Diarrhea: Acute, Sub acute, & Chronic

! Diarrhea: Acute, Sub acute, & Chronic •! Definition: o! Diarrhea: is the passage of loose\watery stool at least 3 times per 24 hours (>200 ml). o! ...
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Diarrhea: Acute, Sub acute, & Chronic •! Definition: o! Diarrhea: is the passage of loose\watery stool at least 3 times per 24 hours (>200 ml). o! Classification based on duration: !! Acute: 4 weeks o! Classification based on etiology: " mainly for acute !! Community acquired !! Nosocomial/ Hospital-acquired •! Acute: 1.! Community acquired: a.! Viral: !! Rotavirus !! Norovirus b.! Bacterial: !! SEVERE WATERY DIARRHEA: 1.! Mechanism: #! Fluid loss from the proximal small intestine without cellular injury. 2.! Course: #! Acute, brief 1-3 days #! Self limited. 3.! Common microorganisms: Organism Enterotoxigenic E.coli

ii.!

Vibrio cholera

Salmonella Listeria

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Notes #! Gram –ve rods, enterobacterae #! Normal colonizer of the lower GIT #! Produces toxins: !! Labile toxin !! Stable toxin #! Curved vibrio, gram –ve rods with long filamentous pilli. #! Found in salty water #! Complications: !! Isotonic dehydration. !! Hypovolemic shock. !! Hypokalemia S&S. !! Metabolic acidosis. #! Characterized by: !! Rice watery stool !! No fever = No inflammation -----------------------------------------------------------

! !! DYSENTERY (BLOODY) DIARRHEA: 1.! Primary site for colonization: colon. 2.! Characteristics: #! Diarrhea in smaller volume than in watery diarrhea BUT lasts longer. #! Diarrhea with BLOOD + PUS. #! Inflammation and/or distinctive changes in the colonic mucosa. 3.! Presents as: fever, abdominal pain and cramps, & tenesmus. #! Most cases resolve spontaneously in 2-7 days. 4.! Common pathogens: Organism Shigella Campylobacter

Note: CHESS commonly cause bloody stool: Campylobacter, Hemorrhagic E.coli, E.histolytica, Salmonella, Shigella.

Notes ---------------------Associated with poultry, eggs, and milk.

Salmonella E.coli 0157:H7 Enterohemolytic E.coli

Associated with the development of hemolytic uremic syndrome.

Enteroinvasive E.coli

Dysentery.

Vibrio parahemolyticus

Associated with shellfish consumption.

Vibrio vulnificus

Increased incidence in ptx with liver disease or high iron states.

Yerisinia Enterocolitica

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!! ENTERIC FEVER (TYPHOID FEVER): 1.! Salmonella enterica serovar typhi 2.! Presents as: gradual onset of a systemic infection with fever and abdominal pain " (diarrhea is not a constant feature!) !! DIARRHEAL DISEASE WITH VOMITING AS A PROMINENT FEATURE: Organism

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Notes

Bacillus cereus

Chinese food and reheated rice.

Staphylococcus aureus

Dairy, cole slaw, picnics.

Clostridium perfinges

Meat that has been sitting out for long time.

! !! Nosocomial/ Hospital-acquired: $! Infants: !! Rotavirus " winter time, breakouts. !! Enteropathogenic E.coli (EPEC): infantile diarrhea. $! Adults: !! Antibiotic associated diarrhea: #! S\E of antibiotics (erythromycin, augmentin, cephalexin, Clindamycin) #! C.difficile overgrowth (takes 3 days). !! Non- antibiotic associated diarrhea: #! CT contrast. #! Laxatives, magnesium, and sorbitol. #! Tube feed diarrhea •! Sub-acute: 1.! Travelers’ diarrhea: ingestion of fecally contaminated food, water, or ice. Stool exam Stool lactoferrin

Notes

Bacteria Parasites

+ive :bloody diarrhea and mostly by gram negative rods. -ive: non-bloody diarrhea Mostly causes food poisoning To check for ova, and giardia antigen

Protozoa

To check for cysts and trophozoites.

Viruses

By exclusion of other causes. Immunoassay for Rotavirus.

a.! Causes: i.! 80% is bacterial cause. ii.! 50% of all cases: Enterotoxigenic E.coli. iii.! 10%-20% of cases: Shigella. iv.! Other: campylobacter jejuni. •! Diagnosis of Acute & Subacute Diarrhea: o! Exclude infection (stool study) ** GOLD STANDARD for acute diarrhea. #! Checking for: mucus, blood (RBCs), WBCs. o! If negative " go for Endoscopy.

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Management of Acute & Subacute Diarrhea: Diarrhea

Bloody

Management •! •!

If stable, observe. Adequate fluid replacement.

Antibiotic •! •!

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Non-Bloody

C.difficile: Pseudomembranous colitis

In severe cases. Ciprofloxacin (fluroquinilones) +\metronidazole. V.vulnificus: doxycycline.

•! •!

In severe cases. Ciprofloxacin (fluroquinilones) +\metronidazole. For AIDS ptxs: •! Cryptosporidosis: paromomycin or metronidazole. •! Isospora: trimethoprim •! •!

Notes

Metronidazole. If symptoms don’t abate after 2days: Vancomycin.

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Most cases are selflimited. Do not wait for culture.

C.difficile positive in stool exam.

•! Chronic: o! Classified according to the characteristic of stool: a)! SECRETORY: 1.! Mechanism: #! Derangement of electrolyte and fluid transport across the intestinal epithelium. #! (Special channels in the walls are disturbed). 2.! Etiology: #! Medication: ethanol, stimulant laxatives. #! Anatomical defects (bowel resection) and Congenital (chloridorrhea, mucosal defect…). #! Toxins (e.g. vibrio cholera). #! Hormones & neuroendocrine tumors (e.g. VIPoma, gastrinoma…). 3.! NOT affected by FASTING! b)! OSMOTIC: 1.! Mechanism: #! Osmotically active solute " driving water into the lumen. 2.! Etiology: #! Osmotic laxatives (poorly absorbed ions: Mg++, SO4+). #! Non-absorbable sugars (artificial sweeteners, lactose intolerance). 3.! Gets better with FASTING!

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! Osmotic gap 50-100mosm\kg

>100 Osmotic diarrhea Normal pH: 7-7.5

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