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PC2: GI-Diarrhea, constipation, IBS

Terms in this set (78)

What is diarrhea?
Increase in stool frequency (.3xs/day) and liquidity
What must a clinician know before diagnosing with diarrhea?
-Pts NORMAL bowel habits
What are the two types of ACUTE diarrhea?
Inflammatory and non-inflammatory
What is the time period for acute diarrhea?
Less than 2 weeks
What is acute diarrhea commonly caused by?
(general terms)
-Infection agents, bacterial toxins or medications
What are the sxs of acute NON-inflammatory diarrhea?
-Watery, non-bloody
-Usually self limited
***Usually no fever/blood
What is acute NON-inflammatory diarrhea normally caused by?
-Virus or NON-invasive bacteria
When do you use diagnostics?
-Pts with severe diarrhea or lasting >7days
Common viruses associated with acute NON-inflam?
Adults=Norovirus

Kids=Rotavirus
(Kids all take time rotating finger in butt)
-There is a vaccine for the Rotavirus
Common protozoan causes of acute non-inflam?
-Giardia
Tell me a little about Giardia
-Most common cause of parasitic diarrhea
-Can be traveler related
-Can be from sewage, contaminated water, etc..
Common bacterial causes of acute non-inflammatory?
-Staph Aureus
-Bacillus c
-Clostridium p
-Vibrio cholerae
What do you common find in custards, pastries, processed meats and picnics?
S. Aureus
What do you see with rice, beans, and sprouts?
Bacillus
What do you see from contaminated water in which a person can lose 1L/hr?
Vibrio cholerae
How do you treat acute non-inflammatory diarrhea?
-It is usually self limiting but...

-Oral rehydration solution (gatorade/pedialyte)
-Abx SPECIFIC for diarrhea
-Pepto or anti-motility meds
What should you remember when treating acute non-inflammatory diarrhea?
***No anti-motility meds if feverish
***No pepto if bloody stool
What are some red flags to watch out for?
-Fever
-Severe diarrhea (> 6 stools/24hrs)
-Severe abdominal pain
-Pts >70yo or immunocompromised
If you give your pt pep to, what should you tell them?
-It will turn your stool and possible tongue, BLACK
If you have a community outbreak of diarrhea, what is it probably caused by?
A virus
What are sxs of acute inflammatory diarrhea?
-Blood or pus
-Fever
What is acute inflammatory diarrhea normally caused by?
(general)
-INVASIVE or toxin producing bacterium
Common viral causes of acute inflammatory?
CMV-Bloody
-See in pts with HIV/immunocompromised
Common protozoan causes of acute inflammatory?
Ameoba (Entamoeba hystolytica)
Bacterial mnemonic?
"C.E. CASSEY"
What are the toxin producers?
C. diff and E. coli
What are the mucosal invaders?
CASSEY
-Camphylobacter
-Amoeba (really a protozoa)
-Salmonella
-Shigella
-E. coli
-Yersenia e.
Why do pts get C.diff?
From abc that clear all bacteria from GI tract such as ampicillin or clindamycin
What is the #1 cause of traveler's diarrhea?
(Usually from contaminated meat/hamburger/water)
E. col
-Common in summer months!
What can come from poultry/feces and can spread from pets to humans?
Camphy
What commonly comes from eggs and poultry?
Salmonella
What commonly comes from contaminated meat/dairy?
Yersenia e

***May also resemble Crohn's disease
What do you have with the following sxs until proven otherwise?
-Fever
-Bradycardia
-Bloody stool
Salmonella
What if you have rose spots and pea-soup stool?
Salmonella typhi
What are rose spots?
-Tiny pink/red 2-4mm macules in crops that blanche
How do you treat acute inflammatory diarrhea?
Abx that are specific for bacteria
Treatment of Camphy?
Erythromicin/Zithro
Treatment for salmonella?
Septra
Treatment for shigella?
Cipro or Septra
Treatment for e. coli?
-None
Treatment for C. diff and protozoa?
Metronidazole
How long does chronic diarrhea last?
-More than 4 weeks
What is secretory diarrhea?
-Increased secretion and decreased absorption

(layman-body is putting water in stool when it is not supposed to)

***If you fast, probably no change in amount
***Will have low STOOL osmotic gap
What is osmotic diarrhea?
-Exchange of anions/nutrients is altered through malabsorption
or
-Ingestion of anion-rich antacid or laxative

(Layman- something in bowel is drawing water in)

***If you fast, you will have a decrease in stool volume

***Will have high STOOL osmotic gap
Common causes of chronic diarrhea?
-Meds
-Osmotic
-Secretory
-Inflammatory
-Malabsorption
-Motility d/o
-Chronic infection
-Factitious/systemic
Common meds involved?
-SSRI
-NSAIDS
-ARB,
-PPI
-Metformin
Common osmotic cause?
-Laxative abuse
-Malabsorption
-Carb intolerance (lactose)
Secretory causes?
-Endocrine tumors
-Bile salt malabsorption
Malabsorption causes?
-Mucosal dz
-Sm. bowel resection
-Bacterial overgrowth
-Pancreatic insufficiency
Motility d/o causes?
IBS-most common chase of chronic diarrhea in young adults
-Abnormal intestinal motility d/o secondary to systemic dz
Chronic infections?
-#1 cause is parasites!!!
Factitious causes?
-Drug induced (Mg and laxatives)
Systemic causes?
-DM
-Thyroid dz
-Collagen Vascular dz
How should you know underlying cause of chronic diarrhea?
-Pt hx and PE should tell you!
What initial labs should you order?
-CBC
-CMP with Albumin
-Phosphorus
-Ca
-TSH
-Vit A/D
-INR
-ESR
-CRP
What should you order for stool?
-Ova/parasite test
-Electrolytes (to calculate osmotic gap)
-Fat content
-FOBT
What other exam should you do?
-Endoscopy/biopsy
What if you want further testing?
-24hr quantification of fecal weight/fat
-CT (looking for pancreatic calcifications/CD)
-Serologic markers (neuroendocrine tumors)
-Breath test (sm. bowel bacterial overgrowth)
What if feces are low weight?
Think IBS
(Also think IBS if abdominal pain)
What if high weight feces?
Secretory
(Will be watery)
What if high fat feces?
Think malabsorption
(greasy and BAD odor)
How do you treat chronic diarrhea?
-Treat underlying cause

-Opioids mixed with motility controllers
-Loperamide
-Codeine (ONLY for chronic/intractable diarrhea)
-Octreoride (used for secretory diarrhea dt neuroendocrine tumor)
-Cholestyramine (if bile salt induced after resection
How do you calculate osmotic gap and what is the normal value?
(Na + K) x2

Normal is < 50mOsm/kg
What are sxs of inflammatory diarrhea?
-Fever, blood, pus, abdominal pain
What are the common bacteria that cause Turista?
-E. coli!!!!!!
-Salmonella
-Salmonella typhy
-Shigella
-E. hystolytica
-Giardia
-Vibrio cholerae
How can you prevent turista?
-Watch food/drink
-Be wary of local water, ice, fruit and veggies
Prophylaxis for turista?
-Pepto (qid)
-Abx are not generally recommended before sxs, but in some cases..
-TMS and Cipro daily
How can you treat turista?
-Pepto (if not bloody_

-Loperamide (<8/day but only if no blood or fever)

-TMS or Cipro for 3 days (for e. coli does have resistance to trim-sulfa)
What are the causes of constipation?
"D3REPS"

-Diet, Dentition, Drugs
-Rest/relaxation (stress will slow you down)
-Exercise (increases motility)
-Psych
-Structure
How can you treat constipation?
-Lifestyle change
-Laxatives/increase fluid intake
-Enema-warm saline
A 35 yr old female presents to your office complaining of abdominal discomfort that is relieved by defecation. She said the symptoms have been occurring about once a week for several months. She recently changed jobs and has noticed that she is having to go to the bathroom more frequently. She is worried this is interfering with her work. What is your diagnosis? TX?
-IBS-D
-TX: loperaminde or Dicyclomine (anticholinergic)
-Restricted TX: Lotronex (only women and only certain providers)
If the pt with IBS-D does not respond to the medication, what should be done next?
stool w/u: celiac panel, stool, fecal leukocytes, giardia
A 50 yr old female presents to your office complaining of abdominal discomfort that is relieved by defecation. She said the symptoms have been occurring about once a week for several months. She recently changed jobs and has noticed that she is having to go to the bathroom more frequently and has been noticing maroon colored stools. She is worried this is interfering with her work. What should be done next
Colonoscopy: IBS does not present with blood in the stool
What are the causes of IBS?
-gut hypersensitivity to visceral pain and perception
-altered GI motility
-Serotonin NT in gut and brain
What classification system is used to diagnose IBS?
Rome III criteria: recurrent abdominal pain at least 3 days/ month for the last 3 months associated with 2 or more of the following:
-pain improved w/ defecation
-onset associated with change in stool frequency
-onset associated with change in stool form
How would treat IBS-C?
-nutrition consult
-psyllium fiber (20-30g/day)
-osmotic laxative
-lubiprostone in females
What labs should be done on a pt w/ suspected IBS?
-CBC
-TSH
-LFT
-ESR
What are the red flags in a pt w/ suspected IBS?
-weight loss
-fever
-melena
-rectal bleeding
-excessive diarrhea
-nocturnal sxs
-new onset >50 yrs
-anemia
-severe constipation
-family hx
-sudden onset/ major change
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