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Diarrhea

Diarrhea . Brian Rempe MD. Goals. Define Diarrhea Statistics Approach to the Patient Who to work up How to work them up Who to treat and with what. Definitions. Any increase in daily stool weight above normal –roughly 200g per day (in men)

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Diarrhea

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  1. Diarrhea • Brian Rempe MD

  2. Goals • Define Diarrhea • Statistics • Approach to the Patient • Who to work up • How to work them up • Who to treat and with what

  3. Definitions • Any increase in daily stool weight above normal –roughly 200g per day (in men) • Clinically, any increase in frequency or change in consistency of stools. • Stool that conforms to the shape of its container

  4. Statistics • 2.2 million deaths per year. • 300-400 deaths per year in the US • 5% of visits to ED are gastroenteritis related.

  5. Etiologies • Infection is most common cause • Vast majority caused by a virus. • Bacteria: 20% • Parasites: <6% • 15 % are not infectious

  6. Non-Infectious Diarrhea Examples • GI bleed • Ischemic gut • Diverticulitis • Endocrine disorders • Numerous drugs • Fish Toxins • Withdrawal

  7. Basic Mechanism • 90% of fluid absorbed by small bowel • 10% in large bowel. • 1% disruption leads to diarrhea

  8. Secretory • Cytotoxin causes an increase in cellular permeability –most ER diarrhea

  9. Invasive • Inflammatory • Cellular damage leads to hypersecretion of water , proteins, blood, mucus • Dysentery

  10. Watery, non-inflammatory(secretory, osmotic) No fever No blood or pus Pain is mild Voluminous stool Generally Supportive care only Inflammatory Fever, significant pain Small frequent stools Fecal leukocytes, blood May benefit from antibiotics Basic Diarrheal Syndromes

  11. Acute vs. Chronic • Acute • <2 weeks • Viral • Persistent • 2-4 weeks • Bacteria, protozoa • Chronic • >4 weeks

  12. Table 1 --  Small versus large bowel diarrhea

  13. Presentation: • Helpful to split into two categories: • Norovirus like • Community acquired • Less than 6 stools per day • Low fever • Only mild abdominal pain • Less than 5 days • Non Norovirus like

  14. Chronic Diarrhea • Protozoa • C-Diff • Campylobacter • Shiga producing E coli • Entamoeba

  15. More Stats • 50-80% of those that go to the doctor for diarrhea have norovirus • Only 8% of diarrhea has a “non-norovirus” syndrome overall

  16. History • Food exposure: especially picnics, seafood, shellfish, fried rice etc. • Travel history: Water supply, travel to endemic areas. • Antibiotic use • Sexual practices

  17. History • AIDS/ HIV risk factors. • Immunosuppressed

  18. Who to test— non-norovirus type. Stool Guiac Fecal Leukocytes Stool Culture Parasite testing Testing in the ED

  19. Lab tests • Fecal leukocytes • Only about 70% sensitive • Must be fresh stool, cannot be allowed to dry • Also positive in IBD/autoimmune disorders, etc • C Diff—up to 12 weeks after abx.

  20. Who should be cultured? • All immunocompromised patients • Public health risks • Food handlers • Day care workers • Health care workers • Nosocomial infections • Institutionalized people

  21. O+P • Chronic diarrhea • Travel • Nepal, Russia • HIV • Day Care Center

  22. Oral Rehydration Therapy • Rehydration solution has helped decrease cholera mortality from 50% in 1961 to 8% in 1991. • Advantages: • Glucose coupled sodium transport is usually not crippled by pathogens. • Can be given at home. • Generally very effective • May be cheaper than IVF

  23. Refeeding(AAP rec) • Early return to age appropriate diet is suggested as soon as vomiting is controlled. • The theory of “Gut Rest” is not supported by animal models. • Milk usually OK. Most lactase deficiency is subclinical. • BRAT diet

  24. ED RX • May require bolus of IVF. • 20cc/kgin children, may be able to tolerate po afterwards. • Zofran, popsicles

  25. Rehydration in Adults • Non-dehydrated sports drinks, dilute juices, soft drinks • Augment with saltines, broth. • Rehydration solution can be used for more severe cases. • As in children, early return to diet is recommended.

  26. Antibiotics • Most patients will improve on their own • Avoid in children • Inappropriate treatment may result in prolonged carrier state, and may increase the risk of : • HUS in E-Coli 0157:H7. • Should treat the culture result in children

  27. ABX • Adults • In more severe invasive cases • Flouroquinolone for 3-5 days • Children • Try to treat culture • Risk of HUS

  28. When is it alright to use anti-diarrheals? • In adults, loperamide is the recommended agent. • Not for use in febrile dysentery • AAP does not recommend

  29. Anti-diarrheals • Can be used in most toxigenic cases, and invasive situations where abx are utilized. • Not for use in EHEC-may worsen neurologic symptoms involved with HUS

  30. Case 1 • 12 month old infant • Voluminous watery diarrhea • Vomiting • Low fever • Not tender • Dry mucus membranes

  31. Case 1 • Further diagnostics? • Diagnosis? • Treatment

  32. Common Causes #1 Viruses

  33. Rotavirus • Very common during winter months in 6-24 month olds • Fecal/oral route, also waterborne. Airborne droplets • 1-3 days incubation • Abrupt onset of vomiting preceding diarrhea • Mild cramping, low fever possible

  34. Rotavirus • Resolution in 3 days of vomiting with 4-7 days of diarrhea • Commonly followed by steatorrhea • Rarely a problem in older children and adults, most have antibodies having been previously exposed

  35. Norwalk Agent • Older children, adults • Can cause family or community wide outbreaks, Cruiseships • Fecal/oral, waterborne, shellfish • 24-48 hr incubation • Abrupt nausea, vomiting, diarrhea, cramps, myalgias • Resolution in 24-48 hrs

  36. Case 2 • 56 year old just returned from Mexico • Benign exam, low fever

  37. Case 2 • Diagnosis • Treatment

  38. ETEC • Common cause of traveler’s diarrhea • Contaminated food or drink, water • Variable illness, from cholera like to mild, watery diarrhea. • Enterotoxin mediated • Fever in less than half. • Duration: 2-3 days to a week • Treat with fluid, or will rapidly resolve with Abx (Cipro)

  39. Traveler’s • 40-50% ETEC • Remainder bacterial/viral • Most treatable with cipro • One day if not invasive • Loperamide

  40. Non-norovirus type syndromes

  41. Campylobacter . • Food/water, poultry— leading cause of foodborne bacterial infection. • Inc: 2-5days. • Invasive

  42. Campylobacter • Bloody BMs possible. Abdominal pain. May mimic appendicitis. • Guillain-Barre • Duration is 5-14 days • Erythromycin, zithromax is 1st line • Resistance growing to quinolones

  43. Salmonella • Accounts for 10-15% of all food poisoning. >2 million/year. • Cafeteria, family outbreaks. • Eggs(unbroken), poultry, meat, other raw food, improperly washed veggies. Pets lizards etc

  44. Salmonella • Inc: 8-24 hrs • Recovery in 2-5 days. • Antidiarrheals not advised • Antibiotics may prolong the carrier phase

  45. Shigella • 25-40 thousand cases/year in US • Fecal/oral contamination, including pools • 24-48 hrs inc.

  46. Shigella • Very few organisms needed for clinical infection. • Exotoxin causes secretory diarrhea followed by more severe symptoms signaling invasion. (only 20-30%)

  47. Shigella • 4-7 days duration • Neurologic symptoms common in children • Reactive arthritis • Relapsing in 10% if not treated. Treat more severe cases and prolonged cases. • Cipro #1, azithro in kids

  48. EntamoebaHistolytica • Inc: 3 days to 2 weeks. (to one year according to Rosen’s) • Consider in dysentery patient, immunosuppresed and chronic diarrhea • Associated with travel, homosexual contact, contaminated water. • May be a systemic illness. • Iodoquinol or metronidazole

  49. Case 3 • 35 year old male • Crampy abdominal pain • Bloody diarrhea • Low fever • Enjoyed steak tartar for his birthday last week • Just wants cipro for his dysentery and will be on his way.

  50. Case 3 • ABX? • Why not?

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