Clinical Tropical Medicine: Diarrhea/ort

Front 1

What 10 factors help determine diarrhea management?

Back 1

Age
Fever
Vomiting
Stool consistency
Blood/mucous in stool
Chronicity (how long going on)
Recent travel
Outbreak pattern
Antibiotic treatment
Other sx (e.g. seizures, rectal prolapse)

Front 2

What age factors influence diarrhea mgmt?

Back 2

Newborns: EPEC
Infants < 12 mos: Campylobacter> Shigella
Infants > 12 months: Shigella

Front 3

What does fever tell us about diarrhea?

Back 3

Invasive pathogen or inflammatory bowel:
Shigella, Salmonella, Capylobacter, e. Hystolytica

Front 4

What does vomiting tell us about diarrhea?

Back 4

Common with viruses
Occasionally with shigella and staph food poisoning

Front 5

What does consistency tell us about diarrhea?

Back 5

Watery (ETE, cholera, viral)
Soft (dysenteric)

Front 6

What does chronicity (>14d) tell us about diarrhea?

Back 6

>14 days suggests untreated bacterial dz or malabsorption from disaccharidase deficiency
(giardia,
strongyloides,
cryptosporidium,
gluten enteropathy,
tropical sprue,
abdominal TB,
HIV)

Front 7

What are common foodborne/waterborne diarrheas?

Back 7

Shigella
Salmonella
Norwalk-like

Front 8

What are daycare associated diarrheas?

Back 8

Giardia
Cryptosporidum, Shigella
Rotavirus

Front 9

Side effect of antibiotic use in diarrhea?

Back 9

Create resistant strains
Select for C diff
HUS
Carrier states

Front 10

What diarrhea causes rectal prolapse?

Back 10

Shigella (due to inflammatory toxin)

Front 11

What diarrhea causes seizures?

Back 11

Shigella

Front 12

How to determine dehydration?

Back 12

Mucous membranes
Skin turgor
Sunken eyes
Sunken fontanelle
Level of alertness
Capillary refill
Urine output

Front 13

4 steps of diarrheal diagnostic workup

Back 13

1. Dehydrated?
2. Fever?
3. Weight (to assess nutrition and fluid deficit)
4. Abdominal exam (distention? ileus? bowel sounds?)

Front 14

Lab tests in diarrhea? (4)

Back 14

Fecal leukoctyes
Stool culture
Parasite exam
Special tests (ELISA, serotyping, tissue culture, PCR/DNA probes)

Front 15

Types of fecal leukocyte tests?

Back 15

Methylene blue or gram stain
Leukotest fecal agglutination assay (false + in breastfed)
Direct stool carbol fushsin counterstain for campylobacter (60% sensitive)

Front 16

Which diarrheas show fecal leukocytes?

Back 16

Inflammatory
Few: shigella, salmonella, campy
Many: shigella

Front 17

Which diarrhea shows sheets of fecal leukocytes?

Back 17

Shigella

Front 18

What are the problems with stool cultures?

Back 18

Separation pathogen vs. normal flora
Time factor
Limited number of pathogens are easily detected
Requires setup

Front 19

Which diarrheas have higher yield on stool culture?

Back 19

Those with fever, severe disease and + fecal leukocytes

Front 20

What diarrheas have ELISA tests?

Back 20

Rotavirus
Giardia
C. diff
ETEC

Front 21

What diarrheas have coagglutination tests?

Back 21

Cholera

Front 22

What diarrheas have serotyping tests

Back 22

EPEC

Front 23

What diarrheas require tissue culture?

Back 23

Toxin assay for c. diff
ETEC
EPEC

Front 24

What diarrheas have PCR/DNA probes?

Back 24

ETEC, EHEC, Shigella

Front 25

How does peptol bismol help diarrhea?

Back 25

Prevents and treats
Prevents interaction of germ on intestinal mucosa

Front 26

What is Hidrasec (Racecadotril)

Back 26

Enkephilinase inhibitor
Blocks cAMP and the effect of secretory toxin mediated diarrheas
E.g. ETEC, cholera, rotavirus

Front 27

What are non-specific antidiarrheal therapies?

Back 27

Peptol bismol
Loperamide
Hidrasec
Pribiotics

Front 28

Common cause of traveller's diarrhea?

Back 28

ETEC
Some strains rotavirus
Other enterobacteria
Intestinal parasites

Front 29

Antibiotic treatment for traveller's diarrhea?

Back 29

If severe (>3stool in 24 hours) with vomiting, cramps, fever, blood in stool
Cipro BID or Norfloxacin 400mg qd
If refractory, Zithromax or rifaximin
NOT Bactrim/doxy

Front 30

Traveler's Diarrhea prophylaxis?

Back 30

Norfloxacin 400mg qd
Cipro 500mg qd
Maybe azithro

Front 31

When was ORT invented?

Back 31

1960s

Front 32

How much can ORT reduce mortality?

Back 32

20-50%

Front 33

What is the deal with glucose and ORT?

Back 33

2-3% glucose enhanses gut absoprtion of water by up to 80%

Front 34

The makeup of ORT:

KNOW THIS

Back 34

NaCl: 3.5g/L
NaHCO3: 2.5g/L OR NaCitrate 2.9 g/L
KCl: 1.5g/L
Glucose 20g/L

Front 35

How do glucose and sodium move into the intestine?

Back 35

Glucose and sodium enter coupled in a 1:1 ratio

To absorb salt, add glucose (or amino acids or galactose)

Front 36

When sodium goes into an intestinal cell, what happens?

Back 36

Water follows

Front 37

Do you absorb nutrients during diarrhea?

Back 37

Yes, 60%
More with ors

Front 38

Traditional ORT helps which diarrhea best?

Back 38

Cholera...due to it's high sodium loss

Front 39

How to make home ORS?

Back 39

8 tsp sugar
1 tsp salt
1 liter water
(missing K and bicarb)

Front 40

3 steps of ORT therapy?

Back 40

1. Assess level of dehydration based on weight
2. Rehydrate with 1.5-2x estimated fluid deficit ovr 4-6 hours
3. At 6 hours, if rehydrated, resume breast/bottle feeds. AND replace losses (under 1y/o: 50-100ml per stool, >1 y/o: 100-200ml/stool)
4. If not rehydrated, repeat step 2

Front 41

What is the difference between New and Traditional ORS?

Back 41

245mOsm/L (lower osmolarity) -- 75meq/L Na and glucose
Can be used for all, even cholera

Front 42

What is the max cc/kg fluid rehydration per hour?

Back 42

100cc/kg/hour (for moderate dehydration)
50cc/kg/hour (for mild)

Front 43

What is maintenance ORT rate?

Back 43

Under 1: 50-100ml/stool
Over 1: 100-200ml/stool

Front 44

Is vomiting a contradiction to ORT?

Back 44

No (unless >3 episodes / hr)
Most vomiting with ORS occurs in the first few hours. Push through.

Front 45

What to do if child vomiting too much for ORT?

Back 45

NGT
IV only if in shock

Front 46

When is hypernatremia a problem?

Back 46

Normally with home made ORT
If give high glucose drinks, will absorb more sodium

Front 47

What's the concern of dropping hypernatremia too fast?

Back 47

Convulsions

Front 48

How do you define severe dehydration?

Back 48

>10% loss body weight
Initially treat with IVF 10-20cc bolus Ringers or D5NS
Can give oral if pt conscious/not in shock

Front 49

What's true about malnourished kids and K?

Back 49

Normally low in K...so diarrhea makes this much worse

Front 50

What does low K do to the gut?

Back 50

Paralytic ileus (contraindicates ORT)

Front 51

What is considered excessive stool loss?

Back 51

>10cc/kg/hr

Front 52

What is the concern of too rapid refeeding in Kwashiorkor?

Back 52

Edema and cardiac failure

Front 53

Will kids tolerate milk during diarrhea?

Back 53

Yes, despite mild lactose intolerance

Front 54

Should you add breast feeding to ORT?

Back 54

Yes, give ORT volume, then breast. Reduces diarrhea by encouraging healing of gut mucosa

Front 55

What foods are good to give during diarrhea?

Back 55

Bananas (K)
Rice
Lentils/beans/fish, meat, eggs

Front 56

What is cereal based ORT?

Back 56

Thick, drinkable fluid of mortised then cooked cerial with addded salt

Front 57

Describe the benefit of cereal ORT?

Back 57

Lower osmotic load with starch polymers. Break into sugar and amino acid peptides
1 osmolarity of starch, reduces osmotic fluid loss
Reduce risk for hypernatremia, because too much won't get absorbed

Front 58

What is the nutritional value of cereal based ORT?

Back 58

200kcal/liter (vs. 80kcal/liter of stardard ORS)

Front 59

Recipe for cereal based ORT?

Back 59

1 fistful dry rice, wash and soak till soft, grind with mortar till paste
Add 600ml waterBoil till first bubles, then cool.
Add 3 finger pinch of salt
Cool
Use within 6-8 hours