Diarrhea and Constipation

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Diarrhea and Constipation

• Nadim J Lalani
• September 9, 2004

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Diarrhea Epidemiology

• 4 million deaths worldwide /year100,000 child
  deaths (lt5yrs) / day.
• US 20 million diagnoses, 200,000
  hospitalisations and 400 deaths per year.
• Rosens Emergency Medicine. 5th Ed. 2002. Mosby
  

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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)

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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?

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• 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.

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Case 1 (contd)

• He just spent a week in New Delhi. He loves to
  immerse himself in other cultures when in Rome
  man! and states that he couldnt keep himself
  from sampling various roadside delicacies.
• No one else sick, no meds, no surgeries.
• What now?

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• 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.

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Differential 5 Is

• Infectious
• Nausea and vomiting predominant
• - Bacillus cereus
• - Staph. Areus
• - C. perfringens (gives more diarrhea though)
• pre-formed toxins cause sympts lt 6 hrs
• short course which resolves within 24 h.
• 2. Diarrhea predominant
• ?Small bowel
• ?Large bowel
• S.Coderre/2003

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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.

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Large bowel (aka inflammatory)

• Bloody, painful, urgency, small volume due to
  invasion of mucosa. More fever, malaise, and
  myalgia.
• Bacteria Campylobacter
• -- Shigella
• -- E. Coli 0157h7
• -- C. Difficile
• ?Parasites E. histolytica
• Colonic invasion but with small bowel sympts.

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The 5 Is (contd)

• Inflammatory
• Non-bloody (Crohns Ileitis)
• Bloody (Ulcerative Colitis and
  Crohns Colitis)
• IBS
• Ischemia
• Impaction with overflow

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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?

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Who gets worked up?

• Main two
• Diarrhea gt5 days Stool cultures /- C.diff
  toxin
• Bloody diarrhea
• O P with suggestive travel histories,
  immunocompromised, diarrhea gt14 days, when the
  diarrheal illness is unresponsive to appropriate
  therapy.
• Blood cultures when bacteremia or systemic
  infection suspected.

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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 gt6 episodes/24 h or
  Fever gt 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.
  200130817836.

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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 travellers includes ETEC,
  Shigella, Salmonella, Campylobacter, Giardia.

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Case 2 Disneys 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?

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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

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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?

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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 lt 1/1000
• Nachamkin I Allos BM Ho T Campylobacter
  species and Guillain-Barré syndrome.Clin
  Microbiol Rev - 01-JUL-1998 11(3) 555-67

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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

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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

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Rehydration (contd)

• 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

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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?

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C Difficile

• 2001-2004 1167 cases in Calgary.
• Previous Hx Antibiotics Clinda gt Cephalosporins
  gt 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.

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C. Diff (contd)

• 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.

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C diff contd

• Other risk factors spinal fracture, intestinal
  obstruction, colon carcinoma, leukemia, severe
  burns, shock, uremia, heavy metal poisoning,
  hemolytic-uremic syndrome, ischemic,
  cardiovascular disease, Crohns 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.

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Case 5 badabababaIm 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.

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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.

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Case 5 (contd)

• 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?

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Case 5

• Pierre later admits having eaten a burger at his
  friends housebut 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 O157H7.

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E.Coli o157H7 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
  O157H7 infections. N Engl J Med.
  200034219301936.
• prospective cohort study of 71 children lt 10
  years old who had diarrhea caused by E. coli
  O157H7.
• 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 O157H7 infection increases the risk
  of the hemolytic-uremic syndrome.

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Safdar N, Said A, Gangnon RE, Maki DG. Risk of
hemolytic uremic syndrome after antibiotic
treatment of Escherichia.coli O157H7 enteritis
a meta-analysis. JAMA. 20022889961001

• 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, 0.79168)
• 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
  O157H7 represented, is needed to conclusively
  determine whether antibiotic treatment of E coli
  O157H7 enteritis increases the risk of HUS.

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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.

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What about adults?

• Adults can certainly get HUS 5-10 of adults in
  nursing home outbreaks of which mortality is as
  high as 80 Rosens 2002
• No data on whether treatment causes HUS in adults.

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Inflammatory Bowel Excacerbations

• Crohns 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

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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

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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

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Inflammatory Bowel Excacerbations

• Treatment
• Sulfasalazine 2-6g/d divided doses
• High dose steroids for severe acute colitis
  (fever, anemia, tachy, gt6-8 stools/d)
• Hydrocortisone 100mg IV q 6-8h
• Methylprednisone 20mg Iv q 6-8h

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Inflammatory Bowel Excacerbations

• Disposition (Both) Admit the dehydrated sickies.

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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 babes loose poops a
  couple of days. Now baby lethargic.
• Ddx?
• Milk allergy
• Anal fissure
• Infectious diarrhea
• NEC

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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.

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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.

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

• fluid resuscitation, bowel rest, and
  broad-spectrum antibiotic coverage.
• Early surgical consultation
• gt80 survival

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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

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Intussusception

• 80 occur before 24 months
• 41 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

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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).

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Clinical assessment of volume status

• Presence of gt or 2/4 high yield criteria is 87
  sensitive in detecting gt 5 dehydration
• Dry mm
• Ill appearance
• No tears
• Cap refill gt 2 secs
• (Acad Em Med 1996)

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Mild Moderate Severe
Infant ? 5 10 15
Child? 3 6 9
Heart Rate Normal Mild tacchy Severe tacchy
BP Normal orthostatic low
Cap Refill lt 2s 2-3s gt3s
Skin temp Normal Slightly cool Cool
Skin Turgor Normal Slow retraction Tenting
Fontanelle Normal Slight depressd Sunken
Eyes Normal Slight sunken Severe sunken
Tears Normal decreased Absent
Mucous Membs Normal dry Parched
Mental Status Alert Irritable Lethargic
Urine output decreased Very low anuria
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Case 8 Full of Sh!

• Mr Farley 54 yo, convinced he is just bunged up.
  No exercise, drinks little H20, eats only carbs
  and occasional meat. No Meds no other illnesses.
  
• PE distended abd. Feels full of stool
• You need to de-bung this guy what approach?

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De-bunging

• Get an AXR
• ?R sided stool-oral fleet(NaPO4)
• ?L sided stool-rectal fleet/glycerine suppository
  one prn
• ?R and L--oral/rectal
• Conservative treatments include increasing fibre
  (Psyllium), exercise, adequate hydration, use of
  stool softeners and cathartics.

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Rectal fecal Disimpaction

• Try warm water, can then go onto phosphate soda
  enemas, saline enemas, or mineral oil enemas
  followed by a phosphate enema.
• May need pain control with manual disimpaction.

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CONSTIPATION

• Straining in gt¼
  defecations
• Lumpy or hard stools
  in gt¼ defecations
• Sensation of
  incomplete evacuation in gt¼ defecations
• Sensation of
  anorectal obstruction/blockade in gt¼
• defecations
• Manual maneuvers to
  facilitate gt¼ defecations (e.g.,
• digital evacuation,
  support of the pelvic floor) and/or
• lt2 defecations/week
• Loose stools are not
  present, and there are
• insufficient criteria
  for IBS
• Thompson WG, Longstreth GF, Drossman DA, Heaton
  KW, IrvineEJ, Muller-Lissner SA. Functional bowel
  disorders and functionalabdominal pain. Gut
  199945(suppl 2)II43-II47

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CONSTIPATION

• Depending on what you read as prevalent as 2 to
  25 .
• Primary
• ? Slow transit/ Colonic inertia (problem with
  peristalsis /- diet /- culture)
• ?Pelvic floor dysfunction (hypertonic vs
  hypotonic)
• Secondary (Meds, other conditions)

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Secondary causes of Constipation

• Drug effects
• Mechanical obstruction
• Colon cancer
• External compression
  from malignant lesion
• Strictures
  diverticular or postischemic
• Rectocele (if large)
• Postsurgical
  abnormalities
• Megacolon
• Anal fissure
• Metabolic conditions
• Diabetes mellitus
• Hypothyroidism
• Hypercalcemia
• Hypokalemia
• Hypomagnesemia
• Uremia
• Heavy metal poisoning

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Secondary causes of Constipation

• Myopathies
• Amyloidosis
• Scleroderma
• Neuropathies
• Parkinson's disease
• Spinal cord injury or
  tumor
• Cerebrovascular
  disease
• Multiple sclerosis
• Other conditions
• Depression
• Degenerative joint
  disease
• Autonomic neuropathy
• Cognitive impairment
• Immobility
• Cardiac disease

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Case 8 (contd)

• Maggie is 15 yo who presents with intermittent
  diarrhea for a month and is now constipated, She
  has some pain, gas, and bloating. No other
  illnesses. No meds. PE normal.
• Ddx?

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Irritable bowel syndrome

• common condition in adolescents
• Three factors hypersensitivity of the gut,
  altered motility, and psychosocial dysfunction
• Temporal fluctuation is characteristic.
• have a high index of suspicion for the presence
  of an eating disorder.

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Newborn constipation

• Normal is seven a day to one in seven days.
• Concern when baby not thriving, lethargic c.
• Can give some prune juice/ brown sugar with
  water.

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Hirschsprungs disease

• Failure of ganglionic migration into terminal
  colon.
• Usually distal 4 to 25 cm involved.
• Often present as neonate, but can present much
  later in mild cases
• Functional obstruction with need for enemas,
  suppositories, c

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Hirschprungs vs Constipation

• Infancy
• Minimal abdo pain
• Episodic obstruction
• No encopresis
• Empty rectum
• Narrow section on barium
• Abnormal monometry

• 2 y.o. or greater
• Colicky pain
• Episodic large stools
• Encopresis
• Full rectum
• Dilated rectum on barium
• Normal monometry studies

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