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APPROACH TO ACUTE DIARRHEA IN PRIMARY CARE

APPROACH TO ACUTE DIARRHEA IN PRIMARY CARE. Department of Family Medicine Assoc Prof Dr Hülya AKAN. CASE DISCUSSION-1. 23 yrs old female , medical student 36 hrs nausea and vomiting , begin with nausea , fallowed by vomiting food contents and after than bile

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APPROACH TO ACUTE DIARRHEA IN PRIMARY CARE

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  1. APPROACH TO ACUTE DIARRHEAIN PRIMARY CARE Department of Family Medicine Assoc Prof Dr Hülya AKAN

  2. CASE DISCUSSION-1 • 23 yrsoldfemale, medicalstudent • 36 hrsnauseaandvomiting, beginwithnausea, fallowedbyvomitingfoodcontentsandafterthan bile • Last meal thedaybefore: breakfastwithorangejuiceandcheeseandwhitebread • Diarrheasoonaftervomiting, no blood no fat, 12 bowelmovementspastday • No fever • Bloatingandmildcramping but no pain

  3. CASE 1 • No travel history • 2 days earlier a friend and 6-mo-old child had visited and she had changed infant’s diaper • Past medical hx: asthma – steroid inhaler, allergic to shellfish • No smoke, no alcohol • Last menstrual period: 3 weeks ago, sexually inactive

  4. CASE 1: PE • İll-appearing, 36,6 °C • Supine 110/70 mmHg, 75/beats/min, • Standing 100/60 mmHg, 104 beats/min • Dry mucous membranes • Clear lungs • Rapid regular heart rythm with 2/6 systolic murmur at the apex • Normoactive bowel sounds, abdomen soft and nontender without distention

  5. CASE 1 • WHAT ASPECTS OF HER HISTORY HELP YOU TO MAKE THE DIAGNOSIS?

  6. Diarrhea is non bloody, vomiting is prominent feature • Absence of subjective fever • Food items are not typical for food-borne illnesses • Exposure to small child?

  7. CASE 1 • HOW DOES PHYSICAL EXAM HELP YOU?

  8. The patient is volume depleted • Dry mucous membranes • Orthostatic hypotension • Afebrile • It is not uncommon for a young women to have flow murmur accentuated by dehydration • Abdominal exam. is benign • It is not needed to perform rectal examination

  9. CASE 1 • WHAT LABORATORY TESTS WOULD BE HELPFUL?

  10. Serum chemistry: electrolytes • Pregnancy test • Stool studies?

  11. CASE 1 • SHOULD THİS PATIENT BE ADDMITTED TO HOSPİTAL? • SHOULD SHE RECEIVE ANTIBIOTICS? • WHAT IS THE LIKELY CAUSE OF HER DIARRHEA?

  12. DEFINITION • Acute diarrhea: more frequent, looser than normal stools less than 2 - 3 weeks • Objectively: >250g stool / day • Acute v chronic: By time span • Chronic diarrhea: lasting >1 month

  13. GIS SYSTEM

  14. Diarrhea second most common illness after upper respiratory tract infection • Living conditions and socio economic factors play a role in the attach of bacterial enteric pathogens - contaminated water sources - undercooked meat - instituliziation - poor sanitation

  15. CAUSES • Acutediarrheais usuallyrelatedto a bacterial, viral, orparasiticinfection. • Chronicdiarrheais usuallyrelatedtofunctionaldisorderssuch as irritablebowelsyndromeorinflammatoryboweldisease. • .

  16. CAUSES Bacterialinfections.Severaltypes of bacteriaconsumedthroughcontaminatedfoodorwater can causediarrhea. CommonculpritsincludeCampylobacter, Salmonella, Shigella, andEscherichiacoli (E. coli). Viralinfections.Manyvirusescausediarrhea, includingrotavirus, Norwalkvirus, entericadenovirus, cytomegalovirus, herpessimplexvirus, andviralhepatitis

  17. CAUSES • Foodintolerances.Somepeopleareunabletodigestfoodcomponentssuch as artificialsweetenersandlactose—thesugarfound in milk. • Parasites.Parasites can enterthe body throughfoodorwaterandsettle in thedigestivesystem. ParasitesthatcausediarrheaincludeGiardialamblia, Entamoebahistolytica, andCryptosporidium.

  18. CAUSES Reactiontomedicines.Antibiotics, bloodpressuremedications, cancerdrugs, andantacidscontainingmagnesium can allcausediarrhea. Intestinaldiseases.Inflammatoryboweldisease, colitis, Crohn’sdisease, andceliacdiseaseoftenleadtodiarrhea. Functionalboweldisorders.Diarrhea can be a symptom of irritablebowelsyndrome.

  19. Clinical presentationPotential food-related agents to consider • Gastroenteritis (vomiting as primary symptom; fever or diarrhea also may be present: Viral gastroenteritis, most commonly rotavirus in an infant or norovirus and other caliciviruses in an older child or adult; or food poisoning caused by preformed toxins (e.g., vomitoxin, Staphylococcus aureus toxin, Bacillus cereus toxin) and heavy metals • Noninflammatory diarrhea (acute watery diarrhea without fever or dysentery; some patients may present with fever)*:Can be caused by virtually all enteric pathogens (bacterial, viral, parasitic) but is a classic symptom of enterotoxigenic Escherichia coli, Giardia, Vibrio cholerae, enteric viruses (astroviruses, noroviruses, and other calciviruses, enteric adenovirus, rotavirus), Cryptosporidium, Cyclospora cayetanensis

  20. Clinical presentationPotential food-related agents to consider • Inflammatory diarrhea (invasive gastroenteritis; grossly bloody stool and fever may be present)†Shigella species, Campylobacter species, Salmonella species, enteroinvasive E. coli, enterohemorrhagic E. coli, E. coli O157:H7, Vibrio parahaemolyticus, Yersinia enterocolitica, Entamoeba histolytica • Persistent diarrhea (lasting at least 14 days): Prolonged illness should prompt examination for parasites, particularly in travelers to mountainous or other areas where untreated water is consumed. Consider Cyclospora cayetanensis, Cryptosporidium, Entamoeba histolytica, and Giardia lamblia.

  21. Clinical presentationPotential food-related agents to consider • Neurologic manifestations (e.g., paresthesias, respiratory depression, bronchospasm, cranial nerve palsies): Botulism (Clostridium botulinum toxin), organophosphate pesticides, thallium poisoning, scombroid fish poisoning (histamine, saurian), ciguatera fish poisoning (ciguatoxin), tetraodon fish poisoning (tetraodontoxin), neurotoxic shellfish poisoning (brevetoxin), paralytic shellfish poisoning (saxitoxin), amnesic shellfish poisoning (domoic acid), mushroom poisoning, Guillain-Barré syndrome (associated with infectious diarrhea caused by Campylobacter jejuni) • Systemic illness (e.g., fever, weakness, arthritis, jaundice)Listeria monocytogenes, Brucella species, Trichinella spiralis, Toxoplasma gondii, Vibrio vulnificus, hepatitis A and E viruses, Salmonella typhi and Salmonella paratyphi, amebic liver abscess

  22. Noninflammatory diarrhea • Noninflammatory diarrhea is characterized by mucosal hypersecretion or decreased absorption without mucosal destruction and generally involves the small intestine. • Some affected patients may be dehydrated because of severe watery diarrhea and may appear seriously ill. This is more common in the young and the elderly. Most patients experience minimal dehydration and appear mildly ill with scant physical findings. • Illness typically occurs with abrupt onset and brief duration. Fever and systemic symptoms usually are absent (except for symptoms related directly to intestinal fluid loss).

  23. Inflammatory diarrhea • Inflammatory diarrhea is characterized by mucosal invasion with resulting inflammation and is caused by invasive or cytotoxigenic microbial pathogens. The diarrheal illness usually involves the large intestine and may be associated with fever, abdominal pain and tenderness, headache, nausea, vomiting, malaise, and myalgia. Stools may be bloody and may contain many fecal leukocytes.

  24. CLINICAL APPROACH: FOCUS • Does the diarrhea originate in the large or small intestine? Small-bowel: frequent, large-volume stools described as watery and related to eating. Large bowel: usually more frequent, with smaller stool vlolumes (1-2 L/day) and associated with tenesmus and bloody stools.

  25. CLINICAL APPROACH: FOCUS • Has therebeenrecenttraveltosuggestenterotoxigenic E. Coli, antibioticconsumptionwithinlast 6 weekstosuggestpseudomembranouscolitisorconsumption of undercookedpoultryor hamburger thatmayimplicateSalmonellaorenterohemorrhagic E. Coli, respectively?

  26. CLINICAL APPROACH: FOCUS ON • Does the patient have other medical conditions that may predispose to diarrhea, such as diabetes, acquired immunodeficiency syndrome,or previous gastrointestinal surgery that may predispose to bacterial overgrowth?

  27. CLINICAL APPROACH: FOCUS • Stoolsshould be studiedforfecalleucocytes, cultureandsensitivity, ova andparasitesandclostridiumdifficiletoxin • Intypicalcasesthatareculturenegative, unpreppedflexiblesigmoidoscopyorcolonoscopy • If no colonpathologyidentified, an esophogogastroduodenoscopywithsmallintestinebiopsies

  28. COMMON PATHOGENS

  29. TAKING HISTORY • Onset of symptoms • Exposure to suspicious food or water (time) • Exposure to sick contacts • History of medication • History of travelling • Associated symptoms( nausea, vomiting, fever, abdominal cramps or severe abdominal pain)

  30. Comorbid conditions (HIV, immunodeficiency, etc.)

  31. Freqency of stool passage • Approximate amount of stool • Colour of stool • Odour of stool • Blood in stool • Mucous on stool • Tenesmus

  32. PHYSICAL EXAMINATION • Vital signs • Volume status - Ortostatic hypotension - Poor skin turgor - Dry mucous membranes • Abdominal examination • Abdominal sounds- absence or presence • Rectal examination and stool guaiac

  33. RED FLAGS • Diarrhea in the elderly or immunocomprimised patient (inc. Acquired immunodeficiency patients, transplant patients, those on chemotherapy and high dose steroids) • Duration of illness greater than 48 hrs • Diarrhea accompanied by severe abdominal pain

  34. RED FLAGS • Diarrhea associated with fever (>38 °C) • Blood in stool • More than six unformed stools a day • Profuse watery diarrhea with dehydration

  35. LABORATORY • FOCUS ON CAUSE It is debatable in patientswithoutredflags, but consider in patientswithredflags - Stolanalysis- leucocytes, blood, - Culture: ifthere is leucocytesandredbloodcells in a patientwithfever, abdominalpainorbloodystools - Bloodystool: E. Coli 0157: H7 - Antibioticuse: C. Difficiletoxin

  36. - Serologictests: rapidtestsfor rota, adenovirus is available. Unecessaryforsalmonellaexceptsystemicdisease is suspected - Ova andparasites: uneccessaryroutinely, considerifyoususpectgiardialamblia, homosexuals, immunocomprimised

  37. LABORATORY • Flexiblesigmoidoscopyandbiopsy: ulcerativecolitis, ischemiccolitis, pseudomembranouscolitis, amebiasis, shigellainfection, proctitis in homosexual men • FOCUS ON SEVERITY - Basicchemistry - Electrolytes

  38. Fever >38.2, dehydration, abdominalpain, bloodystool, >6 stools/day Immunodeficiency >70 yrs Yes No LabFallow Thinkabouthospitilization

  39. TREATEMENT APPROACH • Rehydration- electrolytereplacementifnecessary • Symptomaticrelief • Occasionallyantibiotics(minimal impact on diseasecourse, enterohemoragic E.coli-hemolyticuremicsyndrome,prolongshedding of organism) • Antidiarrhealagents: Loperamide, Lomotil

  40. Composition of the new ORS formulation

  41. ORS This ORS composition has passed extensive clinical evaluations and stability tests. Thepharmacokinetics and therapeutic values of the substances are as follows: • glucose facilitates the absorption of sodium (and hence water) on a 1:1 molar basis in thesmall intestine; • sodium and potassium are needed to replace the body losses of these essential ions duringdiarrhoea (and vomiting); • citrate corrects the acidosis that occurs as a result of diarrhoea and dehydration.

  42. POSSIBLE INDICATIONS OF EMPIRIC ANTIBIOTICS • Patientswithdysanteryormoderateto severe traveler’sdiarrhea • Patientswithfecalleukocytesorblood in theirstoolandfever • PatientswithsuspectedGiardiainfectionwith 2-4 wksdiarrheaand no signs of dysentry Note: antibioticsminimallyimpactthediseasecourse, can prolongshedding

  43. CASE 2 • M.H. 32 yrs-old white woman, two boys • Watery stools for 3 days, 6-8/24 hrs • Onset is sudden and associated with slight abdominal cramping and some nausea but no vomitting • Generalised malaise but no fever, chills, night sweats • No blood or mucous in stools • Able to tolerate her usual diet but don’t feel hunger

  44. CASE 2 • Past medical: renal stone 6 yrs ago • Family hx: grandmother: type 2 diabetes, both grandfathers: hypertension • Health habits: No alcohol, no smoke • Social: Married, 2 boys (2 and 5yrs), working part time as visiting nurse, drinks city water, no travel,no exposure to hepatitis

  45. CASE 2- PE • Appears comfortable • 118/72 mmHg, 88 beat/min,36,5 C, 1.62 cm, 57 kg • PE is normal including rectal examination • LAB: stool test for blood is negative, microscopy showed only few leukocytes, WBC and liver enzymes are normal, no parasite ova or cyst is seen

  46. CASE 2 • What aspects of her history help you to make the diagnosis? • How does physical exam help you? • What laboratory tests would be helpful? • Should this patient be addmitted to hospital? • Should she receive antibiotics? • What is the likely cause of her diarrhea?

  47. DifferentialdxforCase 2 • Viralgastroenteritis (rota, norwalk) • Earlyviralhepatitis • Protozoalinfection: giardialamblia

  48. Whathappenedtocase 2 • Returnedtwowkslater • Diarrheawas okey, but 2 daysago a secondbout of foulsmellingdiarrheaassociatedwithepigastricdiscomfortandincreasedgas, lost 2 kg, generalizedfatigue. Her oldest son had alsostartedhavingloosestools

  49. What is thediagnosis • Stoolanalysisrevealedcysts of giardialamblia • Stolexamination of childrenwerealsopositiveforgiardia • Thesourcewascitywater:There had been a breakdown (it could be duetodaycareepidemics –fromchildrenor her part time job)

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