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Diarrhea

Diarrhea. Definition. Increased liquidity, frequency or decreased consistency of stools. Mechanisms. Osmotic Diarrhea Secretory Diarrhea Deranged Motility Exudation. Osmotic Diarrhea. results from poorly absorbable osmotically active solutes in the gut lumen

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Diarrhea

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  1. Diarrhea

  2. Definition • Increased liquidity, frequency or decreased consistency of stools

  3. Mechanisms • Osmotic Diarrhea • Secretory Diarrhea • Deranged Motility • Exudation

  4. Osmotic Diarrhea • results from poorly absorbable osmotically active solutes in the gut lumen • stops when the patient is fasting • stool analysis - Inc osmotic gap 290 mosm/kgH2O-2(Na+K)mmol/l

  5. Carbohydrate malab gluc-galact malab fructose malab disaccaridase def ingestion (poorly absorbable carbs) lactulose sorbitol fructose fiber Magnesium-Induced Nutritional supplemts antacids laxatives GI Lavage solutions Laxative sodium citrate sodium phophate sodium sulfate Some Causes of Osmotic Diarrhea

  6. Secretory Diarrhea • Results from abnormal ion transport in intestinal epithelial cells • Main categories of secretory diarrhea • congenital defects of ion absorptive process • intestinal resection • diffuse mucosal disease • abnormal mediators

  7. Secretory Diarrhea • Diarrhea persist during a fast • stool Na, K and the accompany anions account for the stool osmolality (small osmotic gap)

  8. Laxatives Phenolophthalein, aloe Medications diuretics Toxins coffee, tea, cola, ETOH Bacterial Toxins S.aureus, C.perf +bot, B.cereus Congenital Bacterial entertoxins V. cholera, C.diff, Y.enterocol, toxigenic E. coli Endogenous laxatives bile acids, LCFA Hormone producing tumors Some Causes of Secretory Diarrhea

  9. Deranged Motility • Enhanced Motility (Intestinal Hurry) - decrease contact time of the stool to the absorptive surface • Abnormally slow motility may results in bacterial overgrowth and resultant diarrhea

  10. Exudation • Results from disruption of the intestinal mucosa from inflammation or ulceration • blood, mucus and serum proteins in gut lumen • bacillary dysnentery • Inflammatory bowel disease

  11. Approach to Patients with Diarrhea • History • Characteristics of the onset of diarrhea should be precisely noted (congenital, abrupt, gradual) • Pattern of diarrhea should be recorded (continuous or intermittent) • Duration of the symptoms • Epidemiological factors (travel, exposure to contaminated food or water, illness in other contacts)

  12. History • Stool characteristics should be investigated (watery, bloody, fatty) • Presence of fecal incontinence • Presence of abdominal pain • Presence of weight loss • Aggravating factors (diet or stress) • Mitigating factors (alteration of diet, OTC meds) • Previous evaluations

  13. History • Iatrogenic causes (medication history, surgical history, radiation history) • Factitious diarrhea (history of eating disorders, secondary gain and malingering) • Careful ROS (hyperthyroidism, diabetes mellitus, CVD, AIDS, etc)

  14. Approach to Patients with Diarrhea • Physical Exam • Presence of rashes or flushing • mouth ulcers • thyroid masses • wheezing • arthritis • anal rectal examination

  15. Erythema Nodosum

  16. Acute Diarrhea • Less than 2-3 weeks duration • Majority of cases are mild and self limiting • 4 million deaths world-wide per year in children under 5 years • Categories • infectious • noninfectious • drugs, fecal impaction, elixir diarrhea, enteral feedings, chemotherapy or radiation therapy, runner’s diarrhea

  17. Who Needs Evaluation? • High fever (>102F) • orthostatic symptoms or presyncope • bloody diarrhea • severe abdominal pain • immunocompromised persons

  18. Diagnostic Tests for Acute Diarrhea • Spot Stool Sample • Culture, Ova and Parasite, C.diff toxin, fecal leukocytes • Blood Tests • CBC, electrolytes, SMA 7, blood culture • Plain X-rays • Endoscopy • flex sig

  19. Treatment for Acute Diarrhea • Symptomatic • fluid replacement • Oral replacemet solutions or IV fluids • antidiarrheals • Bismuth subsalicylate • Antimicrobial therapy • quinolones • metronidazole • Bactrim • Rifaximin

  20. Antidiarrheals and Infectious Acute Diarrheas • Bismuth Subsalicylates (Pepto-Bismol) • safe and efficacious • antidiarrheal effects, antibacterial, antiinflammatory • Loperamide • safe in traveler’s diarrhea • Kaolin-pectin, opiates, anticholingerics • not effective

  21. Recommended Shigellosis Cholera Traveler’s diarrhea Pseudomembranous enterocolitis parasites STDs Not Recommended E.coli 0157:H7 Antibiotics in Acute Diarrheas

  22. Antibiotics • First Line • Ciprofloxacin - effective against most enteric infections • Metronidazole - if symptoms suggest Giardia • Second Line • Bactrim - effective second line therapy for most infectious diarrheas

  23. Rifaximin (Xifaxan) • Nonabsorbed • Broad-spectrum antibacterial activity invitro • No known drug interactions • 200 mg PO TID or 400 mg PO BID comparable to cipro

  24. Nosocomial Acute Diarrheas • Fecal impaction • Drugs • Elixir Diarrhea • Enteral Feedings • Infectious Nosocomial Diarrhea • Chemotherapy/Radiation Therapy

  25. Infectious Nosocomial Diarrheas • Usually from C.difficile • Salmonella, Shigella, 0+P extremely rare if diarrhea develops after 3-4 days in hospital • In the immunosuppressed, viral infections are an important cause

  26. Algorithm for Acute Diarrhea Noninfectious Infectious Assess severity, duration immocompetence of host Eval and Rx of underlying cause Rehydration and wu Symptomatic therapy resolves Continues Possible abx antidiarrheal agents

  27. Chronic Diarrhea • At least 3 to 4 weeks duration • accounts for 30% of patients in GI practices • Categories • Organic • malabsorpitive, secretory, exudative (inflammatory) • Functional

  28. Diagnostic Test for Chronic Diarrhea • Blood tests • CBC, SMA, ESR, Thyroid function • Stool studies • Spot • WBCs, occult blood, O+P, culture, giardia Ag • Quantitative • volume/weight, electrolytes, osmolality, fat, pH • fecal osm gap: 290-2([Na] + [K])

  29. Diagnostic Tests • Endoscopy • Flex sig or colonoscopy with biopsies • Upper endoscopy • biopsies • aspiration for bacterial counts and parasites • Radiology • Plain Radiographs • UGI/Small Bowel Series

  30. Malabsorptive Diarrhea • Fat Malabsorption • intraluminal maldigestion • mucosal malabsorption • postmucosal malabsorption • intestinal lymphangiectasia, vasuclitis • Carbohydrate Malabsorption • Protein Malabsorption (Azotorrhea)

  31. Intraluminal Phase Cirhosis Bile duct obstruction Bacterial overgrowth Pacreatic exocrine insufficiencyl Mucosal Phase Drugs Infectious disease Immune system dz Tropical sprue Celiac sprue Whipple’s dz Abetalipoproteinemia Malabsorptive Diarrheas (Fat)

  32. Celiac Sprue Normal small bowel

  33. Schilling Test • Vitamin B 12 deficiency • 1. Intrinsic factor deficiency • 2. Pancreatic insufficiency • 3. Bacterial overgrowth • 4. Extensive Ileal disease or resection

  34. Schilling Test 1. Ingestion of labeled Vit B12 and Non- labeled IM Vit B12 2. Urine labeled Vit B12 <8%/24 hr= malabsorption (Corrects) IF def (PA) Intrinsic factor Pancreatic enzymes Panc exoc def Antibiotic therapy Bact overgrowth Ileal disease or resection

  35. Malabsoprtive Diarrhea (Carbs) • Sorbitol diarrhea • Fructose diarrhea • Glucose-galactose deficiency • Diasaccharidase deficiency

  36. Lactose/Hydrogen Breath Test • Step 1 - measure baseline end-expiratory breath hydrogen levels • Step 2 - ingestion of lactose 50 gm • Step 3 - measure breath Hydrogen levels at 30, 60, 90, 120 min • rise >20 ppm suggest lactose malabsorption

  37. D-Xylose Test • Step 1 - 25 gm dose of D-xylose ingestion • Step 2 - urine collected for next 5 hours • Step 3 - at 1 hour, a blood sample taken (optional) • <4gm (16% excretion) in urine or serum conc <20mg/dl of d-xylose = abnormal intestinal absorption

  38. Secretory Diarrheas • Carcinoid Syndrome • Gastrinoma (ZE syndrome) • Vipoma or Watery Diarrhea-Hypokalemia Achlorhydria Syndrome • Medullary Carcinoma of the Thyroid • Glucagnoma • Villous Adenomas • Systemic Mastocytosis

  39. Inflammatory Diarrheas • Inflammatory Bowel Disease • Eosinophilic Gastroenteritis • Protein-Losing Enteropathy

  40. Inflammatory bowel disease Crohn’s disease Granuloma

  41. Treatment for Chronic Diarrhea • Antidiarrheal therapy • Mild to Moderate Diarrhea • Bismuth subsalicylates, opiates, bulk-forming agents, silicates, anticholingerics, cholestyramine • Secretory Diarrhea • octreotide, clonidine, Ca++ channel blockers, H2blockers, PPIs, H1 blockers, serotonin antagonist, indomethacin, glucocorticoids

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