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Approach to the patient with diarrhea

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Title: Approach to the patient with diarrhea


1
Approach to the patient with diarrhea
  • ????????????
  • 1. ???? Definition ??? Diarrhea
  • 2. ???? ??????????? Diarrhea
  • 3. ?????????????????????????????????????????
    Diarrhea
  • 4. ???????????????????????????????

2
Definition of Diarrhea
  • Pathophysiology - Stool weight gt 200 g/day
  • (infant stool weight gt 10 g/kg/day)
  • Clinical Frequency , Liquidity,
  • Changing character
  • Form water
  • mucous - bloody

3
Frequency of bowel movement in general population
Mean number of bowel movement /day
4
Daily intake and endogenous secretion and
absorption
Oral intake 2000
Net balance 2000-2001800
Salivary 1500 Glands
Stomach 2500
Endogenous secretions 7000 ml
Bile 500
Pancreas 1500
absorbed 8800/900098
Intestine 1000
9000
- 8800
200
Stool
5
The amount of fluid absorbed differs throughout
the intestine
Duodenum / jejunum 5.5 L
Ileum 2 L
Colon Rectum 1.3 L
Intake 2 liter
Stool lt200 ml
6
Mechanism of Diarrhea
  • 1. Osmotic diarrhea
  • 2. Secretory diarrhea
  • 3. Inflammatory diarrhea
  • 4. Abnormal gastrointestinal motility

7
Osmotic Diarrhea
?????? 1. Unabsorbable osmotic load 2.
Malabsorption or maldigestion ???? 1.
Unabsorbable solute load ---gt more fluid
transport to lumen
8
Osmotic Diarrhea
9
Raised CI Secretion
10
Clinical approach to diarrhea
  • Diarrhea Pseudodiarrhea
  • Acute Chronic

11
Acute Diarrhea
  • Infectious Non infectious

12
Non infectious acute diarrhea
  • Drug induced
  • Diet
  • Poisoning

13
Acute Infective Diarrhea
  • Clinical Evaluation
  • Severity of illness Special
  • Underlying disease Consideration
    and management

Clinical setting Diagnosis treatment
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15
  • Etiology of infectious diarrhea
  • Bacterial
  • Shigella Sp.
  • Aeromonas Shigelloides
  • Salmonella Sp.
  • Vibrio Sp.
  • Compylobactor Sp.
  • Clostridium difficile
  • E.coli (ETEC, EPEC, EIEC, EAEC and EHEC)

16
  • Viral
  • Norwalk
  • Rotavirus
  • Enteric adenovirus
  • Cytomegalovirus
  • Herpes simple virus
  • Fungal
  • Candida Sp.
  • Histoplasma Sp.
  • Parasite
  • Entamoeba histolytica
  • Giardia lamblia
  • Strongyloides
  • Cryptosporidium
  • Cyclospora Cayetanensis

17
  • Severity of Diarrhea
  • Sunken eyeballs
  • Poor skin turgor
  • Orthostatic hypotension
  • Tachycardia
  • Oliguria or Anuria
  • Alteration of consciousness

18
Underlying diseases
  • AIDS
  • Hyperthyroidism

19
History of Diet
  • ???????????? ????????? diarrhea
  • ???? Amanita phelloides
  • ???????????? Botulism
  • ?? Lactose deficiency
  • Samonella Campylobacter
  • ??????, ???????? , ??????? Bacillus cereus
  • ????????? Vibrio cholerae
  • Vibiro pararhemolyticus
  • Vibrio non-O-group I
  • Norwalk virus

20
History of Diet
  • ???????????? ????????? diarrhea
  • ???????? ????????????????? Samonella ,
    Campylobacter
  • ?????? Salmonella , S aureus
  • ??????????? Giardia , Aeromonas
  • ??????????????????? Shigilla , Salmonella
  • E histolytica
  • E coli (EHEC)
  • ?????, ??? V. cholera , E coli
  • ??????? Norwalk Virus

21
???????????????
  • ??
  • Antacid
  • Lactose containing drugs
  • Cancer chemotherapy
  • Neomycin
  • Cadiovascular drugs digitalis , quinidine ,
    ganglionic - blocking agent
  • Antibiotics
  • ????????? diarrhea
  • Magnesium induce osmotic diarrhea
  • Osmotic diarrhea
  • Mucosal Injury
  • Malabsorption
  • Increase motility
  • Antibiotic associated enterocolitis (Clostridium
    difficile)

22
Clinical Setting
  • Food poisoning Water Diarrhea
    Dysentery
  • (entero/neuro
    (non-Invasive (Invasive organism)
  • toxin producing)
    Organism)
  • Fever Rare Non or Low
    Grade Common
  • Incubation lt 6 hours
    6 hours-3 days 1-3 days
  • Peroid
  • Mucous-bloody stool Non Non
    Common
  • Nausea vomiting
  • Tenesmus - -
  • Voluminous stool
  • Etiology Staphylococcus
    EPEC, ETEC, EAEC Shigella
  • aureus, C.perfringens Aeromonas,
    P.shigelloides
  • B, ceceus Vibrio
    Cholerae EIEC EHEC
  • Salmonella Giardia, Salmonella
  • Cryptospodium
    Campylobactor
  • Salmonella C.difficile,
    virus E.Histolytica
  • V.Parahemolyticus

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25
Stool Leukocyte
  • Present stool leukocyte Absent stool
    leukocyte
  • HSV Adenovirus
  • CMV Norwalk virus
  • Aeromonas Rotavirus
  • Campylobacter Bacillus cereus
  • EIEC, EHEC Staphylococcus aureus
  • Shigella ETEC, EPEC, EAEC
  • Salmonella Giardia lamblia
  • V.parahemolyticus Cryptosporidium
  • Plesiomenas Shigiloides V. cholerae
  • E.Histolytica Cyclospora sp.
  • Microsporidium
  • Strongyloides

26
Treatment
  • 1. Supportive
  • 2. Symptomatic
  • 3. Specific

27
Antimicrobial treatment
  • Fecal WBC
  • Severe volume depletion
  • Community out break
  • Impaired host

28
????????
  • ????? Drug of choice
    Alternative
  • Shigella sp. Norfloxacin , ofloxacin
    Ciprofloxacin, ceftriaxone
  • Areomonas sp. Amlnoglycoside
    TMP/SMX, loramphenical
  • Ceftriaxone
  • Campylobacter Erythromycin
    Ciprofloxacin
  • Norfloxacin
  • Clostridium difficile Metronidazole
    Bacitacin
  • Vancomycin
  • Vibrio cholerae Tetracycline
    Doxycycline , TMP/SMX
  • E. histolytica Metronidazole
    Emitine
  • Giardia lamblia Metronidazole
    Quinacrine hydrochloride
  • Strongyloides Thiabendazole
    Albendazole

29
Chronic Diarrhea
Functional Organic
HIV Non-HIV
30
Causes of chronic diarrhea in Thai-AIDS
  • 29/45 Found causative organism
  • Cryptosporidium 20 TB 17.8
  • Salmomella spp. 15.5
  • CMV 11.1
  • MAC 6.6
  • Strongyloidiasis 4.4
  • Giardiasis 4.4
  • Cryptococcus 2.2
  • Histoplasma carsulatum 2.2
  • Campylobacter 2.2
  • Cyclospora 2.2
  • Manatsathit S. et al. J Gastroenterol.199631(4)
    533-7.

31
Chronic organic diarrhea (Non HIV)
  • Inflammatory Secretory
  • Malabsorption

32
Chronic Inflammatory Diarrhea
  • Infection
  • Inflammatory bowel
  • Radiation
  • Ischemic

33
Malabsorption syndrome
  • Diarrhea
  • Malnutrition

34
Intestinal epithelial cells are continually
renewed
Cell death And sloughing
Villus Region
Turn over time 48 72hr
Crypt Region
Diving cells
Paneth cells
Normally Cells entering villus Cells
dying
35
The intestine has a very large surface area
for absorption
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38
Malabsorption syndrome
  • Strongyloidiasis
  • Giardiasis
  • Capillariasis
  • Lymphoma

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  • Vipoma
  • Carcinoid syndrome
  • ZE syndrome

43
Constipation
  • ????????????
  • ???? Definition
  • ?????????????? Constipation
  • ??????????
  • ??????????????????????????????????
  • ???????????????????????????????

44
  • Definition
  • Acute
  • Chronic
  • Patient review
  • Clinical review

45
Rome II Criteria for chronic constipation (At
least 2 of following)
  • Fever than 3 bowel movement/week
  • Hard stool in more than 25 of BM
  • A sense incomplete evaluation in more than 25 of
    BM
  • Excessive staining in more than 25 of BM
  • The necessity of digital manipulation to
    facilitate evaluation
  • Any 12 week period in the least 12 months

46
Pathogenesis
Drugs (opiates, phenothiazines)
Obstruction Pseudo-obstruction
47
Cause of constipation
  • Extrinsic
  • Structural
  • Systemic
  • Neurological
  • Drugs

48
Extrinsic
  • Inadequate dietary fiber, fluid
  • Ignoring urge to defecate

49
Structural
  • Colorectal neoplasms, stricture, ischemia ,
    volvulus, diverticular disease
  • Anorectal inflammations, prolapse,
    rectocele,fissure, stricture

50
Systemic
  • Hypokalemia
  • Hypercalcemia
  • Hyperparathyroidism
  • Hypothyroidism
  • Hyperthyroidism
  • Diabetes mellitus

51
Neurological
  • CNS Parkinsons disease, multiple sclerosis,
    trauma, ischemia, tumor
  • Sacral nerves trauma, tumor
  • Autonomic neuropathy
  • Aganglionosis (Hirschsprungs disease)

52
Drugs
  • Analgesics
  • Opiates, non-steroidal anti-inflammatory
  • Anticholinergics
  • Atropine agent, antidepressants, neuroleptics

53
Drugs
  • Metal ions
  • Aluminum (antacids, sucralfate), barium sulfate
    , bismuth, calcium, iron, heavy metals (arsenic,
    mercury)
  • Resins
  • Cholestyramine, polystyrene

54
Diagnosis and differential
  • History taking
  • Physical examination
  • Diagnostic techniques

55
History taking
  • How many stools per week?
  • Chronic constipation or not?
  • Is there concomitant abdominal pain?
  • Dietary history
  • Lifestyle
  • Use of laxative
  • Use of other drugs

56
Physical examination
  • Percussion (check for gas)
  • Palpable feces (loaded colon)
  • Rectal palpation
  • Consistency / impaction
  • Presence of non fecal masses pr abnormalities
    (tumor, hemorrhoid, fissures, fistulas, prolapse,
    neoplasms)
  • Presence of blood
  • Sphincter tone

57
Diagnostic techniques
  • Stool analysis (assess seriousness)
  • weighing 3 days lt 100 g average means
    constipation
  • Abdominal Xray (assess seriousness)
  • Radiological or Endoscopic investigation (to
    assess/exclude obstructions)
  • megacolon
  • redundant sigmoid colon
  • pattern of haustral folds
  • IBS patients ---gt normal length haustral colon
  • Colon inertia ---gt longer length less haustral
    colon

58
Diagnostic techniques
  • Anorectal function tests (indicated only in
    selected cases)
  • manometry (no rectoanal inhibition reflex in
    Hirschsprungs disease
  • electromyography spastic PFD?
  • Rectal mucosal biopsy
  • acetylcholinesterase stain to exclude
    Hirschsprungs disease. Brown-black pigmentation
    of colonic mucosa
  • Colonic transit time (radioopaque markers)

59
Major Alarm symptoms especially in patients gt 50
yr
  • New onset constipation
  • Anemia
  • Weight loss
  • Anal blood loss
  • Positive occult blood test
  • Sudden change in defecation pattern and
    appearance of stool

60
Stepped Treatment of Constipation
change lifestyle and diet
Stop medications which cause constipation
Bulk-forming agent
Osmotic laxatives
Pelvic floor physiotherapy

Contact laxatives
Enema
Prokinetics
61
Laxatives
  • Bulk laxative
  • Psyllium
  • Polycarbophil
  • Methylcellulose
  • Lubricating agents
  • Mineral oil

62
Laxatives
  • Osmotic agents
  • Magnesium and phosphate salts
  • Lactulose
  • Sorbitol
  • Polyethylene glycol
  • Glycerin suppositories

63
Laxatives
  • Stimulant laxatives
  • Surface acting agents
  • Ducusate
  • Bile acids
  • Diphenymethane derivates
  • Phenolphtalein
  • Bisacodyl
  • Sodium picosulfate
  • Ricinoleic acid
  • Anthraquinones
  • Senna
  • Cascara sagrada
  • Aloe
  • Rhubarb

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