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Diarrhea. Case Presentation 48 yo woman c/o diarrhea –2-3 large volume, watery BMs since her 20s –associated abdominal pain (localized to the epigastrum.

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Presentation on theme: "Diarrhea. Case Presentation 48 yo woman c/o diarrhea –2-3 large volume, watery BMs since her 20s –associated abdominal pain (localized to the epigastrum."— Presentation transcript:

1 Diarrhea

2 Case Presentation 48 yo woman c/o diarrhea –2-3 large volume, watery BMs since her 20s –associated abdominal pain (localized to the epigastrum and periumbilical area) –no fevers,chills significant weight loss, blood or mucus in the stool –rare noctural diarrhea –PMH 1. Hypertension 2. Osteopenia –PSH: TAH-BSO

3 Case Presentation –SH: 3rd generation Mexican-American, married with 3 adult children, No tobacco, alcohol or illicit drug use. No blood transfusion –Meds: Accupril, Premarin, Calcium/Vit D –PE: thin, well appearing woman VS: afebrile, BP 105/60, HR 72, wt 105, ht 5’1” Heent: pale conjunctiva Abdomen: NABS, soft NT, no massess, well healed scar in RUQ

4 Case Presentation –Labs: Bloods –nl electrolyes, BUN, creatinine and glucose, Hgb 10.2 g/dl, MCV 77, Platelets 400K –Stool: Culture: normal fecal flora, no leukocytes, neg 0+P, neg Sudan fat

5 Definition Increased liquidity, frequency or decreased consistency of stools

6 Mechanisms Osmotic Diarrhea Secretory Diarrhea Deranged Motility Exudation

7 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

8 Some Causes of Osmotic Diarrhea 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

9 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

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

11 Some Causes of Secretory Diarrhea 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

12 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

13 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

14 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)

15 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

16 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)

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

18 Erythema Nodosum

19 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

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

21 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

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

23 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

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

25 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

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

27 Nosocomial Acute Diarrheas Fecal impaction Drugs Elixir Diarrhea Enteral Feedings Infectious Nosocomial Diarrhea Chemotherapy/Radiation Therapy

28 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

29 Runner’s Diarrhea 20-40% of runner’s (more common in women) Mechanism –release of GI hormones –release of inflammatory mediators –?ischemia

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

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

32 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])

33 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

34 Malabsorptive Diarrhea Fat Malabsorption –intraluminal maldigestion –mucosal malabsorption –postmucosal malabsorption intestinal lymphangiectasia, vasuclitis Carbohydrate Malabsorption Protein Malabsorption (Azotorrhea)

35 Malabsorptive Diarrheas (Fat) 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

36 Celiac Sprue Normal small bowel

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

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

39 Malabsoprtive Diarrhea (Carbs) Sorbitol diarrhea Fructose diarrhea Glucose-galactose deficiency Diasaccharidase deficiency

40 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

41 D-Xylose Test Step 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

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

43 Inflammatory Diarrheas Inflammatory Bowel Disease Eosinophilic Gastroenteritis Protein-Losing Enteropathy

44 Inflammatory bowel disease Crohn’s disease Granuloma

45 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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