Diarrhea and Constipation

1. Diarrhea and Constipation Nadim J Lalani September 9, 2004

2. Diarrhea: Epidemiology • 4 million deaths worldwide /year…100,000 child deaths (<5yrs) / day. • US: 20 million diagnoses, 200,000 hospitalisations and 400 deaths per year. [Rosen’s Emergency Medicine. 5th Ed. 2002. Mosby ]

3. Definitions • Diarrhea:stool weight greater than 200 g in 24 hours. Clinically - a change in stools, usually defined as passage of three or more loose or watery stools in 24 hours. Acute diarrhea lasts less than 14 days. • Gastroenteritis: Gut inflammation with diarrhea and vomiting • Dysentery: Diarrhea with blood and/or mucus. • Beware of vomiting kids! (need broad DDx)

4. Case #1 “Turkish trots” • Mr. Montezzuma is a 35-year-old who presents with a 4-day history of abdominal cramps, headache, and 8-10 episodes/day of watery diarrhea. He has had a few episodes of vomiting but denies fever or bloody diarrhea. He was previously healthy. • What else?

5. HISTORY: What do they mean by “diarrhea”. Features (onset, blood?) Other Symptoms (vomits, cramps, fever) Travel / Camping Infectious Contacts Recent Meds? What food ? Potential toxins? Medications, PmHX, FmHx Surg. &c.

6. Case 1 (cont’d) • He just spent a week in New Delhi. He loves to immerse himself in other cultures “when in Rome man!” and states that he couldn’t keep himself from sampling various roadside delicacies. • No one else sick, no meds, no surgeries. • What now?

7. P/E: afebrile, normal vitals,well dehydrated but has a diffusely tender abdomen with hyperactive bowel sounds but no rebound or guarding. • DDx? • Likely organisms?. • What if no clear travel history/camping &c.

8. Differential – 5 I’s • Infectious • Nausea and vomiting predominant - Bacillus cereus - Staph. Areus - C. perfringens (gives more diarrhea though) pre-formed toxins cause sympts < 6 hrs short course which resolves within 24 h. 2. Diarrhea predominant Small bowel Large bowel [S.Coderre/2003]

9. Small bowel (aka non-inflammatory): • watery, less pain (cramps), large volume - due to mucosal hypersecretion and abN absorption. Fever and systemic symptoms usually absent. Viruses Bacteria -- C. perfringens – Vibrio cholera -- E. coli (ETEC) -- Salmonella* -- Yersinia* • Parasites – Giardia *can give “large bowel” sympts.

10. Large bowel (aka inflammatory): • Bloody, painful, urgency, small volume due to invasion of mucosa. More fever, malaise, and myalgia. • Bacteria – Campylobacter -- Shigella -- E. Coli 0157:h7 -- C. Difficile * Parasites – E. histolytica * Colonic invasion but with small bowel sympts.

11. The 5 I’s (cont’d) • Inflammatory • Non-bloody (Crohn’s Ileitis) • Bloody (Ulcerative Colitis and Crohn’s Colitis) • IBS • Ischemia • Impaction with overflow

12. Back to Case #1 • a 4-day history of abdominal cramps, headache, and 8-10 episodes/day of watery diarrhea. He has had a few episodes of vomiting but denies fever or bloody diarrhea. • Is any work up indicated here?

13. Who gets worked up? • Main two: • Diarrhea >5 days Stool cultures +/- C.diff toxin • Bloody diarrhea • O & P with suggestive travel histories, immunocompromised, diarrhea >14 days, when the diarrheal illness is unresponsive to appropriate therapy. • Blood cultures when bacteremia or systemic infection suspected.

15. “Delhi belly”: To treat or not to treat? • Mostly ETEC infections(40-50%).Generally do not require antibiotic therapy. Treatment is mainly supportive (fluids). • Sandford 2003: Mild Diarrhea (≤3 unformed stools/d minimal sympts) Rehydration Moderate Diarrhea (≥4 stools/d +/- systemic sympts) add antimotility agents Severe Diarrhea: see below • Antibiotics for: severe invasive (bloody) or >6 episodes/24 h or Fever > 38.5 • high risk: elderly, diabetics, cirrhotics, and immunocompromised patients, • empirical treatment with a quinolone antibiotic for 3 to 5 days. [Oldfield III EC, Wallace MR. The role of antibiotics in the treatment of infectious diarrhea. Gastroenterol Clin North Am. 2001;30:817–836. ]

16. Antibiotics and Antimotiliy Agents: • Ciprofloxacin (Cipro) one 750-mg dose. • In the absence of dysentery, Loperamide (Imodium), 4mg at the start of diarrhea, followed by 2mg after each loose stool (maximum daily dosage: 16 mg) . Can also give Pepto-Bismol 2 tabs (262 mg) PO QID. • Cipro vs placebo for severe diarrhea decreased duration of diarrhea and symptoms but did not change fecal carriage (NEJM 340: 1525, 1999) [Note: Ddx for traveller’s includes: ETEC, Shigella, Salmonella, Campylobacter, Giardia.]

17. Case #2: Disney’s Cruise Runs • Marge is a 65 yo retired, just went on a cruise to Alaska and came back with 3-4 days of loose/watery stools and some abd cramping. Her husband and friends also came down with “the runs”. Otherwise well. Nothing else on history. PE normal. • Likely org?

18. Viruses in Alberta mostleast: • Rotavirus: generally kids, in winter and hospitalised. • Adenovirus 40/41,Caliciviruses and Astroviruses (kids/daycare) • Norwalk/Norwalk-like: adults, eldercare facilities. • No Rx. Supportive care. NOTE: dehydration in kids and elderly

19. Case #3: “I let the colonel do the cooking last night!” • Rob got tired of cooking steaks and went out for some finger-lickin’ goodness. Developed intermittent fever, crampy abdominal pain x 1 day. Now has had low volume bloody diarrhea 8-10 times a day for three days. Well hydrated otherwise perfectly healthy. No other Hx. PE normal. • Likely organism?

20. Campylobacter factoids: • The most common bacterial cause of food-borne illness. • Contaminated food mostly chicken • Can mimic appendicitis. • “Campylobacter is the single most identifiable antecedent infection associated with the development of GBS …via molecular mimicry”. • Incidence < 1/1000 [Nachamkin I; Allos BM; Ho T Campylobacter species and Guillain-Barré syndrome.Clin Microbiol Rev - 01-JUL-1998; 11(3): 555-67]

21. Other factoids: • Yersinia can perfectly mimic appendicitis because it causes terminal ileitis. • If someone has been eating oysters/ shellfish think Vibrio parahaemolyticus. • Vibrio cholera causes a secretory diarrhea that can result in profound hypovolemia. • The volume of fluid lost through the stools in 24 hours can vary from 5 ml/kg (near normal) to 200 ml/kg

22. Rehydration in the Field • Ceralyte, Pedialyte, or generic solutions. • Make your own: 4 tsps sugar,3/4 tsps of salt,1 tsp baking soda,one cup orange juice, dilute with water to one litre. [Dr Ukrainetz 2002] • Fluids given = fluid loss

23. Rehydration (con’td) • WHO-recommended solutions can also be prepared by a pharmacy by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or 2.9 g of Na citrate), 1.5 g of KCl, and 20 g of glucose or glucose polymer (e.g., 40 g of sucrose or 4 tablespoons of sugar or 50-60 g of cooked cereal flour such as rice, maize, sorghum, millet, wheat, or potato) per liter of clean water. This makes a solution of approximately Na 90 mM, K 20 mM, Cl 80 mM, HCO3 30 mM, and glucose 111 mM. [Guerrant RL Practice guidelines for the management of infectious diarrhea.Clin Infect Dis - 1-FEB-2001; 32(3): 331-51]

24. Case #4: “Hey! Everyone needs a colectomy!” • 65 yr old male, major tooth pain and likely abscess. The dentist gave him clindamycin which helped. Four weeks later he begins to have profuse watery stools 6-10 times a day. Now has a lot of abd pain. No remarkable Hx. PE: diffuse abdominal tenderness +ve peritonitis warm, flushed, shocky appearing. • Likely pathogen?

25. C Difficile: • 2001-2004 1167 cases in Calgary. • Previous Hx Antibiotics: Clinda > Cephalosporins > Penicillins. (but any Abx can do it). • Avoid use of clinda for dental abscesses use Penicillin instead. • Treated with flagyl or vanc. High risk may need prophylaxis.

26. C. Diff (cont’d) • The first reported case of pseudomembranous enterocolitis (PMC) was reported by J. M. Finney in association with William Osler in 1893. • The most common clinical setting in those cases not associated with antibiotic therapy was colonic, pelvic, or gastric surgery.

27. C diff cont’d • Other risk factors: spinal fracture, intestinal obstruction, colon carcinoma, leukemia, severe burns, shock, uremia, heavy metal poisoning, hemolytic-uremic syndrome, ischemic, cardiovascular disease, Crohn’s disease, shigellosis, severe infection, ischemic colitis, and Hirschsprung disease. • There is no definitive explanation but it may be related to alterations in host defense mechanisms and enteric flora. Several postoperative cases were related to hypotension and shock, suggesting an ischemic origin.

28. Case #5: “badabababa…I’m luvin it” • Pierre is a 5 yo brought to the ED by his mother with a 2-day hx of severe abdominal cramps and diarrhea (5 to 7 watery stools daily). Today noticed blood in his diarrheal stools. No fever or vomiting He refuses to eat, but has been drinking well. Not sure of urine output. Previously healthy, no significant weight loss or other symptoms.

29. Case #5: Hx • Traveled to USA a month ago, No camping, no one else sick, baby sister goes to daycare. He eats eggs, veggies, meats especially hot dogs and chicken tenders. He likes apple juice, and his older brother has a pet Iguana.

30. Case #5 (cont’d) • P/E: afebrile, normal blood pressure, normal respirations and normal cap refill. Dry mucosa, but skin turgor is normal. • Abdomen: hyperactive bowel sounds, mild distension, and diffuse tenderness, but is soft with no rebound or guarding. He has grossly bloody soiling of his underpants. • Ddx? • Work up?

31. Case# 5 • Pierre later admits having eaten a burger at his friend’s house…but he says it was brown in the middle not pink. • You do a Stool C & S. • What treatment? • The lab calls you with the results of the stool culture. Pierre's stool grew E. coli O157:H7.

32. E.Coli o157:H7 Abx or no? • Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med. 2000;342:1930–1936. • prospective cohort study of 71 children < 10 years old who had diarrhea caused by E. coli O157:H7. • HUS developed 10 children (14%). Five of these 10 children had received antibiotics. • treatment with antibiotics (RR 14.3)(95% CI 2.9- 70.7) was significantly associated with HUS. • Conclusions: Antibiotic treatment of children with E. coli O157:H7 infection increases the risk of the hemolytic-uremic syndrome.

33. Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia.coli O157:H7 enteritis: a meta-analysis. JAMA. 2002;288:996–1001 • meta-analysis of 9 studies published between 1990 and 2000. • Total of 1111 patients; 16% (range among studies, 8%-35%) developed HUS. • The pooled odds ratio was 1.15 (95% confidence interval, 0.79–168) • Conclusion: “meta-analysis did not show a higher risk of HUS associated with antibiotic administration. A randomized trial of adequate power, with multiple distinct strains of E coli O157:H7 represented, is needed to conclusively determine whether antibiotic treatment of E coli O157:H7 enteritis increases the risk of HUS”.

34. Commentary: • The authors note the major limitation of the meta-analysis: they were not able to analyze the risk of HUS according to choice of antimicrobial agent or timing and duration of therapy. • Some in vitro studies and animal models suggest the importance of drug choice, drug timing, and infecting strain. • Some studies indicate that early treatment with an appropriate dose of an appropriate antimicrobial agent may reduce the risk of HUS. Other studies indicate that antimicrobial agents may be detrimental. • Perhaps the currently available data, including the meta-analysis, are insufficient to resolve this issue.

35. What about adults? • Adults can certainly get HUS 5-10% of adults in nursing home outbreaks of which mortality is as high as 80% [Rosen’s 2002] • No data on whether treatment causes HUS in adults.

36. Inflammatory Bowel Excacerbations • Crohn’s Disease: Mild diarrhea (not bloody), Abd pain and fever w/ spont improvement. 45% Ileocolitis 35% Ileitis 20% Colitis – rectal bleeding • Can cause SBO • Extra intestinal manifestations

37. Inflammatory Bowel Excacerbations • Treatment: metronidazole (10 mg/kg/d in divided doses) or ciprofloxacin (500 mg twice a day) as adjunctive treatment with 5-aminosalicylates (ASA), steroids, or immunosuppressive agents [Isaacs KL; Sartor RB Treatment of inflammatory bowel disease with antibiotics. Clin North Am - 01-JUN-2004; 33(2): 335-45]

38. Inflammatory Bowel Excacerbations • Ulcerative Colitis: bloody diarrhea, rectal bleeding (v common) Abd pain, tenesmus, fever, wt loss, fatigue anorexia. • More extra abdominal sympts • Look out for toxic megacolon, perforation, LBO, GI haemorrhage

39. Inflammatory Bowel Excacerbations • Treatment: Sulfasalazine 2-6g/d divided doses High dose steroids for severe acute colitis (fever, anemia, tachy, >6-8 stools/d) • Hydrocortisone 100mg IV q 6-8h • Methylprednisone 20mg Iv q 6-8h

40. Inflammatory Bowel Excacerbations • Disposition (Both): Admit the dehydrated sickies.

41. Case #6: “post partum blues” • 1 week old male, born at 36 weeks, normal delivery, babe is perfectly healthy. Parents noticed some blood in the babe’s loose poops a couple of days. Now baby lethargic. • Ddx? • Milk allergy • Anal fissure • Infectious diarrhea • NEC

42. Necrotizing enterocolitis • NEC typically seen in the NICU, occurring in premature infants in their first few weeks of life. Occasionally, it is encountered in the term infant, usually within the first 10 days after birth. • Neonatal stress leading to hypovolemia, bowel ischemia and • Necrosis can lead to perforation, sepsis, and death.

43. Necrotizing enterocolitis • typically present appearing quite ill, with lethargy, irritability, decreased oral intake, distended abdomen, and bloody stools. • Nb Symptoms might present fairly mildly, with only occult blood-positive stools. • High index of suspicion with birthing stress/anoxia.

44. plain abdominal film shows pneumatosis intestinalis, caused by gas in the intestinal wall.

45. Management • fluid resuscitation, bowel rest, and broad-spectrum antibiotic coverage. • Early surgical consultation • >80% survival

46. Case #7: “mmm… is that currant jelly?” • Billy is an 8 month old brought in by parents because of intermittent abd pain, vomiting and bloody/mucousy stools. • History unremarkable • PE shows distended and tender abdomen. Normal vitals. • Ddx? • Gastro, Meckels, Intussusception

47. Intussusception • 80% occur before 24 months • 4:1 boys to girls • Palpable “sausage shaped mass” not always found. • Current jelly stools are a late sign (20%) • Rectal bleeding 50% • Lethargy increasingly recognized as significant

48. Intussusception • Diagnosis: • Films unreliable. May be normal  show signs of obstruction. • The barium enema has been the gold standard for diagnosis and treatment of intussusception. • air enemas being used increasingly (faster and safer).

49. Clinical assessment of volume status: • Presence of > or = 2/4 high yield criteria is 87% sensitive in detecting > 5% dehydration • Dry mm • Ill appearance • No tears • Cap refill > 2 secs (Acad Em Med 1996)