Rosens Notes – 24 – Diarrhea And – 92 - Gastroenteritis

Front 1

Dysentry Vs Diarrhea

Back 1

Diarrhea = increased frequency or volume and looser consistency than normal

Dysentery = diarrhea + intestinal inflammation producing mucus and/or blood in stool

Front 2

LIST FOUR CLASSES AND GIVE EXAMPLES OF EACH

Back 2

· Osmotic diarrhea:
Ø Solutes that draw fluid into the intestine
Ø Diarrhea resolves with fasting or stopping the drug
Ø Laxatives, foods with sorbitol, mannitol, drugs (colchicine, etc)
· Secretory diarrhea
Ø Water and electrolytes secreted into gut
Ø Persists despite fasting
Ø Etiologies include infections, drugs, and hormones
· Inflammatory
Ø Intestinal mucosal damage leading to secretion of water and electrolytes
Ø Infectious, chemotherapy, radiation induced, hypersensitivity reactions, autoimmunedisorders, IBD
· Abnormal Motility
Ø Chronic diarrhea
Ø Dx of exclusion

Front 3

Types of Diarrhea

Back 3

INfectious

Food Borne

Non infectious

Front 4

Infectious(85%)

Back 4

· Viral (60%): inflammatory or secretory
· Bacterial (20%): invasive vs non-invasive
· Parasitic (5%): inflammatory or secretory

Front 5

FOOD BORNE ILLNESS

Back 5

· Clostridium perfringens: MCC (25%)
· Staphlococcus aureus
· Salmonellla
· Bacillus ceruleus
· Ecoli 0157:H7
· Enterotoxigenic Ecoli (travelors)
· Seafood
Ø Cholera
Ø Vibrio parahaemolyticus
Ø Pleisomonas

Front 6

NON-INFECTIOUS DIARRHEA (15%)

Back 6

· Drugs
· Foods
· Plant toxins
· Miscellaneous toxins: cholinergics!!
· GI pathology
Ø Bowel obstruction
Ø Appy
Ø Celiac
Ø Diverticular dz
Ø GI bleeds
Ø IBD
Ø Short gut
· Endocrinopathy
Ø Hyperthyroid
Ø Carcinoid syndrome
Ø ZES
Ø Adrenal insuff
Ø Pancreatic insuff
Ø Somatostatinoma
Ø Mastocytosis
· Systemic Illnesses
Ø Alcoholism
Ø HUS, HSP
Ø Lymphoma
Ø Sepsis
Ø Toxic shock
Ø Ectopic

Front 7

Hx Q for Diarrhea

Back 7

· History
Ø Travel
Ø Suspicious food
Ø Contaminated water
Ø Undercooked meat
Ø Others sick
Ø Immunsuppressed
Ø Recent antibiotics
Ø Symptoms of invasive infection
Ø Drugs that might cause diarrhea
Ø Recent laxative use
Ø Recent hospitalizations
Ø Toxic exposures: organophosphates, etc
Ø Sexual history: anal intercourse

Front 8

Indications of invasive gastoenteritis

Back 8

Ø Fever
Ø Tachycardia
Ø Severe cramps
Ø Bloody diarrhea
Ø Systemic symptoms: anorexia, fatigue, myalgias, arthalgias
Ø Significant abdominal tenderness

Front 9

Indications for stool cultures

Back 9

Ø Bloody or other features of invasive infection
Ø Non-bloody > 5 days (some say 7)
Ø Travel
Ø Immuncompromised
Ø Toxic, septic, severe diarrhea
· Fecal leukocytes
Ø Associated with invasive colitis but not 100% sensitive
· Stool for O&P
Ø Not routinely indicated
Ø Persistent diarrhea, travel, contaminated water, immunosuppressed, day cares

Front 10

MANAGEMENT

Back 10

Oral Rehydration: 50 ml/kg over 4hrs
IV adults: bolus 1-2L NS then 250 cc/hr X 4hrs
IV kids: bolus NS 20 ml/kg then D51/2NS at 2-3 times maintenance

Do not suggest complete bowel rest: prolongs the diarrhea
· BRAT diets are no longer recommended
· Avoid caffeine
· Milk can cause lactose intolerance b/c some bugs cause temporary lactase deficiency
· Antimotility agents
Ø Safe for use in non-invasive
Ø Do NOT use alone in invasive, can combine with antibiotic tx
Ø Lomotil (diphenoxylate + atropine): 4mg qid X 2/7 (Pearl = diphenoyxlate is an opiod and atropine is an anticholinergic which was added to decrease the abuse of the drug!)
Ø Imodium (loperamide): 4mg initially then 2 mg after each stool (max is 16 mg/day)

Front 11

Antibiotics

Back 11

Ø Kids: treat only based on stool cultures (mainly because increased HUS noted in retrospective studies of kids treated with abx with Ecoli 0157H7 and shigella)

Ø Adults: indications for empiric treatment (Cipro 500 bid X 5 days)
Systemic toxicity: fever, ill appearing, systemic symptoms
Severe diarrhea
Traveller’s diarrhea

Ø Other factors with abx treatment
Persistently symptomatic when cultures return
Asymptomatic patients that are a public health risk (after cultures return)

Front 12

CAMPYLOBACTER

Back 12

· MCC of bacterial diarrhea
· More common in summer months
· Opportunistic infections in AIDS patients
· Common cause of “backpackers” diarrhea (after giardia)
· C. jejuni, C.coli, C.fetus
· Fecal - oral contamination of food and water or direct contact
· Animal resevoirs: chickens, pigs, birds
· Blood in diarrhea is variable: none to frank hematochezia or melena

· Onset 2-5 days, resolution 1 week
· Can look like new onset IBD; colitis seen of endoscopy
· Ddx is other invasive gastros: shigella,salmonella, Ecoli 0157H7

· Antibiotics if severe or if not resolved when cultures return
· Ciprofloxacin 500 mg po bid X 7 days
· NO lomotil b/c invasive

Front 13

SALMONELLA

Back 13

· 15% of food poisoning
· Chicken, turkey, duck, eggs
· Pets: dogs, cats, reptiles, turtles, snakes, iguanas (can cause outbreaks)
· Salmonella can survive well cooked food
· Eggs can be contaminated (unbroken eggs!): passed from hen to egg

· Cooking usually eradicates salmonella that is in eggs
· Raw-egg foods: hollandaise sauce, homemade eggnos, caesar salad dressing, french toast

· People can be asymptomatic excreters of salmonella for months
-Salmonella typhei: typoid fever
-Salmonella choleraesuis: sepsis common
-Salmonella enteritidis: egg source

·More common in leukemia, lymphoma, AIDS, other cancers
·Sickle cell patients and other hemolytic anemias are especially prone to salmonella bacteremia

· Incubation 8-24h, duration 2-5 days
· Antibiotics if severe, not resolved when the cultures return, food handler or teachers, or health care professions (eradicate carrier state and decrease spread)
· Ciprofloxacin 500 mg po bid X 7 days
· No lomotil alone, can use if using antibiotics
· Food handlers and health care professionals should be treated and should not return to work until they have negative stool cultures returned

Front 14

SHIGELLA (DYSENTRY)

Back 14

· Common in developing countires b/c of ineffective sanitation
· Common here in jails, nursing homes, reservations
· Fecal-oral spread
· Oubreaks at pools, parks, fountains, hot tubs have occurred
· MOST effective pathogen at producing disease (50 bugs will make you sick!)

·Spectrum of severity from watery diarrhea to severe bloody diarrhea with cramps (30% of culture proven cases develop true invasive dysentry)

· Medium incubation and duration – 1-2 day incubation, 4-7 day duration
·Antibiotic treatment partly depends on which bug is isolated

Ø S. sonnei or flexneri do not need to be treated if their symptoms have resolved unless there is a public health concern

Ø S.dysenteriae should always be treated b/c of general public health concerns

· Ciprofloxacin 500 mg po bid X 7 days
· No antimotility agents if signs of invasive disease unless also receiving antibiotics
·Follow up cultures to document clearance should be done for S. dysenteriae