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Download tests that may be useful in evaluation of patients with acute diarrhea
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Diarrhea is loosely defined as passage of abnormally liquid or unformed Stool at an increased frequency. For adults on a typically western Diet, stool weight exceeding 200g/d Can generally be considered diarrheal. Pathophysiologic classification of diarrhea Secretory diarrhea Osmotic diarrhea Inflammatory ( exudative ) diarrhea Motility ( dismotile ) diarrhea Anatomic ( decreased absorptive surface) Secretory diarrhea Increased secretion and / or decreased absorption of electrolytes. Large volume watrey stool,no blood, no FSG, no pus, no response to fasting. Small intestine type diarrhea. Some causes of Secretory diarrhea Cholera ,Ecoli, and Salmonella toxins. Serotonine,VIP,Calcitonine,Bile acids. Castrol oil, Biscodyl, Senna, Villus atrophy (Celiac sprue , Int. lymphoma). Collagen vascular dis.) ( SLE , MCTD OSMOTIC DIARRHEA Non absorbable,osmoticlly active molecules in gut lumen. Watrey stool, no blood, no pus in the stool. Improves with fasting. May have high FSG. FSG = 280 – (fecal Na + fecal K ) * 2 Some causes of osmotic diarrhea Disacaridase deficiencies. Lactulose, Manitol, Sorbitol, Mg ++ Sulfate, phosphate (Laxatives). Sodium citrate ingestion. Steatorrhea, generalized malabsoption. Rotavius induced diarrhea. EXUDATIVE DIARRHEA Destruction of intestinal mucosa. Small frequent bloody stools with pus, and tenesmus. Fever Large intestine type diarrhea. Some causes of exudative diarrhea Entero-invasive E.coli Shigella E. histolitica Ulcerative colitis Ischemic colitis Acute if < 2 weeks Persistent if 2 to 4 weeks Chronic if > 4 weeks Epidemiology of Acute Diarrhea Worldwide, >1000,000,000 people/year 5 -8 million deaths / year in developing countries. 3000/year mortality in US. High risk groups for diarrhea Travelers. 40 % of tourists develop diarrhea Most commonly duo to ETEColi Consumers of certain foods. Picnic, restaurant, undercooked hamberger, seafoods(raw) Immunodeficient persons Daycare participants and their family members. Institutionalized persons. Gastrointestinal Viruses Virus type Major risk group Rotavirus Seasonality Dx test Children< 3 y Winter Rx ELISA ORS (groupA) Adenovirus children< 3y year-round ELISA ORS (types 40,41) Calicivirus Astrovirus Norwalk like viruses young children young children children , adults unknown EM(?) ORS winter EM(?) ORS winter EM (?) ORS Factors that influence virulance of entric pathogens Inoculum size (Shigella,EPEC,giardia 10-100) Adherence Toxin production (enterotoxin, cytotoxin, neurotoxin) Invasion Normal flora of the host Gastric acid Intestinal motility Immunity Major Causes of Acute Diarrhea INFECTIONS (Including Travelers Diarrhea) Bacterial : Campylobactre Species, C.difficile, E.coli, Salmonella eneritides , Shigella Species Parasitic/protozoal : E. histolytica, Giardia lambilia,Cryptosporidium ,Cyclospoa Viral : Adenovirus , Norwalk virus , Rotavirus ,AIDS, Others Fungal FOOD POISONING : MEDICATIONS RECENT INGESTION OF LARGE AMOUNT OF POORLY ABSORBABLE SUGARS INTESTINAL ISCHEMIA FECAL IMPACTION PELVIC INFLAMMATION GRAFT VS HOST DISEASE B.Cereus , C . Perfringens , Salmonella species , S .aureus, Vibrio species, Shigella species , Camppylobacter.jejuni, E.coli MAJOR CAUSES OF CHRONIC DIARRHEA IBS IBD Ischemic bowel disease Chronic bacterial / mycobacterial infection Parasitic & fungal infections Radiation enteritis Malabsorption Syndromes Medications, Alcohol Colon cancer , Villous Adenoma ,intestinal Lymphoma Diverticulitis Previous Surgery ( gastrectomy, vagatomy, intestinal resection ) Endocrine causes Fecal impaction Heavy metal poisoning Epidemic idiopathic chronic diarrhea 1. 2. 3. 4. 5. 6. 7. Indications for evaluation a patient with acute diarrhea Profuse diarrhea with dehydration. Grossly bloody diarrhea. Fever > or = 38.5 C New community outbreaks. Associated sever abdominal pain in patients older than 50 years. Elderly (> or = 70). Immunocompromised patients. TESTS THAT MAY BE USEFUL IN EVALUATION OF PATIENTS WITH ACUTE DIARRHEA Stool Exam for: WBCs , Ova of parasites , Culture for bacteria & virus , Clostridium difficile toxin , Giardia , Entameba , Viral antigens ( Rotavirus ) Blood test for: CBC , Na , K , BUN , Creatinine , Culture Flexible Sigmoidoscopy Abdominal Radiograph Acute diarrhea Likely infectious Mild Likely noninfecutios Hx & P.Ex Moderate Severe Activities altered (Incapacitated) Evaluate & Rx Institue fluid & electrolyte replacement Observe Fever >38 .bloody stool, fecal WBCs Immunocompromised or elderly host Resolves No Yes Stool microbiology study No Pathogen found Specific Rx Yes Antidiarrheal agents Persist Empiric Rx +further evaluation Empiric treatment in acute diarrhea Moderately to severly ill patients with febrile desentry. Give Ciprofluxacin 500 mg bid for 3-5 days. Suspected Giardiasis Rx with Metronidazole 250 mg qid for 7 days. Indications of antibiotic coverage wether or not a causative organism is discovered in acute diarrhea 1. 2. 3. Immunecompromised patient. Mechanical heart valves or recent vascular graft. Elderly. Antibiotic prophylaxis is indicated for travelers (to high risk countries), with Gastric achlorhydria 2. IBD 3. Immunocompromise 1. Give Co-trimoxazole Ciprofluxacine or Thank you The end