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Diarrhea is loosely defined as passage of abnormally liquid or unformed

Diarrhea is loosely defined as passage of abnormally liquid or unformed Stool at an increased frequency . For adults on a typically western Diet, stool weight exceeding 200g/d Can generally be considered diarrheal. Pathophysiologic classification of diarrhea. Secretory diarrhea

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Diarrhea is loosely defined as passage of abnormally liquid or unformed

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  1. Diarrhea is loosely defined as passage ofabnormally liquidor unformed Stool at an increased frequency. For adults on a typically western Diet, stool weight exceeding 200g/d Can generally be considered diarrheal.

  2. Pathophysiologic classification of diarrhea • Secretory diarrhea • Osmoticdiarrhea • Inflammatory( exudative ) diarrhea • Motility ( dismotile ) diarrhea • Anatomic ( decreased absorptive surface)

  3. Secretory diarrhea • Increased secretion and / or decreased absorption of electrolytes. • Large volume watrey stool,no blood, no FSG, no pus, no response to fasting. • Small intestine type diarrhea.

  4. Some causes of Secretory diarrhea • Cholera ,Ecoli, and Salmonella toxins. • Serotonine,VIP,Calcitonine,Bile acids. • Castrol oil, Biscodyl, Senna, • Villus atrophy (Celiac sprue , Int. lymphoma). • Collagen vascular dis.) ( SLE , MCTD

  5. OSMOTIC DIARRHEA • Non absorbable,osmoticlly active molecules in gut lumen. • Watrey stool, no blood, no pus in the stool. • Improves with fasting. • May have high FSG. FSG = 280 – (fecal Na + fecal K ) * 2

  6. Some causes of osmotic diarrhea • Disacaridase deficiencies. • Lactulose, Manitol, Sorbitol, Mg ++ • Sulfate, phosphate (Laxatives). • Sodium citrate ingestion. • Steatorrhea, generalized malabsoption. • Rotavius induced diarrhea.

  7. EXUDATIVE DIARRHEA • Destruction of intestinal mucosa. • Small frequent bloody stools with pus, and tenesmus. • Fever • Large intestine type diarrhea.

  8. Some causes of exudative diarrhea • Entero-invasive E.coli • Shigella • E. histolitica • Ulcerative colitis • Ischemic colitis

  9. DIARRHEA Acute if < 2 weeks Persistent if 2 to 4 weeks Chronic if > 4 weeks

  10. Epidemiology of Acute Diarrhea Worldwide, >1000,000,000 people/year 5 -8 million deaths / year in developing countries. 3000/year mortality in US.

  11. High risk groups for diarrhea Travelers. 40 % of tourists develop diarrhea Most commonly duo to ETEColi Consumers of certain foods. Picnic, restaurant, undercooked hamberger, seafoods(raw) Immunodeficient persons Daycare participants and their familymembers. Institutionalized persons.

  12. Gastrointestinal Viruses Virus type Major risk group Seasonality Dx test Rx Rotavirus Children< 3 y Winter ELISA ORS (groupA) Adenovirus children< 3y year-round ELISA ORS (types 40,41) Calicivirus young unknown EM(?) ORS children Astrovirus young winter EM(?) ORS children Norwalk like children , winter EM (?) ORS virusesadults

  13. Factors that influence virulance of entric pathogens • Inoculum size (Shigella,EPEC,giardia 10-100) • Adherence • Toxin production (enterotoxin, cytotoxin, neurotoxin) • Invasion • Normal flora of the host • Gastric acid • Intestinal motility • Immunity

  14. Major Causes of Acute Diarrhea • INFECTIONS(Including Travelers Diarrhea) Bacterial : Campylobactre Species, C.difficile, E.coli, Salmonella eneritides , Shigella Species Parasitic/protozoal: E. histolytica, Giardia lambilia,Cryptosporidium ,Cyclospoa Viral :Adenovirus , Norwalk virus , Rotavirus ,AIDS, Others Fungal • FOOD POISONING :B.Cereus , C . Perfringens , Salmonella species , S .aureus, Vibrio species, Shigella species , Camppylobacter.jejuni, E.coli • MEDICATIONS • RECENT INGESTION OF LARGE AMOUNT OF POORLY ABSORBABLE SUGARS • INTESTINAL ISCHEMIA • FECAL IMPACTION • PELVIC INFLAMMATION • GRAFT VS HOST DISEASE

  15. MAJOR CAUSES OF CHRONIC DIARRHEA • IBS • IBD • Ischemic bowel disease • Chronic bacterial / mycobacterial infection • Parasitic & fungal infections • Radiation enteritis • Malabsorption Syndromes • Medications, Alcohol • Colon cancer , Villous Adenoma ,intestinal Lymphoma • Diverticulitis • Previous Surgery ( gastrectomy, vagatomy, intestinal resection ) • Endocrine causes • Fecal impaction • Heavy metal poisoning • Epidemic idiopathic chronic diarrhea

  16. Indications for evaluation a patient with acute diarrhea • Profuse diarrhea with dehydration. • Grossly bloody diarrhea. • Fever > or = 38.5 C • New community outbreaks. • Associated sever abdominal pain in patients older than 50 years. • Elderly (> or = 70). • Immunocompromised patients.

  17. TESTS THAT MAY BE USEFUL IN EVALUATION OF PATIENTS WITH ACUTE DIARRHEA • Stool Exam for: WBCs , Ova of parasites , Culture for bacteria & virus , Clostridium difficile toxin , Giardia , Entameba , Viral antigens ( Rotavirus ) • Blood test for: CBC , Na , K , BUN , Creatinine , Culture • Flexible Sigmoidoscopy • Abdominal Radiograph

  18. Acute diarrhea Likely infectious Likely noninfecutios Hx & P.Ex Moderate Activities altered Severe (Incapacitated) Mild Evaluate & Rx Institue fluid & electrolyte replacement Fever >38 .bloody stool, fecal WBCs Immunocompromised or elderly host Observe Stool microbiology study No Resolves Yes Antidiarrheal agents Pathogen found No Persist Empiric Rx +further evaluation Specific Rx Yes

  19. Empiric treatment in acute diarrhea • Moderately to severly ill patients with febrile desentry. Give Ciprofluxacin 500 mg bid for 3-5 days. • Suspected Giardiasis Rx with Metronidazole 250 mg qid for 7 days.

  20. Indications ofantibiotic coveragewether or not a causative organism is discovered in acute diarrhea • Immunecompromised patient. • Mechanical heart valves or recent vascular graft. • Elderly.

  21. Antibiotic prophylaxisis indicated fortravelers (to high risk countries), with • Gastric achlorhydria • IBD • Immunocompromise Give Co-trimoxazole or Ciprofluxacine

  22. Thank youThe end

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