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68 Cards in this Set

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What is stool weight of diarrhea?
200 gms / day or more
What is psuedodiarrhea?
Increased freqeuncy with no change in consistence with weight less than 200 gms
what is fecal incontience?
ivoltunary release of rectal contents
more common in elderly, eomen, and stool liquid
What are three types of diarrhea (characterized by time) and what are their time periods?
acute: symptoms less than 14 days
persistent: 14-30 days
chronic: more than 30 days
Where is most fluid abs?
colon
What are the three categories of diarrheal pathophysiology?
osmotic, secretory, inflammatory
When does osmotic diarrhea happen?
absorbable solute is not abs properly
higher gut lumen concentration than normal
alter/decrease water abs, retaining water in the intestinal lumen
What is steatorrhea?
fat in feces, frothy foul smell fecal floaty matter, fat malabs, mal abs of water causing
bacterial overgrowth
what are common cause of osmotic diarrhea?
dairy products/lactose
sugar alcohols lke sorbitol
laxatives like polyethelene glycol, lactulose, magneium hydroxide
What is secretory diarrhea?
active secretion of water into the intestinal lumen
caused by bacterial infection of the gut
enteric pathogen invade epithelium making enterotoxin or cytotoxin
not because of solute
there is a stool osmotic gap
this type occurs even without food intake, continous day and night, triggers release of cytokines attracting inflamm cells
what is stool osmotic gap?
290-2X(stool na + stool K)
less than 50 for secretory
what are causes of secretory diarrhea?
laxatives like bisacodyl, senna, cascara, castol oil

inflammatory mediators like UC and crohns

Bacterial infections like vibrio cholera and shigella
What is inflammatory Diarrhea?
inflamm process causing destruction of villous cells and/or dysfunction of the transporters, leading to loss of fluids and electrolytes
Lead to exudation of mucous and proteins and blood into the gut

USUALLY LIKE UC or CROHNS DISEASE
What causes inflammatory diarrhea?
infection: salmonella, clostridium difficile, shigella, campylobacter; vibrio

celiac disease

IBD like uc or crohns
What is clinical presentation of a patient with diarrhea?
Timing: congenital, abrupt, gradual
diet: sugar free food and milk
Weight loss
Stool: consistency, blood (ibd cancer infection, mucus (ibd infection), color (white tan bile celiac), oil or greasy
What is lactose intolerance?
Osmotic diarrhea: lactose hydrolyzed by intestinal lactase to glucose and galactose in the small intestine

Up to 75% of unabsorbed lactose passes into the colon bringing water with it.
Lactose converted to short chain fatty acid andd hydrogen gas by the bacterialflora
How do you get lactose intolerance?
race: more in asian and africans
developmental lactase deficiency: prematurity born 28-32 weeks
Acquire disorders: bacterial overgrowth of small intestine, infectious giardia, mucosal injury like celiac inflammatory bowel disease
What is the patient presentation of lactose intolerance?
abdominal pain that's crampy, bloating, flatulence, diarrhea (bulky watery frothy)

Physical exam: pain localized to periumbilical area or lower quardrant
borborygmi after lactose intolerance

diarrhea is key
How do you diagnose lactose intolerance?
oral abs of 50 gms lactose and monitor blood glucose at 0 60 120 min and increase of blood glucose by less than 20 mg plus symptoms is diagnostic
lactose breath hydrogen: oral lactose at 2 gm/kg mausing at baseline and every 30 min for up to three hours.
10 ppm is normal, 10-20 is indertminant, greater than 20 is diagnositc

MAYBE JUST DO LACTOSE AVOIDANCE
How do you treat lactose intolerance?
Reduce dietary lactose intake
food allergen avoidance
administer with enzyme subsitute like lactaid or lactrase or lactace or dairyease or lactrol

replace of calcium and vitamin d
What is celiac disease and what does it put you at risk for?
Celiac sprue, gluten sensitive enteropathy,
Damage immune system causing autoimmune
increased risk for small intestine lymphoma and adenocarcinoma

Villious atropy, malabs, steattorrhea, weight loss, sign of nutrient or vvitamin def; resolution of the mucosal lesions and symptoms upon withdrawal of gluten foods. uncontrolled adenocarincoma?
What is the patient presentation/clinical presentation for celiac sprue?****************
Anemia, abdominal pain, bloating, diarrhea, steatorrhea, weight loss, failure to thrive, commonly seen in children once they've started on cereal.

B12 macrosidic iron deficiency
How do you diagnose Celiac Disease?
Labs: IgA endomysial antibody IgA EMA
IgA tissue transglutaminase antibody IgAtTG
IgA antigliadin antibody (IgAAGA)
IgG antigliadin antibody IgGAGA

Small bowel biopsy shows duodenal bulbs and second and third portion of the duodenum problems
How do you treat celiac disease?
Gluten free diet causing 70% improvement within two weeks
poor compliance or gluten ingestion
consider other things for non responders
bowel bacterial over growth or pancreatic insufficiency as well
What type of diarrhea does infectious diarrhea cause?
inflam or secretory
watery
most cases self limiting
history is important for iding pathogen
What happens in large and small bowel during infectious diarrhea?
small: fluid enzyme secretion and absorption, large volume, associated with abdominal cramping, bloating, gas, and weight loss

large bowel: absorbs fluids, salt, and secrets potassium, frequent and regular, small volume, often painful bowel movements
which bugs cause small bowel infolvement and which ones are large bowel involvements?
small: salmonella, e coli, c perfringens, s aureus, bacillus cereus, vibrio cholerae, rotovirus, cyrsptosporidium, giardia

large: campylo, shigella, c difficlle, enteroinvasive e coli, adenovirus, entamoeba histolytica
What does fever suggest with diarrhea and what does blood suggest?
fever means invasive organism: salmonella, shigella, campylo, c dificle

bloody means enterohemorrhagic e coli, shigella, campylobacter, salmonella
What are some time lines for bacterial symptoms and which bacteria are they associated with?
6 hours: preformed toxin from s aureus or bacillus cereus

8-16 are clostridium perfringens

more than 16 are e coli or virus

syndrome that begins with diarrhea but goes to more systemic stuff is listeria monocytogenes
What are some associations with hospital/antibiotics, travel, daycare, nursinghome/cruiseships/camps/military, and swimming pool bacterias?
C difficile for antibiotics,
travel: e coli, shigella, campylobacter, salmonella

day care: shigella, rotavirus, hep A, giardia, cryptosporidium

nursing home: norovirus, hepatitis A
swimming pool: giardia lamblia, shigella
bacterial diarrhea clinical diagnostic evaluation indicators: what are they?
profuse watery diarhea with hypovolemia, passage of stool containing blood or mucus, temp of greater than 101.3, severe abdominal pain, hospitalized or recent use of antibiotics, in elderly or immuno compromised, systemic illnesses
What are diagnostic evaluation techniques for infectious diarrhea?
Stool analysis: sodium potassium, red blood cell, leukocytes
Stool culture: not too effective, good for immunocomromised, bloody diarrhea, IBD history, food handlers; ova/parasite: persistent diarrhea, travel daycare worker, bloody diarrhea
Endoscopy: used to distinguish IBD from infectious diarrhea
What is the treatment for infectious diarrhea?
hydration with water, sodium, glucose
Antibiotics
Antimotility drugs like loperamide, bismuth subsalicylate, but don't use if you have a fever or bloody diarrhea
What is travel diarrhea and what are the forms?
mild: 1-2 unformed stools/24 hours without other symptoms

moderate: 1-2 unformed stools/24 hours plus at least 1 symptom of nausea vomiting abdominal pain fever blood in stool
OR three or more unformed stool/24 hours without other symptoms

classic: three or more unformed stools/24 hrs plus at least one symtpom of nausea vomiting abdominal pain fever blood in stools
What are clinical signs of traveler's diarrhea?
4-14 days after arrival, self limited symtoms for 1 to five days, maliase, anorexia, abdominal cramps followed by sudden onset of watery diarrhea
may also have nausea vomiting low grade fever
abdominal pain with palpation
diagnosis with stool culture
how do you treat traveler's diarrhea?
fluid replacement
antibiotics more than four unformed stooll daily with fever, bnlood, pus, or mucus in stool
prophylaxis
antimolity
education
What are inflammatory bowel diseases?
UC or crohns
incidence is constant for UC but increase progressively for crohns
Awful diagnosis, vigil approach, lifelong comittment for medications
What are risk factors for IBD?
jewish
mimodal age: 5-50 and 50-80
genetics with first degree relative
most common late teens early 20 onset with first degree relative in the family
Cigarette smoking (40% lower risk of developing UC, 2x likely for crohns disease), diet (western), perinatal health events (diarrheal illness during illness)
What is UC?
recurring episodes of inflammation limited to the mucosal layer of the colon
almost invariably begins in the rectum and goes to the colon
What are the types of UC?
ulcerative proctitis: rectum limitation
ulcerative proctosigmoiditis: rectum and distal sigmoid colon
left sided or istal UC; goes to the splenic flexure
pancolitis or extensive colitis: extends beyond the splenic flexure but not as far as the ceum

THE more affected The more malignancy there is
What is ulcerative colitis patient presentations?
Mild: intermitten rectal bleeding, passage of mucus, diarrhea, mild crampy abdominal pain, tenesmus

moderate: frequent blody diarrea, mild anemia, moderate abdominal pain, low grade fever, four to ten stools

severe: frequent bloody diarrhea, severe abdoninal pain, fever rapid weight loss, greater than 10 stools

the more sick you are the more hospitalization and acute management you ened
How do you diagnose UC?
Done by H and P, endoscopy or flex sigmoidoscopy
maybe a ct scan
if it is inflammed you don't wanna do this
BARIUM ENEMA IS CONTRA INDICATED
pseudopolyps
What are extraintestinal complications of UC?
peripheral arthritis, uveitis, erthema nodsum, pyoderma gangrenosum
Gangrene
What are complications of Ulcerative colitis?
colon cancer and toxic megacolon
colon cancer: 1% at 10 year durationk, 3.5 at 15 year, 10-15 at 20 years, 30 at 30 years
lining is going to get messed up, risk for colon cancer, increased risk means regular surveillance for dyspasia.

patient with UC and involvement of left colon should have endoscopy 15 years after diagnosis and then every 1 to 2 years.
Surveillance is not indicated in patients with ulcerative proctitis
What are the complication of Toxic Megacolon from UC and patient presentation?
Acute dilation of colon plus system toxicity, patient at highest risk for developing early in disease. 30% in three months, 60% within first three years
potentially lethal of IBD or infectious colitis: perf with sepsis and death
Presentation: severe bloody diarrhea, altered sensorium/confusion, fever, tachycardia, fever, postural hypotension, lower badomoinal tenderness and distenstion
POOR outcome
How do you diagnose Toxic Megacolon?
Plain abdominal film, transverse or right colon is most dilated and multiple air fluid levels
ct scal
COLONOSCOPY AND BARIUM ENEMA SHOULD BE AVOIDED DUE TO PERF RISK
How do you treat toxic megacolon in UC?
Complete bowel rest, NG tube for decompression, enteral feeding after improvement, total parenteral nutrition doesn't offer improvment really, stop antimolity agent opiate or anticholinergics, IV steroids, 5 ASA only after attack is resolved, SURGERY FINAL CASE or for emergent
What is the treatment for Ulcerative Proctitis?
5 ASA suppository or steroid foam twice a day
Thish has blood in stool

USually see remission in four to six weeks and then discontinue/tape down the drugs
How do you treat proctosigmoiditis?
5 asa enema or hydrocoriisone enema twice daily with 5 asa suppository given twice daily
active 8 cm from rectum to splenic flexure
remission in 6 to 8 weeks
steroid enema isn't great so DON"T use it
use oral for people who don't take up the butt
What is the treatment for left sided colitis or pancolitis?
Combination: oral 5 asa like sulfasaline 3-4g/day remission in 4 to six weeks. never 5 asa
5 asa or steroid supposotiry and enemas
oral predisone for more sever, 40-60 mg for two weeks
take them off steroids is goal
What do you use surgery for?
Toxic Megacolon, Perforation, refractory fulminant, severe hemorrhage, fail medical therapy, dysplasia, carcinomas
What is crohns disease? Where does it commonly occur
How does it happen?
anywhere from anus to mouth, difficult to diagnose, commonly in terminal ileum, commonly caused by genetics and triggers like viral stuff/enviromental
What is patient presentation of crohns disease?
Fatigue, not as much bleeding as UC so usually without it, bile acids absorbed in the distal ileum , steatorrhea, abdominal crampy pain limtied to distal ileum in the RLQ, weight loss, fever, thin, pale, looking forn out,

can have fever with abscess and fistula
What are complications with crohns disease?
Fistula: tract that connect two epithelial lined organs, colovesicular fistula: poop your penis
penetrates all layers of bowel in fistula
Phlegmon/abscess: walled off inflam mass without infectio, ileal involvement by mass in rlq, malabs of A d E b12 and zinc, ferinal disease like fistula, fissue abscess
What are extraintestinal manifestations of crohns?
arthritis in large joints, uveitis, erythema nodosum, pyoderma gangrenosum, osteoporosis and bone loss, pernicious anermia
How do you diagnose Crohns disease?
Endoscopy: colonscopy with intubation of terminal ileum
Ulcerationo adjacentto areas of the normal mucosa : SKIP LESIONS
pseudopoyps maybe present
video capsule endoscopy should be avodied in strictture patients
upper gi series with small bowel folow thru with contrast
ct enterography: use neutral contrast for better evaluation of wall of small bowel and abscess formation
CT IS PREFERRED
MRI enterography: similar to ct enterography high cost and limited availability
What is a problem with stricture and narrowing because of crohns?
Narrowing causes inflammatory response occuring day in and day out.
scarring occurs which contracts and bowel gets smaller and smaller
get a fecal impaction
How do you treat crohns disease in gastroduodenal disease manifestation?
Oral 5 asa mesalamine slow release, glucocorticoid predisone, immunomodulators azathioprine and methotrextate
entecort: budesonide
prenisone is dirt cheap
What is treatment for ileitis and colitis manifestation of crohns disease?
oral 5 asa maybe seeing 3 -4 week improvement, antibiotics like cipro or metronidazole, glucocorts like prednisone, immunomodulators, tnf inhibitors

USE Ttop down
takes 6 to 12 months to improv
When would you do surgery for crohns and what does it do for crohns
surg isnt curative, usually comes back in six to 12 months if you don't get it checked out you got a porblme
surg for obstruction k, fistula formation, abscess
What are findings and patterns of UCD and Crohns Disease?
Crohns disease: skip lesions transmural ulcers not that much involvement of rectum

UCD: ascending continuous from rectum, superficial mucosal ulcers and a huge involvement of rectum
________________________________________________________
Crohns is patchy and deep, they don't bleed much, rectum is in UC and indeterminent colitis is something in the middle
What are findings of polyps and fistualas in UC and Crohns?
Crohns has fistula and rectum involvement
no involvemtn of ileum in UC
pseudopolyps in UC
What is IBS
GI syndrome characterized by chronic abdoninal pain and altered bowel habits in absence of organic cause
most commonly diagnosed as GI condition
Pathophysiology is uncertain: GI motility, inflamm, post infectious, bacterial overgrowth, food sensitivity, genetics
gastroparesis
hydrogen breath treat
What is IBS presentation?
Abdoninal pain, crampy, variable intensity and periodic exacerbations, emotional stress and eating
defecation provide relief sometimes, also have badominal bloating and increaesd gas production
bowel habit can change to a degree
What are bowel habits like with IBS?
Altered bowels: diarrhea: frequent losse stools of small to moderate volume, most often in the mornig or after meals, preceded by lower abdominal cramps and urgency, about one half oa patient have mucus discharge with stools

constipaton: stools are hard and pellet shaped, experience a sense of incomplete evacuation even when rectum is empty
What are alarming symptoms with IBS that you probably shouldn't have?
Alarming symtoms that shouldn't be had: anorexia, weight loss, abdominal pain is progressive, pain awakes from sleep or prevents sleep, large svolume stool. bloody stools ,noctural diarrhea, greasy stool
How do you diagnose IBS?
HIstory physical and negative tests
Diarrhea predominant IBS: celciac disease screen, 24 stool collection, colonscopy and flex sig with biopsy

constipation type: plain flim of abdomen or ccolonoscopy with flex sig
How do you treat IBS?
Therapeutic: non judgemental set expectation and limit, involve patient in decisions, fever ibs related follow ups
diety mod: lactose free, gluten free, exclusion of foods that increase flatulence, avoid of carbos like olio di monosaccarides, polyols, fuctans, galactans, lactose, fructose, sobitol, xylitol, mannitol,

increase fiber intake, physiccal activity, antidiarrheals, anti pasmodic agents anti depressants