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

2. CASE DISCUSSION-1 23 yrs old female, medical student 23 yrs old female, medical student 36 hrs nausea and vomiting, begin with nausea, fallowed by vomiting food contents and after than bile 36 hrs nausea and vomiting, begin with nausea, fallowed by vomiting food contents and after than bile Last meal the day before: breakfast with orange juice and cheese and white bread Last meal the day before: breakfast with orange juice and cheese and white bread Diarrhea soon after vomiting, no blood no fat, 12 bowel movements past day Diarrhea soon after vomiting, no blood no fat, 12 bowel movements past day No fever No fever Bloating and mild cramping but no pain Bloating and mild cramping but no pain 2

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

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

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

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

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

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

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

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

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

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

13. GIS SYSTEM 13

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

15. CAUSES Acute diarrhea is usually related to a bacterial, viral, or parasitic infection. Acute diarrhea is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhea is usually related to functional disorders such as irritable bowel syndrome or inflammatory bowel disease. Chronic diarrhea is usually related to functional disorders such as irritable bowel syndrome or inflammatory bowel disease.. 15

16. CAUSES Bacterial infections. Several types of bacteria consumed through contaminated food or water can cause diarrhea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli (E. coli). Bacterial infections. Several types of bacteria consumed through contaminated food or water can cause diarrhea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli (E. coli). Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus, enteric adenovirus, cytomegalovirus, herpes simplex virus, and viral hepatitis Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus, enteric adenovirus, cytomegalovirus, herpes simplex virus, and viral hepatitis 16

17. CAUSES Food intolerances. Some people are unable to digest food components such as artificial sweeteners and lactose—the sugar found in milk. Food intolerances. Some people are unable to digest food components such as artificial sweeteners and lactose—the sugar found in milk. Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. 17

18. CAUSES Reaction to medicines. Antibiotics, blood pressure medications, cancer drugs, and antacids containing magnesium can all cause diarrhea. Reaction to medicines. Antibiotics, blood pressure medications, cancer drugs, and antacids containing magnesium can all cause diarrhea. Intestinal diseases. Inflammatory bowel disease, colitis, Crohn’s disease, and celiac disease often lead to diarrhea. Intestinal diseases. Inflammatory bowel disease, colitis, Crohn’s disease, and celiac disease often lead to diarrhea. Functional bowel disorders. Diarrhea can be a symptom of irritable bowel syndrome. Functional bowel disorders. Diarrhea can be a symptom of irritable bowel syndrome. 18

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 19

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. 20

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 21

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). 22

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. 23

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. 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. 24

25. CLINICAL APPROACH: FOCUS Has there been recent travel to suggest enterotoxigenic E. Coli, antibiotic consumption within last 6 weeks to suggest pseudomembranous colitis or consumption of undercooked poultry or hamburger that may implicate Salmonella or enterohemorrhagic E. Coli, respectively? Has there been recent travel to suggest enterotoxigenic E. Coli, antibiotic consumption within last 6 weeks to suggest pseudomembranous colitis or consumption of undercooked poultry or hamburger that may implicate Salmonella or enterohemorrhagic E. Coli, respectively? 25

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? 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? 26

27. CLINICAL APPROACH: FOCUS Stools should be studied for fecal leucocytes, culture and sensitivity, ova and parasites and clostridium difficile toxin Stools should be studied for fecal leucocytes, culture and sensitivity, ova and parasites and clostridium difficile toxin In typical cases that are culture negative, unprepped flexible sigmoidoscopy or colonoscopy In typical cases that are culture negative, unprepped flexible sigmoidoscopy or colonoscopy If no colon pathology identified, an esophogogastroduodenoscopy with small intestine biopsies If no colon pathology identified, an esophogogastroduodenoscopy with small intestine biopsies 27

28. COMMON PATHOGENS Scenario Likely organism Treatement Fever,bloody stools,with or without abdominal pain Shiegella, salmonella, campylobacter, entomoeba hystolytica, enterohemorrha gic Escherichia coli ShigellaSalmonellaCampylobacterEntomoeba E. coli Bactrim, Cipro Bactrim, cipro ErythromycinCiproCipro Onset of symptoms <6 hrs from a meal Staphylococcus aureus, Bacillus cereus Supportive therapy only Onset of symptoms 8-14 hrs from a meal Clostridium perferinges Supportive therapy only Onset of symptoms >14 hrs with vomiting major component Viruses: Rota and Norwalk Supportive therapy only 28

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

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

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

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

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

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

35. LABORATORY FOCUS ON CAUSE FOCUS ON CAUSE It is debatable in patients without red flags, but consider in patients with red flags It is debatable in patients without red flags, but consider in patients with red flags - Stol analysis- leucocytes, blood, - Stol analysis- leucocytes, blood, - Culture: if there is leucocytes and red blood cells in a patient with fever, abdominal pain or bloody stools - Culture: if there is leucocytes and red blood cells in a patient with fever, abdominal pain or bloody stools - Bloody stool: E. Coli 0157: H7 - Bloody stool: E. Coli 0157: H7 - Antibiotic use: C. Difficile toxin - Antibiotic use: C. Difficile toxin 35

36. - Serologic tests: rapid tests for rota, adenovirus is available. Unecessary for salmonella except systemic disease is suspected - Serologic tests: rapid tests for rota, adenovirus is available. Unecessary for salmonella except systemic disease is suspected - Ova and parasites: uneccessary routinely, consider if you suspect giardia lamblia, homosexuals, immunocomprimised - Ova and parasites: uneccessary routinely, consider if you suspect giardia lamblia, homosexuals, immunocomprimised 36

37. LABORATORY - Flexible sigmoidoscopy and biopsy: ulcerative colitis, ischemic colitis, pseudomembranous colitis, amebiasis, shigella infection, proctitis in homosexual men FOCUS ON SEVERITY FOCUS ON SEVERITY - Basic chemistry - Basic chemistry - Electrolytes - Electrolytes 37

38. Fever >38.2, dehydration, abdominal pain, bloody stool, >6 stools/day Fever >38.2, dehydration, abdominal pain, bloody stool, >6 stools/day Immunodeficiency Immunodeficiency >70 yrs >70 yrs Yes No Yes No Lab Fallow Lab Fallow Think about hospitilization Think about hospitilization 38

39. TREATEMENT APPROACH Rehydration- electrolyte replacement if necessary Rehydration- electrolyte replacement if necessary Symptomatic relief Symptomatic relief Occasionally antibiotics(minimal impact on disease course, enterohemoragic E.coli-hemolytic uremic syndrome,prolong shedding of organism) Occasionally antibiotics(minimal impact on disease course, enterohemoragic E.coli-hemolytic uremic syndrome,prolong shedding of organism) Antidiarrheal agents: Loperamide, Lomotil Antidiarrheal agents: Loperamide, Lomotil 39

40. Composition of the new ORS formulation New ORSgrams/litr e New ORSmmol/litre Sodium chloride 2.612.683Sodium75 Glucose anhydrOUS 13.565.854Chloride65 Potassium chloride 1.57.317Glucose, anhydrous 75 Trisodium citrate, dihydrate 2.914.146Potassium20 Citrate10 TOTAL20.5100.0Total Osmolarity245 40

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 the small intestine; sodium and potassium are needed to replace the body losses of these essential ions during diarrhoea (and vomiting); citrate corrects the acidosis that occurs as a result of diarrhoea and dehydration. 41

42. POSSIBLE INDICATIONS OF EMPIRIC ANTIBIOTICS Patients with dysantery or moderate to severe traveler’s diarrhea Patients with dysantery or moderate to severe traveler’s diarrhea Patients with fecal leukocytes or blood in their stool and fever Patients with fecal leukocytes or blood in their stool and fever Patients with suspected Giardia infection with 2-4 wks diarrhea and no signs of dysentry Patients with suspected Giardia infection with 2-4 wks diarrhea and no signs of dysentry Note: antibiotics minimally impact the disease course, can prolong shedding 42

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

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

45. CASE 2- PE Appears comfortable Appears comfortable 118/72 mmHg, 88 beat/min,36,5 C, 1.62 cm, 57 kg 118/72 mmHg, 88 beat/min,36,5 C, 1.62 cm, 57 kg PE is normal including rectal examination 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 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 45

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

47. Differential dx for Case 2 Viral gastroenteritis (rota, norwalk) Viral gastroenteritis (rota, norwalk) Early viral hepatitis Early viral hepatitis Protozoal infection: giardia lamblia Protozoal infection: giardia lamblia 47

48. What happened to case 2 Returned two wks later Returned two wks later Diarrhea was okey, but 2 days ago a second bout of foul smelling diarrhea associated with epigastric discomfort and increased gas, lost 2 kg, generalized fatigue. Her oldest son had also started having loose stools Diarrhea was okey, but 2 days ago a second bout of foul smelling diarrhea associated with epigastric discomfort and increased gas, lost 2 kg, generalized fatigue. Her oldest son had also started having loose stools 48

49. What is the diagnosis Stool analysis revealed cysts of giardia lamblia Stool analysis revealed cysts of giardia lamblia Stol examination of children were also positive for giardia Stol examination of children were also positive for giardia The source was city water:There had been a breakdown The source was city water:There had been a breakdown (it could be due to day care epidemics –from children or her part time job) 49