Download APPROACH TO DİARRHEA IN PRIMARY CARE

APPROACH TO ACUTE
DIARRHEA
IN PRIMARY CARE
Department of Family
Medicine
Assoc Prof Dr Hülya AKAN
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CASE DISCUSSION-1
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23 yrs old female, medical student
36 hrs nausea and vomiting, begin with
nausea, fallowed by vomiting food
contents and after than bile
Last meal the day before: breakfast with
orange juice and cheese and white bread
Diarrhea soon after vomiting, no blood no
fat, 12 bowel movements past day
No fever
Bloating and mild cramping but no pain
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CASE 1
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No travel history
2 days earlier a friend and 6-mo-old
child had visited and she had
changed infant’s diaper
Past medical hx: asthma – steroid
inhaler, allergic to shellfish
No smoke, no alcohol
Last menstrual period: 3 weeks ago,
sexually inactive
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CASE 1: PE
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İll-appearing, 36,6 °C
Supine 110/70 mmHg, 75/beats/min,
Standing 100/60 mmHg, 104 beats/min
Dry mucous membranes
Clear lungs
Rapid regular heart rythm with 2/6
systolic murmur at the apex
Normoactive bowel sounds, abdomen soft
and nontender without distention
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CASE 1
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WHAT ASPECTS OF HER HISTORY
HELP YOU TO MAKE THE
DIAGNOSIS?
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Diarrhea is non bloody, vomiting is
prominent feature
Absence of subjective fever
Food items are not typical for foodborne illnesses
Exposure to small child?
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CASE 1
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HOW DOES PHYSICAL EXAM HELP
YOU?
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The patient is volume depleted
Dry mucous membranes
Orthostatic hypotension
Afebrile
It is not uncommon for a young women to
have flow murmur accentuated by
dehydration
Abdominal exam. is benign
It is not needed to perform rectal
examination
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CASE 1
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WHAT LABORATORY TESTS WOULD
BE HELPFUL?
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Serum chemistry: electrolytes
Pregnancy test
Stool studies?
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CASE 1
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SHOULD THİS PATIENT BE
ADDMITTED TO HOSPİTAL?
SHOULD SHE RECEIVE
ANTIBIOTICS?
WHAT IS THE LIKELY CAUSE OF HER
DIARRHEA?
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DEFINITION
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Acute diarrhea: more frequent,
looser than normal stools less than 2
- 3 weeks
Objectively: >250g stool / day
Acute v chronic: By time span
Chronic diarrhea: lasting >1 month
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GIS SYSTEM
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Diarrhea second most common illness
after upper respiratory tract infection
Living conditions and socio economic
factors play a role in the attach of
bacterial enteric pathogens
- contaminated water sources
- undercooked meat
- instituliziation
- poor sanitation
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CAUSES
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Acute diarrhea is usually related to a bacterial,
viral, or parasitic infection.
Chronic diarrhea is usually related to functional
disorders such as irritable bowel syndrome or
inflammatory bowel disease.
.
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CAUSES
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Bacterial infections. Several types
of bacteria consumed through
contaminated food or water can
cause diarrhea. Common culprits
include Campylobacter, Salmonella,
Shigella, and Escherichia coli (E.
coli).
Viral infections. Many viruses
cause diarrhea, including rotavirus,
Norwalk virus, enteric adenovirus,
cytomegalovirus, herpes simplex
virus, and viral hepatitis
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CAUSES
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Food intolerances. Some people are
unable to digest food components such as
artificial sweeteners and lactose—the
sugar found in milk.
Parasites. Parasites can enter the body
through food or water and settle in the
digestive system. Parasites that cause
diarrhea include Giardia lamblia,
Entamoeba histolytica, and
Cryptosporidium.
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CAUSES
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Reaction to medicines. Antibiotics,
blood pressure medications, cancer
drugs, and antacids containing
magnesium can all cause diarrhea.
Intestinal diseases. Inflammatory
bowel disease, colitis, Crohn’s
disease, and celiac disease often lead
to diarrhea.
Functional bowel disorders.
Diarrhea can be a symptom of
irritable bowel syndrome.
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Clinical presentationPotential foodrelated agents to consider
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Gastroenteritis (vomiting as primary symptom; fever or
diarrhea also may be present: Viral gastroenteritis, most
commonly rotavirus in an infant or norovirus and other
caliciviruses in an older child or adult; or food poisoning
caused by preformed toxins (e.g., vomitoxin,
Staphylococcus aureus toxin, Bacillus cereus toxin) and
heavy metals
Noninflammatory diarrhea (acute watery diarrhea without
fever or dysentery; some patients may present with
fever)*:Can be caused by virtually all enteric pathogens
(bacterial, viral, parasitic) but is a classic symptom of
enterotoxigenic Escherichia coli, Giardia, Vibrio cholerae,
enteric viruses (astroviruses, noroviruses, and other
calciviruses, enteric adenovirus, rotavirus),
Cryptosporidium, Cyclospora cayetanensis
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Clinical presentationPotential foodrelated agents to consider
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Inflammatory diarrhea (invasive gastroenteritis;
grossly bloody stool and fever may be
present)†Shigella species, Campylobacter
species, Salmonella species, enteroinvasive E.
coli, enterohemorrhagic E. coli, E. coli O157:H7,
Vibrio parahaemolyticus, Yersinia enterocolitica,
Entamoeba histolytica
Persistent diarrhea (lasting at least 14 days):
Prolonged illness should prompt examination for
parasites, particularly in travelers to mountainous
or other areas where untreated water is
consumed. Consider Cyclospora cayetanensis,
Cryptosporidium, Entamoeba histolytica, and
Giardia lamblia.
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Clinical presentationPotential foodrelated agents to consider
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Neurologic manifestations (e.g., paresthesias, respiratory
depression, bronchospasm, cranial nerve palsies): Botulism
(Clostridium botulinum toxin), organophosphate pesticides,
thallium poisoning, scombroid fish poisoning (histamine,
saurian), ciguatera fish poisoning (ciguatoxin), tetraodon
fish poisoning (tetraodontoxin), neurotoxic shellfish
poisoning (brevetoxin), paralytic shellfish poisoning
(saxitoxin), amnesic shellfish poisoning (domoic acid),
mushroom poisoning, Guillain-Barré syndrome (associated
with infectious diarrhea caused by Campylobacter jejuni)
Systemic illness (e.g., fever, weakness, arthritis,
jaundice)Listeria monocytogenes, Brucella species,
Trichinella spiralis, Toxoplasma gondii, Vibrio vulnificus,
hepatitis A and E viruses, Salmonella typhi and Salmonella
paratyphi, amebic liver abscess
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Noninflammatory diarrhea
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Noninflammatory diarrhea is characterized by
mucosal hypersecretion or decreased
absorption without mucosal destruction and
generally involves the small intestine.
Some affected patients may be dehydrated
because of severe watery diarrhea and may
appear seriously ill. This is more common in the
young and the elderly. Most patients experience
minimal dehydration and appear mildly ill with
scant physical findings.
Illness typically occurs with abrupt onset and
brief duration. Fever and systemic symptoms
usually are absent (except for symptoms related
directly to intestinal fluid loss).
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Inflammatory diarrhea
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Inflammatory diarrhea is characterized by
mucosal invasion with resulting
inflammation and is caused by invasive
or cytotoxigenic microbial pathogens. The
diarrheal illness usually involves the large
intestine and may be associated with
fever, abdominal pain and tenderness,
headache, nausea, vomiting, malaise, and
myalgia. Stools may be bloody and may
contain many fecal leukocytes.
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CLINICAL APPROACH: FOCUS
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Does the diarrhea originate in the
large or small intestine? Smallbowel: frequent, large-volume stools
described as watery and related to
eating. Large bowel: usually more
frequent, with smaller stool vlolumes
(1-2 L/day) and associated with
tenesmus and bloody stools.
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CLINICAL APPROACH: FOCUS
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Has there been recent travel to
suggest enterotoxigenic E. Coli,
antibiotic consumption within last 6
weeks to suggest
pseudomembranous colitis or
consumption of undercooked poultry
or hamburger that may implicate
Salmonella or enterohemorrhagic E.
Coli, respectively?
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CLINICAL APPROACH: FOCUS
ON
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Does the patient have other medical
conditions that may predispose to
diarrhea, such as diabetes, acquired
immunodeficiency syndrome,or
previous gastrointestinal surgery that
may predispose to bacterial
overgrowth?
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CLINICAL APPROACH: FOCUS
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Stools should be studied for fecal
leucocytes, culture and sensitivity,
ova and parasites and clostridium
difficile toxin
In typical cases that are culture
negative, unprepped flexible
sigmoidoscopy or colonoscopy
If no colon pathology identified, an
esophogogastroduodenoscopy with
small intestine biopsies
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COMMON PATHOGENS
Scenario
Likely organism
Treatement
Fever,bloody
stools,with or
without
abdominal pain
Shiegella,
salmonella,
campylobacter,
entomoeba
hystolytica,
enterohemorrha
gic Escherichia
coli
Shigella
Salmonella
Campylobacter
Entomoeba
E. coli
Onset of
Staphylococcus
symptoms <6
aureus, Bacillus
hrs from a meal cereus
Supportive
therapy only
Onset of
Clostridium
symptoms 8-14 perferinges
hrs from a meal
Supportive
therapy only
Onset of
symptoms >14
Supportive
therapy only
Viruses: Rota
and Norwalk
Bactrim, Cipro
Bactrim, cipro
Erythromycin
Cipro
Cipro
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TAKING HISTORY
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Onset of symptoms
Exposure to suspicious food or water
(time)
Exposure to sick contacts
History of medication
History of travelling
Associated symptoms( nausea,
vomiting, fever, abdominal cramps
or severe abdominal pain)
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Comorbid conditions (HIV,
immunodeficiency, etc.)
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Freqency of stool passage
Approximate amount of stool
Colour of stool
Odour of stool
Blood in stool
Mucous on stool
Tenesmus
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PHYSICAL EXAMINATION
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Vital signs
Volume status
- Ortostatic hypotension
- Poor skin turgor
- Dry mucous membranes
Abdominal examination
Abdominal sounds- absence or
presence
Rectal examination and stool guaiac
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RED FLAGS
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Diarrhea in the elderly or
immunocomprimised patient (inc.
Acquired immunodeficiency patients,
transplant patients, those on
chemotherapy and high dose
steroids)
Duration of illness greater than 48
hrs
Diarrhea accompanied by severe
abdominal pain
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RED FLAGS
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Diarrhea associated with fever
(>38 °C)
Blood in stool
More than six unformed stools a day
Profuse watery diarrhea with
dehydration
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LABORATORY
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FOCUS ON CAUSE
It is debatable in patients without red
flags, but consider in patients with red
flags
- Stol analysis- leucocytes, blood,
- Culture: if there is leucocytes and red
blood cells in a patient with fever,
abdominal pain or bloody stools
- Bloody stool: E. Coli 0157: H7
- Antibiotic use: C. Difficile toxin
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- Serologic tests: rapid tests for rota,
adenovirus is available. Unecessary
for salmonella except systemic
disease is suspected
- Ova and parasites: uneccessary
routinely, consider if you suspect
giardia lamblia, homosexuals,
immunocomprimised
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LABORATORY
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Flexible sigmoidoscopy and biopsy:
ulcerative colitis, ischemic colitis,
pseudomembranous colitis,
amebiasis, shigella infection, proctitis
in homosexual men
FOCUS ON SEVERITY
- Basic chemistry
- Electrolytes
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Fever >38.2, dehydration, abdominal
pain, bloody stool, >6 stools/day
Immunodeficiency
>70 yrs
Yes
No
Lab
Fallow
Think about hospitilization
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TREATEMENT APPROACH
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Rehydration- electrolyte replacement
if necessary
Symptomatic relief
Occasionally antibiotics(minimal
impact on disease course,
enterohemoragic E.coli-hemolytic
uremic syndrome,prolong shedding
of organism)
Antidiarrheal agents: Loperamide,
Lomotil
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Composition of the new ORS
formulation
New ORS
grams/litr
e
New ORS
mmol/litre
Sodium
chloride
2.6
12.683
Sodium
75
Glucose
anhydrOUS
13.5
65.854
Chloride
65
Potassium
chloride
1.5
7.317
Glucose,
anhydrous
75
Trisodium
citrate,
dihydrate
2.9
14.146
Potassium
20
Citrate
10
Total
Osmolarity
245
TOTAL
20.5
100.0
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ORS
This ORS composition has passed extensive
clinical evaluations and stability tests.
Thepharmacokinetics and therapeutic
values of the substances are as follows:
 glucose facilitates the absorption of
sodium (and hence water) on a 1:1 molar
basis in the small intestine;
 sodium and potassium are needed to
replace the body losses of these essential
ions during diarrhoea (and vomiting);
 citrate corrects the acidosis that occurs as
a result of diarrhoea and dehydration.
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POSSIBLE INDICATIONS OF
EMPIRIC ANTIBIOTICS
Patients with dysantery or moderate
to severe traveler’s diarrhea
 Patients with fecal leukocytes or
blood in their stool and fever
 Patients with suspected Giardia
infection with 2-4 wks diarrhea and
no signs of dysentry
Note: antibiotics minimally impact the
disease course, can prolong shedding
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CASE 2
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M.H. 32 yrs-old white woman, two boys
Watery stools for 3 days, 6-8/24 hrs
Onset is sudden and associated with slight
abdominal cramping and some nausea but
no vomitting
Generalised malaise but no fever, chills,
night sweats
No blood or mucous in stools
Able to tolerate her usual diet but don’t
feel hunger
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CASE 2
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Past medical: renal stone 6 yrs ago
Family hx: grandmother: type 2
diabetes, both grandfathers:
hypertension
Health habits: No alcohol, no smoke
Social: Married, 2 boys (2 and 5yrs),
working part time as visiting nurse,
drinks city water, no travel,no
exposure to hepatitis
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CASE 2- PE
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Appears comfortable
118/72 mmHg, 88 beat/min,36,5 C, 1.62
cm, 57 kg
PE is normal including rectal examination
LAB: stool test for blood is negative,
microscopy showed only few leukocytes,
WBC and liver enzymes are normal, no
parasite ova or cyst is seen
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CASE 2
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What aspects of her history help you to
make the diagnosis?
How does physical exam help you?
What laboratory tests would be helpful?
Should this patient be addmitted to
hospital?
Should she receive antibiotics?
What is the likely cause of her diarrhea?
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Differential dx for Case 2
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Viral gastroenteritis (rota, norwalk)
Early viral hepatitis
Protozoal infection: giardia lamblia
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What happened to case 2
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Returned two wks later
Diarrhea was okey, but 2 days ago a
second bout of foul smelling diarrhea
associated with epigastric discomfort
and increased gas, lost 2 kg,
generalized fatigue. Her oldest son
had also started having loose stools
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What is the diagnosis
Stool analysis revealed cysts of
giardia lamblia
 Stol examination of children were
also positive for giardia
 The source was city water:There had
been a breakdown
(it could be due to day care epidemics
–from children or her part time job)
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