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GI Disorders II Nursing 870 Diarrhea • Increase in stool frequency or greater looseness – Increase from normal frequency – > 3/day • Acute versus chronic – Acute: up to < 2 weeks – Chronic: usually > 2 weeks • May be a symptom, result from a disorder, SE of medication, others Diarrhea • Distinguish from – Incontinence – Rectal urgency – Incomplete evacuation Diarrhea • Acute – Viral – Parasitic – Bacterial – New medication Symptoms that Need Evaluation • • • • • • • • • • Fever Moderate to severe abdominal pain Bloody diarrhea Diarrhea with pre-existing co-morbidities; DM, heart disease, AIDS No improvement after 48 hrs. Moderate or severe dehydration Prolonged vomiting that prevents oral intake Diarrhea after antibiotic use After return from developing countries In patients with chronic disease of intestines Viral Gastroenteritis • Most common cause of acute diarrhea worldwide • Incubation period 48-72 hrs • Presents with abrupt onset nausea, vomiting, cramps, diarrhea, headache, low grade fever – Usually lasts 48-72 hrs; up to 1 week – Usually mild or no fever – No blood or pus in stool Food Poisoning • Defined as an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses, or chemicals • Symptoms within several hours after food or water ingestion • Most common causes include – Staph aureus • Food sources • Symptoms 2-8 hrs after food ingested • Symptoms last < 12 hrs – Clostridium perfringens • Food sources • Incubation of 8-24 hrs. • Diarrhea and cramping; limited vomiting Food Poisoning – Salmonella – Camphylobacter – Norovirus • CDC (2013) reports – Green leafy vegetables were the most common cause of (22%), primarily due to Norovirus species and e coli – Poultry was the most common cause of death from food poisoning (19%), with Listeria and Salmonella species being the main infectious organisms – Dairy items were the second most frequent causes of foodborne illnesses (14%) and deaths (10%), with the main factors being contamination by Norovirus from food handlers and improper pasteurization resulting in contamination with Campylobacter species Food Poisoning: S & S • Abdominal pain: Most severe in inflammatory processes; painful abdominal muscle cramps suggest underlying electrolyte loss • Vomiting: Major presenting symptom of S aureus, B cereus, or Norovirus • Diarrhea: Usually lasts less than 2 weeks • Headache • Fever: May be an invasive disease or an infection outside the GI tract • Stool changes: Bloody or with mucus if invasion of intestinal or colonic mucosa; profuse rice-watery if cholera or a similar process • Reactive arthritis: Seen with Salmonella, Shigella, Campylobacter, and Yersinia infections • Bloating: May be due to giardiasis Food Poisoning: History • Food sources ingested • Any travel • Frequency and characteristic of stool may give clues • Vomiting • Presence of fever or not • Any other systemic symptoms Food Poisoning: PE • Major focus is to evaluate for dehydration • Perform rectal exam on all patients – Directly visualize the stool – To palpate for any lesions Diagnostics • CBC – Assess the inflammatory response and the degree of dehydration • Electrolytes, BUN, Creatinine – Assess the inflammatory response and the degree of dehydration. • Stool for O & P • Blood culture for fever • C difficile – To help rule out antibiotic-associated diarrhea in patients receiving antibiotics or in those with a history of recent antibiotic use. Diagnostics • Flat and upright abdominal x-ray (KUB) – Obtained if the patient experiences bloating, severe pain, or obstructive symptoms or if perforation is suggested • Colonoscopy/ Sigmoidoscopy – Consider in patients with bloody diarrhea – Can be useful in diagnosing inflammatory bowel disease, antibiotic-associated diarrhea, shigellosis, and amebic dysentery Treatment • Main objective is adequate rehydration and electrolyte supplementation • Oral rehydration – Clear liquids and sodium-containing and glucosecontaining solutions. A simple ORS may be composed of 1 level teaspoon of salt and 4 heaping teaspoons of sugar added to 1 liter of water. • The use of ORS has reduced the mortality rate associated with cholera from higher than 50% to less than 1%. • ORS also is indicated in other dehydrating diarrheal diseases. • The World Health Organization (WHO) recommends a solution containing 3.5 g of sodium chloride, 2.5 g of sodium bicarbonate, 1.5 g of potassium chloride, and 20 g of glucose per liter of water. Treatment • IV solutions are indicated in patients who are severely dehydrated or who have intractable vomiting • Absorbents (eg, Kaopectate, aluminum hydroxide) help patients have more control over the timing of defecation – They do not alter the course of the disease or reduce fluid loss Treatment • Antisecretory agents, such as bismuth subsalicylate (Pepto-Bismol), may be useful – 30 mL every 30 minutes, not to exceed 8-10 doses. • Antiperistaltics (opiate derivatives) should not be used in patients with fever, systemic toxicity, or bloody diarrhea or in patients whose condition either shows no improvement or deteriorates Treatment • Dietary Considerations – Often develop an acquired disaccharidase deficiency due to washout of enzymes • Avoiding milk, dairy products, and other lactosecontaining foods is advisable Complications • Complications are very rare in healthy hosts, except in cases of botulism or mushroom poisoning. • Infants, elderly people, and immunocompromised hosts are more susceptible • Other complications include – Guillain-Barré syndrome (Campylobacter infection) – Reactive arthritis – Hemolytic uremic syndrome (E coli O157:H7) Traveler’s Diarrhea • Usual cause is e-coli (pathogenic) • Visitors to foreign countries – Warm climate – Poor sanitation • • • • Eat contaminated food Symptoms start 3-7 days after arrival Symptoms subside within 3 days Other causes last > 3 days – Shigella – Giardia – Campylobacter Bacterial Entercolitis • • • • Abdominal pain, cramps Fever Blood or pus in stool Causes – Campylobacter jejuni (Most common in US) – Shigella – Salmonella – Clostridium difficile – E. coli Parasites • Giardia lamblia – Transmitted via drinking water – Diarrhea with pus in stool – No blood or pus in stool – Mild or no fever • Cryptosporidium – Transmitted via contaminated water Stray cat with Giardia Tourists with Giardia? Drug Induced • • • • • • Drugs containing Mg NSAID’s Chemotherapy Antibiotics Antiarrhythmics Antihypertensives Diagnostics • Highly individualized – May be extensive testing – May need no testing – Stool for leukocytes – Stool of ova and parasites – Sigmoidoscopy – Other GI tests may be needed – https://www.youtube.com/watch?v=jsVgi8hoFFc Management • Hydration • Some medication use – Giardiasis: metronidazole (250 mg tid x 7-10d) – Pseudomembranous colitis (Oral liquid vancomycin or metronidazole), probiotic, some use for cholestyramine Clostridium Difficile (C. diff) • C difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C difficile, and the release of toxins that cause mucosal inflammation and damage • Antibiotic therapy is the key factor that alters the colonic flora • Occurs primarily in hospitalized patients C. Difficile • Should be suspected in – Any patient with diarrhea who has received antibiotics within the previous 3 months – Been recently hospitalized – And/or has an occurrence of diarrhea 48 hours or more after hospitalization • Can be a cause of diarrhea in community dwellers without previous hospitalization or antibiotic exposure C. Difficile: Symptoms • Mild to moderate watery diarrhea that is rarely bloody • Cramping abdominal pain • Anorexia • Malaise C. Difficile: PE • • • • Fever: Especially in more severe cases Dehydration Lower abdominal tenderness Rebound tenderness – Raises the possibility of colonic perforation and peritonitis C. Difficile: Diagnostics • CBC: Leukocytosis may be present • Electrolytes, including serum creatinine: Dehydration, anasarca, and electrolyte imbalance may accompany severe disease • Albumin levels – Hypoalbuminemia may accompany severe disease • Serum lactate level – Lactate levels are generally elevated (≥5 mmol/L) in severe disease • Stool examination: Stool may be positive for blood in severe colitis, but grossly bloody stools are unusual; fecal leukocytes are present in about 50% C. Difficile: Diagnostics • Stool assays for C difficile, from the most to the least sensitive – Stool culture: The most sensitive test (sensitivity, 90-100%; specificity, 84-100%), but the results are slow and may lead to a delay in the diagnosis if used alone (Gold Standard for Dx) – Glutamate dehydrogenase enzyme immunoassay (EIA): This is a very sensitive test (sensitivity, 85-100%; specificity, 87-98%); it detects the presence of glutamate dehydrogenase produced by C difficile – Real-time polymerase chain reaction (PCR) assay: This test is an alternative gold standard to stool culture (sensitivity, 86%; specificity, 97%[5] ); it may be used to detect the C difficile gene toxin C. Difficile: Diagnostics – Stool cytotoxin test: A positive test result is the demonstration of a cytopathic effect that is neutralized by a specific antiserum (sensitivity, 70100%; specificity, 90-100%) – EIA for detecting toxins A and B: This test is used in most laboratories (moderate sensitivity, 7980%; excellent specificity, 98%) – Latex agglutination technique: Another means of detecting glutamate dehydrogenase; however, the sensitivity of this test is poor (48-59%), although the specificity is 95-96% C. Difficile: Diagnostics • Abdominal CT – Imaging modality of choice when pseudomembranous colitis, other complications of CDI, or other intraabdominal pathology is suspected • If sepsis due to suspected megacolon, abdominal radiography may be performed instead of CT to establish the presence of megacolon in a timely manner • Endoscopy – Less sensitive than stool assays C. Difficile: Differential • • • • • • • • • • Crohn’s Disease Diverticulitis Viral Gastroenteritis Intra abdominal sepsis IBS Malabsorption Salmanellosis Shigellosis Ulcerative Colitis Other Infections C. Difficile: Treatment • European Society of Clinical Microbiology 2013 Guidelines – For patients with nonepidemic, nonsevere CDI clearly induced by antibiotic use, with no signs of severe colitis, it may be acceptable to stop antibiotic treatment and observe the clinical response for 48 hours – Antibiotic treatment is recommended for all except very mild cases actually triggered by antibiotic use; suitable treatments include metronidazole, vancomycin, and fidaxomicin – For mild/moderate disease, oral metronidazole (500 mg 3 times daily for 10 days) is recommended as initial treatment – In patients for whom oral treatment is inappropriate, fidaxomicin may be used; specific indications include first-line treatment in patients with recurrence or at risk for recurrence C. Difficile: Treatment – For patients with severe CDI • Vancomycin (oral, 125 mg 4 times daily for 10 days; may be increased to 500 mg 4 times daily) or fidaxomicin (200 mg twice daily for 10 days) • Use of fidaxomicin is not supported in life-threatening CDI • Use of oral metronidazole in severe or life-threatening CDI is discouraged • Fecal transplantation is recommended for multiple recurrent CDI – For patients with colonic perforation and/or systemic inflammation and deteriorating clinical condition despite antibiotic treatment, total abdominal colectomy or diverting loop ileostomy combined with colonic lavage is recommended – Additional management measures include discontinuing unnecessary antimicrobial therapy, adequate replacement of fluids and electrolytes, avoiding antimotility medications, and reviewing the use of proton pump inhibitors C. Difficile: Treatment • The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) – Recommend a regimen of metronidazole (500 mg PO TID for 10-14 days) as first-line therapy for mild to moderate disease without complications (lower cost and similar efficacy to PO vancomycin in these patients) – For patients who are unable to tolerate oral medication, intravenous metronidazole is effective. C. Difficile: Treatment • For severe cases – Vancomycin (125 mg PO QID for 10 days) is the recommended first-line therapy. C. Difficile: Other Considerations • Relapse occurs in 20-27% of patients treated with metronidazole or vancomycin • Most recurrences occur 3 days to 3 weeks after discontinuing antibiotic treatment • Once a patient has 1 relapse, the risk for a 2nd relapse is 45%. C. Difficile: Other Considerations • Age greater than 65, severe underlying illnesses, and ongoing antibiotic treatments during C difficile therapy are all risk factors for recurrence • For the first relapse, the choice of antibiotic should be based on severity – Mild symptoms of recurrence in patients who are otherwise well may be managed without further antibiotic therapy – Initial recurrence that is not severe can be treated with metronidazole – For subsequent recurrences, patients may benefit from vancomycin in a prolonged tapered and/or pulse regimen or fidaxomicin with or without probiotics. C. Difficile: Other Considerations • Prevention – Minimize antibiotic use – Probiotics not recommended (ISDA) References • Cohen, S. et al. (2010. Clinical practice guidelines for clostridium difficile infection in adults: 2010 Update by the Society for Healthcare Epidemilogy of America and the Infectious Disease Society of America. DOI 10.106/651706. Available at: http://www.cdc.gov/HAI/pdfs/cdiff/Cohen-IDSA-SHEA-CDI-guidelines-2010.pdf