Diarrhea

1
Internal Medicine Conference
Victor Ghobrial, MD Dr. Balkisson Maharajh, MD
2
HPI

• Female pt. 46 ys old
• C/O weakness and diarrhea for 6 days
• Her usual BMs are EOD, that time she was having
  10 - 15 BMs/ day of fluid stool
• Denied nausea or vomiting
• Denied fever, skin rash, Bl or mucous or other
  constitutional symptoms

3
HPI

• She had history of recent travel to New York, one
  week prior to developing symptoms
• Pt had chicken salad lunch in a restaurant, on
  that very day she started developing her symptoms
• No body else dinning with her ever had such
  symptoms

4
PMH

• Hypothyroidism ( following radio active I )
• Hypercholesterolemia
• Abnormal MRI of brain ( DD stroke vs MS )
• Abdominal hystrectomy ( fibroid uterus )
• C section x 2

5
Meds

• Paxil 20mg po QD
• ASA 81mg po QD
• Synthroid 0.125mg po QD
• Premarin 1.25mg po QD
• Zocor 20mg po QD
• No recent Abx use
• NKDA (no known drug allergy)

6
Social Hx

• Negative for alcohol or tobacco use
• Lives with family
• Works as an accountant

7
Family Hx

• Negative for DM, CAD, HTN
• No history of cancer
• No history of colon polyps or ulcerative colitis

8
Phys Exam

• BP T RR
  PR
  
  84/60 98.2 16
  84
• HEENT Unremarkable
• Neck No lymphadenopathy or thyroid enlargement
  
• Heart RRR, no murmurs or gallop detected
• Lungs CTAs

9
Phys Exam

• Abdomen Soft, mild diffuse tenderness without
  organomegally. No abdominal skin rash
• Extrem No E,C,C. ve PP
• Neuro AAO, no focal deficits or CN palsies
• Rectal No masses, normal tone of anal sphicter
  with Guiac - ve heme stools

10
Labs

• Hgb Hct RBCs WBCs
  Plat
  14.2 43 4.99
  6.0 211
• Na K Cl Co2 BUN
  Cr Gluc 133 3.0 100
  24 13 0.6 111
• Urinalysis Unremarkable
• T4 TSH
  
  8.5
  5.84

11
Course

• Pt continued on IVFs with close monitoring of
  I/Os and was given metamucil 2tsp TID
• Stool cultures grew Gm - ve pathogens
• Pt started on Ciprofloxacin 400mg IV Q 12hs
• Subcultures grew salmonella sero group D
• Flex sigmoidoscopy Erythema and edema of colon
  compatible with salmonella colitis
• Abx D/Cd after one day, diarrhea resolved

12
Diarrhea
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Definitions

• Increase in daily stool weight above 200gm
• Increase in frequency, fluidity or amount
• Differentiate from incontinence and IBS
• Acute lasts less than 7 - 14 days
• Chronic lasts more than 2 - 3 weeks

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Acute Diarrhea

• INFLAMMATORY
• Fever bloody with Leukocytes, volume lt1L/ 24 hr
  secondary to colonic damage
• Shigella, Salmonella, Amebiasis, C.diff, E coli
  0157H7 toxin, Ischemia, UC, Crohns,
  Cytomegalovirus

• Non-INFLAMMATORY
• Watery with N/V, volume gt1L/ 24hr secondary to
  small intestine disease
• Norwalk Rota virus, entrotoxins as Giardia,
  Staph aureus, Cholera, E coli, Bile acid,
  Laxatives, Malabsorpt

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Evaluation

• Most pt with acute diarrhea respond in 5-7 d for
  rehydration and antidiarrheal agents
• Isolation rate of pathogen from stool lt 3
• Stool leukocytes is inexpensive test to
  differentiate inflammatory vs non- inflammatory
  types
• Sigmoidoscopy indicated for Proctitis, C
  diff, UC, Ischemic colitis

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Management

• Inflammatory
• Antidiarrheal agents are avoided
• Moderate to severe cases start empiric Abx
  Ciprofloxacin, TMP-SMA, Erythromycin
• Always treat C diff, Amebiasis, Enteric
  fever, Shigella, STDs

• Non-inflammatory
• Rehydration is most important
• Loperamide offers relief, Anticholinergic
  contraindicated for megacolon
• Always treat Cholera, Giardiasis, Travelers
  diarrhea

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Salmonella food poisoning

• Contaminated poultry especially egg yolk
• Incubation 8- 48 Hrs
• Diarrhea, low temp. Bacteria grow on surface with
  little invasion
• No Abx unless immune compromised
• Pt remains as carrier for up to 2 months

18
Enteric fever

• Caused by Salmonella typhi, incubation 2 w
• Fever, bradycardia, altered behavior,
  constipation followed by diarrhea
• 2nd week Rose spots on abdomen thorax,
  Spleenomegally and Lymphadenopathy
• Rx Chloramphenicol, Ciprofloxacin, Ampicillin

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Travelers diarrhea

• E coli produces heat labile entrotoxin and heat
  stable, causes 40 - 75
• Diarrhea lasts 3- 5 days
• Other pathogens - Shigella, Salmonella,
  Rotavirus, Giardia
• Rx Ciprofloxacin, TMP- SMA, Aztreonam

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Chronic Diarrhea

• Persists gt 2 weeks
• Do stool cultures, ova and parasites
• Stool collection for 48 - 72 Hrs for weight , fat
  content, lytes and osmolality
• Sigmoidoscopy for visualization of mucosa and
  biopsy

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Osmotic Diarrhea

• Stool osmotic gap (Normally lt50) Measured -
  Estimated (Na K) X 2
• Stool volume decreases with fasting
• Common causes
• Lactose intolerance
• Sorbitol
• Laxatives
• Antacids

22
Secretory Diarrhea

• Increased intestinal secretion or decreased
  absorption with gt 1 L diarrhea
• Little change with fasting
• Endocrine diseases

VIPoma medullary carcinoma carcinoid Zollinger
- Ellison syndrome Bile salts Villous
adenoma
23
Inflammatory Diarrhea

• Fever , hematochezia and abdominal pain
• Causes
• Ulcerative colitis
• Crohns disease
• Microscopic colitis
• Radiation enteritis
• Malignancy

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Malabsorption

• Wt loss, anemia, vitamin deficiency with fecal
  fat gt 7 - 10 g/24 Hs
• Causes
• Tropical sprue
• Whipples disease
• Pancreatitis
• Bacterial overgrowth
• ( vagotomy , diabetes )

25
Infections

• Chronic infectious agents
• Giardia
• Entamoeba histolytica
• Cyclospora
• AIDS related infctions
• Cytomegalovirus
• Cryptosporidium

26
Motility Disorders

• Charachterised by systemic disease or prior
  abdominal surgery
• Diabetes Mellitus
• Hyperthyroidism
• Irritable bowel syndrome

27
Thank You
The End