risk patients.
Fecal leukocytes and occult blood
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Lactoferrin is a marker for fecal leukocytes, but its measurement is more precise
sensitivity and specificity ranging from 90 to100 percent in distinguishing inflammatory diarrhea (eg, bacterial colitis or inflammatory bowel disease) from noninflammatory causes (eg, viral colitis, irritable bowel syndrome)
Lactoferrin
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low rate of positive stool cultures in most reports (1.5 to 5.6 percent)
most infectious causes of acute diarrhea are self-limited
it is reasonable to continue symptomatic therapy for
several days before considering further evaluation
When to obtain stool cultures
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we recommend obtaining stool cultures on initial presentation in the following groups of
patients:
Immunocompromised patients, including those infected with HIV
Patients with comorbidities that increase the risk for complications
Patients with more severe, inflammatory diarrhea (including bloody diarrhea)
Patients with underlying inflammatory bowel disease in whom the distinction between a flare and superimposed infection is critical
Some employees, such as food handlers
When to obtain stool cultures
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Persistent diarrhea (associated with Giardia, Cryptosporidium,and Entamoeba histolytica)
Persistent diarrhea with exposure to infants in daycare centers(associated with Giardia and Cryptosporidium)
Diarrhea in a man who has sex with men (MSM) or a patient with AIDS (associated with Giardia and Entamoeba histolytica in the former, and a variety of parasites in the latter).
A community waterborne outbreak (associated with Giardia and Cryptosporidium)
Bloody diarrhea with few or no fecal leukocytes (associated with intestinal amebiasis)
Three specimens should be sent on consecutive days (or each specimen separated by at least 24 hours)
When to obtain stool for ova and parasites
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Begins with general measures such as hydration and alteration of diet.
Antibiotic therapy is not required in most cases since the illness is usually self-limited.
Oral rehydration solutions: Oral rehydration solutions were developed
following the realization that, in many small bowel diarrheal illnesses, intestinal glucose absorption via sodium-glucose cotransport remains intact.
TREATMENT
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The composition of the oral rehydration solution (per liter of water) recommended by the World Health Organization consists of:
3.5 g sodium chloride 2.9 g trisodium citrate or 2.5 g sodium bicarbonate
1.5 g potassium chloride 20 g glucose or 40 g sucrose
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Those with moderate to severe travelers' diarrhea as characterized by more than four unformed stools daily, fever, blood, pus, or mucus in the stool.
Those with more than eight stools per day
volume depletion
symptoms for more than one week
those in whom hospitalization is being considered
Immunocompromised hosts
Signs and symptoms of bacterial diarrhea such as fever, bloody diarrhea (except for suspected EHEC or C. difficile infection
Presence of occult blood or fecal leukocytes in the stool.
When to treat
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empiric therapy:An oral fluoroquinolone ( ciprofloxacin
500 mg twice daily, norfloxacin 400 mg twice daily, or levofloxacin 500 mg once daily) for three to five days in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection
Azithromycin (500 mg PO once daily for three days) or erythromycin (500 mg PO twice daily for five days) are alternative agents if fluoroquinolone resistance is suspected
Empiric antibiotic therapy
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The benefit of specific dietary recommendations other than oral hydration has not been well-established in controlled trials.
Adequate nutrition during an episode of acute diarrhea is important to facilitate enterocyte renewal
Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are indicated in patients with watery diarrhea;
crackers, bananas, soup, and boiled vegetables may also be consumed
Foods with high fat content should also be avoided
In addition, secondary lactose malabsorption is common following infectious enteritis and may last for several weeks to months. Thus, temporary avoidance of lactose-containing foods may be reasonable
Dietary recommendations
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Chronic Diarrhea
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Chronic diarrhea affects approximately 5 percent of the population
EPIDEMIOLOGY
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The principal causes of diarrhea depend upon the socioeconomic status of the population.
In developing countries, chronic diarrhea is frequently caused by:
chronic bacterial, mycobacterial and parasitic infections, although functional disorders, malabsorption, and inflammatory bowel disease are also common.
In developed countries, common causes are : irritable bowel syndrome (IBS), inflammatory bowel
disease, malabsorption syndromes (such as lactose intolerance and celiac disease), and chronic infections (particularly in patients who are immunocompromised).
ETIOLOGY
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Optimal strategies for the evaluation of patients with chronic diarrhea have not been established
Recommendations have been derived mostly from expert opinion and from experience
The selection of specific tests, timing of referral, and the extent to which testing should be performed depend upon an appraisal of the likelihood of a specific diagnosis, the availability of treatment, the severity of symptoms, patient preference, and comorbidities.
EVALUATION
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1) A clear understanding of what led the patient to complain of diarrhea(eg, consistency or frequency of stools, the presence of urgency or fecal soiling)
2) Stool characteristics (eg, greasy stools that float and are malodorous may suggest fat malabsorption while the presence of visible blood may suggest inflammatory bowel disease)
3) Duration of symptoms, nature of onset (sudden or gradual)
4) Travel history5) Risk factors for HIV infection6) Weight loss
History
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7) Whether there is fecal incontinence (which may be confused with diarrhea)
8) Occurrence of diarrhea during fasting or at night (suggesting a secretory diarrhea)
9) Family history of IBD10) The volume of the diarrhea (eg, voluminous watery
diarrhea is more likely to be due to a disorder in the small bowel while small-volume frequent diarrhea is more likely to be due to disorders of the colon)
11) The presence of systemic symptoms, which may indicate inflammatory bowel disease (such as fevers, joint pains, mouth ulcers, eye redness)
History
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12) All medications (including over-the-counter drugs and supplements)
13) A relevant dietary (including possible use of sorbitol-containing products and use of alcohol)
14) Association of symptoms with specific food ingestion (such as dairy products or potential food allergens)
15) A sexual history (anal intercourse is a risk factor for infectious proctitis and promiscuous sexual activity is a risk factor associated with HIV infection) ·
16) A history of recurrent bacterial infections (eg, sinusitis, pneumonia),which may indicate a primary immunoglobulin deficiency.
History
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The physical examination rarely provides a specific diagnosis.
However, a number of findings can provide clues These include:1) findings suggestive of IBD (eg, mouth ulcers, a skin
rash, episcleritis, an anal fissure or fistula,
2) the presence of visible or occult blood on digital examination,
3) abdominal masses or abdominal pain
Physical examination
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4) evidence of malabsorption (such as wasting, physical signs of anemia, scars indicating prior abdominal surgery)
5) Lymphadenopathy (possibly suggesting HIV infection),
6) Abnormal anal sphincter pressure or reflexes (possibly suggesting fecal incontinence)
7) Palpation of the thyroid and examination for exophthalmos and lid retraction may provide support for a diagnosis of hyperthyroidism.
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A large number of tests are available for diagnosing specific causes of diarrhea
There is no firm rule as to what testing should be done.
The history and physical examination may point toward a specific diagnosis for which testing may be indicated
laboratory evaluation
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The minimum laboratory evaluation in most patients should include :
a complete blood count and differential, erythrocyte sedimentation rate, thyroid function tests, serum electrolytes, total protein and albumin, stool occult blood
most patients require some form of endoscopic evaluation and mucosal biopsy (either sigmoidoscopy, colonoscopy, or sometimes upper endoscopy), depending upon the clinical setting
laboratory evaluation
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Another useful way to guide specific testing is to attempt to categorize diarrhea as:
watery diarrhea(secretory or osmotic)fatty diarrheainflammatory diarrhea
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continues despite fasting is associated with stool volumes >1 liter/day occurs day and night (in contrast to osmotic
diarrhea)
Although usually unnecessary, the distinction between an osmotic and a secretory diarrhea can also be established by measuring stool electrolytes and calculating an osmotic gap.
Secretory diarrhea
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(290 - 2 ({Na+} + {K+})
An osmotic gap of >125 mOsm/kg suggests an osmotic diarrhea
while a gap of <50 mOsm/kg suggests a secretory diarrhea
osmotic gap
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Further testing in patients with secretory diarrhea may include:
1) stool cultures to exclude chronic infection,
2) imaging of the small and large bowel
3) selective testing for secretagogues, such as gastrin or vasoactive intestinal polypeptide
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Further testing in patients with osmotic diarrhea may be unnecessary if the osmotic agent can be identified based upon the history.
An example is inadvertent ingestion of sorbitol (such as in sugarless candies) or lactose in patients who have lactose intolerance.
Temporary avoidance of lactose-containing foods can help establish the diagnosis of lactose intolerance in patients who were unaware of the diagnosis.
osmotic diarrhea
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Testing the stool for laxatives may occasionally be required if laxative abuse is suspected.
Laxative abuse can be suggested by the presence of melanosis coli on sigmoidoscopy or colonoscopy.
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Inflammatory diarrhea should be suspected in patients with:
1) clinical features suggesting inflammatory bowel disease,
2) clinical features suggesting C. difficile infection3) those at risk for opportunistic infections such as
tuberculosis4) those with a travel history.5) Serum markers of acute inflammation (such as the
sedimentation rate and C-reactive protein levels6) fecal leukocytes and Fecal calprotectin
Inflammatory diarrhea
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Diagnosis can usually be established by:
sigmoidoscopy or colonoscopy or by analysis of stool specimens (ie, culture or
testing for C. difficile toxin).
Inflammatory diarrhea
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Fatty diarrhea (steatorrhea) should be suspected in patients who report greasy, malodorous stools and those who are at risk for fat malabsorption, such as patients with chronic pancreatitis.
A variety of tests can be used to confirm the diagnosis.
Currently, the gold standard for diagnosis of steatorrhea is quantitative estimation of stool fat.
Fatty diarrhea
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empiric therapy may be warranted in certain situations: ◦ · When comorbidities limit diagnostic evaluation.◦ · When a diagnosis is strongly suspected.
Examples include a daycare worker who develops diarrhea after a known outbreak of Giardiasis
a patient who develops diarrhea following limited (<100 cm) ileal resection in whom bile acid malabsorption is likely,
a patient with known recurrent bacterial overgrowth, and an otherwise healthy patient with suspected lactose
intolerance
empiric therapy
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Symptomatic therapy is indicated when the diagnosis has been made but definitive treatment is unavailable.
A variety of medications can help relieve symptoms, including loperamide, anticholinergic agents, and intraluminal adsorbents (such as clays, activated charcoal, bismuth, fiber and bile acid binding resins).
Symptomatic therapyTHE END