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IMS : Diarrhoea. By Semester 6 and Smester 7. Agenda of the day. Overview of diarrhoea -Ambiga and Hui Yan Acute Diarrhoea (Acute Gastroenteritis) -Wen Jiun and Vanessa. Epidemiology of Diarrhoea. Leading cause of illness and death among children in developing countries.

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ims diarrhoea

IMS : Diarrhoea

By Semester 6 and Smester 7

agenda of the day
Agenda of the day
  • Overview of diarrhoea

-Ambiga and Hui Yan

  • Acute Diarrhoea (Acute Gastroenteritis)

-Wen Jiun and Vanessa

epidemiology of diarrhoea
Epidemiology of Diarrhoea
  • Leading cause of illness and death among children in developing countries.
  • estimated 1.3 thousand million episodes and 4 million deaths occur each year in under-fives.
  • Main cause of death from acute diarrhoea is dehydration. Other important causes of death are dysentery and undernutrition.
definitions
Definitions

Acute Diarrhoea

  • sudden onset and lasts less than two weeks
  • 90% are infectious in etiology
  • 10% are caused by medications, toxin ingestions, and ischemia

Chronic Diarrhoea

  • Diarrhoea which lasts for more than 4 weeks
  • Most of the causes are non-infectious

Persistent Diarrhoea

-Diarrhoea lasting between 2 to 4 weeks

clinical features
Clinical Features
  • Stools
    • Loose
    • Blood stained
    • Offensive smell
    • Steatorrhea (floating, oily, difficult to flush)
  • Sudden onset of bowel frequency
  • Crampy abdominal pain
  • Urgency
  • Fever
  • Loss of appetite
  • Loss of weight
classifications of diarrhoea
Classifications of Diarrhoea
  • Duration-

( Acute, Chronic)

  • Causes-

( infectious, post-infectious, drugs, endocrine, factitious)

  • Chronic Dirrhoea-

Pathophysiologic mechanism

(osmotic, secretory, inflammatory, abnormal motility)

slide7
Acute Diarrhoea

Viral,Bacterial,

Protozoa (90%)

Medications

Laxatives or diuretic abuse

Ingestion of environmental preformed toxin such as seafood

Ischemic Colitis

Graft versus Host

Chronic Diarrhoea

Irritable Bowel Syndrome

Diverticular disease

Colorectal Cancer

Bowel Resection

Malabsorption

Inflammatory Bowel Disease

Celiac Disease

Carcinoid tumour

mechanism of diarrhoea
Mechanism of Diarrhoea
  • Osmotic Diarrhoea
  • Secretory Diarrhoea
  • Inflammatory Diarrhoea
  • Abnormal Motility Diarrhoea
osmotic diarrhoea
Osmotic Diarrhoea
  • Mechanism :

-retention of water in the bowel as a result of an accumulation of non‐absorbable water‐soluble compounds

-cease with fasting, discontinue oral agents

  • Causes :

-Purgatives like magnesium sulfate or magnesium containing antacids

-especially associated with excessive intake of sorbitol and mannitol.

-Disaccharide intolerance

-Generalized malabsorption

secretory diarrhoea
Secretory Diarrhoea
  • Mechanism :
    • Active intestinal secretion of fluid and electrolytes as well as decreased absorption.
    • Large volume, painless, persist with fasting
  • Causes :
    • Cholera enterotoxin, heat labile E.coli enterotoxin
    • Vasoactive Intestinal Peptide hormone in Verner-Morrison syndrome
    • Bile salts in colon following ileal resection
    • Laxatives like docusate sodium
    • Carcinoid tumours
inflammatory diarrhoea
Inflammatory Diarrhoea
  • Mechanism :

-damage to the intestinal mucosal cell leading to a loss of fluid and blood

-pain, fever, bleeding, inflammatory manifestations

  • Causes :

-- Immunodeficiency patient

    • Infective conditions like Shigella dysentary
    • Inflammatory conditions
      • Ulcerative colitis and Crohns disease
abnormal motility diarrhoea
Abnormal Motility Diarrhoea
  • Mechanism :

-Increased frequency of defecation due to underlying diseases

-large volume, signs of malabsorption (steatorrhoea)

  • Causes :
    • Diabetes mellitus- autonomic neuropathy
    • Post vagotomy
    • Hyperthyroid diarrhoea
    • Irritable Bowel Syndrome
acute gastroenteritis14
Acute Gastroenteritis
  • Gastroenteritis is the inflammation of the lining of stomach, small and large intestine.
  • >90% of cases are infectious, although acute gastroenteritis may follow ingestion of drugs and chemical toxins (10%).
  • Acute gastroenteritis is common among children, elderly, and those who are immunocompromised.
infectious agents
InfectiousAgents
  • Acquired by
    • fecal-oral route via direct personal contact
    • ingestion of food or water contaminated with pathogens from human or animal feces
  • Acute infection occurs when the ingested agent overwhelms the host’s mucosal immune and non-immune (gastric acid, digestive enzymes, mucus secretion, peristalsis, and suppressive resident flora) defenses.
aetiology causative pathogens
Aetiology: Causative Pathogens
  • Bacteria
  • Viral
  • Protozoa
bacterial
Bacterial
  • Campylobacter jejuni
  • Salmonella sp.
  • Shigella
  • Escherichia coli
  • Staphylococcal enterocolitis
  • Bacillus cereus
  • Clostridium perfringens
  • Clostridium botulinum
  • Gastrointestinal tuberculosis
viral
Viral

Protozoa

  • Rotavirus
  • Norovirus
  • Adenovirus
  • Entamoeba histolytica
  • Cryptosporidium
  • Giardia intestinalis
  • Schistosomiasis
high risk groups
High Risk Groups
  • Travelers
  • Consumers of certain foods
  • Immunodeficient person
  • Daycare participants
  • Institutionalized person
1 travelers
1. Travelers
  • Tourists to Latin America, Africa, and Asia develop “traveler's diarrhea” commonly due to enterotoxigenic Escherichia coli, Campylobacter, Shigella, and Salmonella.
  • Visitors to Russia may have increase risk of Giardia-associated diarrhea.
  • Visitors to Nepal may acquire Cyclospora.
  • Campers, backpackers, and swimmers in wilderness areas may become infected with Giardia.
2 consumers of certain food
2. Consumers of Certain Food
  • Diarrhea closely following food consumption may suggest infection with
    • Salmonella or Campylobacter from chicken;
    • Enterohemorrhagic Escherichia coli (O157:H7) from undercooked hamburger
    • Bacillus aureus from fried rice
    • S. aureus from mayonnaise or creams
    • Salmonella from eggs
    • Vibro species, acute hepatitis A or B from (raw) seafood
3 immunodeficiency persons
3. Immunodeficiency Persons
  • Primary immunodeficiency
    • IgA deficiency, common variable hypogammaglobulinemia, chronic granulomatous disease
  • Secondary immunodeficiency
    • AIDS, senescence, pharmacologic suppression
4 daycare participants
4. Daycare Participants
  • Infections with Shigella, Giardia, Cryptosporidium, rotavirus, and other agents are very common and should be considered.
5 institutionalized persons
5. Institutionalized Persons
  • Most frequent cause of nosocomial infections in many hospitals and long-term care facilities
  • The causes are a variety of microorganisms but most commonly Clostridium difficile.
pathophysiology
Pathophysiology
  • Infectious agents cause diarrhoea in 3 different ways as follows:
    • Mucosal adherence
    • Mucosa Invasion
    • Toxin Production
mucosal adherence
Mucosal adherence
  • Bacteria adhere to specific receptors on the mucosa, e.g. adhesions at the tip of the pili or fimbriae
  • Mode of action: effacement of intestinal mucosa causing lesions, produce secretory diarrhoea as a result of adherence
  • Causing moderate watery diarrhoea
  • e.g. enteropathogenic E.coli
mucosa invasion
Mucosa Invasion
  • The bacteria penetrate into the intestinal mucosa, destroying the epithelial cells and causing dysentery
  • e.g. Shigella spp.

Enteroinvasive E.coli

Campylobacter spp

toxin production
Toxin Production
  • Enterotoxins

- toxin produced by bacteria adhere to the intestinal epithelium, induce excessive fluid secretion into the bowel lumen, results in watery diarrhoea without physically damaging the mucosa.

  • Some enterotoxin preformed in the food can cause vomiting
  • e.g Staph.aureus (enterotoxin B)

Bacillus cereus

Vibrio cholerae

  • Cytotoxins

- damage the intestinal mucosa and sometimes vascular endothelium, leads to bloody diarrhoea with inflammatory cells, decreased absorptive ability.

  • e.g. Salmonella spp.

Campylobacter spp.

Enterohaemorrhagic E.coli 0157

bacterial causes of watery diarrhoea and dysentery
Bacterial causes of watery diarrhoea and dysentery

Watery diarrhoeaDysentery

  • Vibrio cholerae - Shigella spp
  • Enterotoxigenic E.coli (ETEC) - Yersinia enterocolitica
  • Enteropathogenic E.coli (EPEC) - Campylobacter spp
  • Salmonella spp. - Salmonella spp.
  • Clostridium difficile - Clostridium difficile
  • Clostridium perfringens - Enteroinvasive E.coli
  • Campylobacter jejuni - Enterohaemorrhagic
  • Bacillus cereus E.coli (EHEC)
  • Staphylococus aureus

+ profuse vomiting

clinical features31
Clinical Features
  • Diarrhoea
    • Watery
    • Bloody
  • Cramping abdominal pain
  • Nausea, +/- Vomiting
  • Fever
  • Loss of appetite
  • Lethargy
  • Shock
investigations
Investigations
  • FBC
  • U&E, BUN
  • Stool culture
  • Stool examination, microscopy for ova, cysts, parasites and fecal WBC
  • ELISA test

** For unresolved diarrhoea: sigmoidoscopy, rectal biopsy and radiological studies to rule out other organic causes

management
Management

Aims/Goals of management:

  • Prevent, identify and treat dehydration
  • Eradicate causative pathogens
    • Tetracycline, Ciprofloxacin
  • Prevent spread by early recognition and institution of infection-control measures
    • immunization, chemoprophylaxis, good hygiene, improve sanitation
prevent identify treat dehydration
Prevent, Identify & Treat Dehydration
  • Moderate to severe dehydration need referral to hospital
  • Oral Rehydration Solution (ORS)
    • Glucose, Na, Cl, K, bicarbonate or citrate
    • encourage fluid intake e.g. salt + glucose drink to assist in co-transport of sodium into the epithelial cells via the SGLT1 protein, which enhances water and sodium re-absorption in small intestines.
  • IV fluids (lactate Ringer’s solution) are preferred in those with severe dehydration.
causes
Causes
  • Chronic Fatty Diarrhea (Diarrhea due to Malabsorption)
  • Chronic Inflammatory Diarrhea
  • Chronic Watery Diarrhea
    • Secretory Diarrhea
    • Osmotic Diarrhea
    • Drug-Induced Diarrhea
  • Infectious Diarrhea
  • Malignancy
  • Functional Diarrhea (diagnosis of exclusion)
    • Irritable Bowel Syndrome
history
History
  • Age
  • Diarrhea pattern
  • Differentiating small bowel from large bowel
  • Stool characteristics
  • Diurnal variation
  • Weight Loss
  • Medication and dietary intakes
  • Recent travel to undeveloped areas
slide38
Age
  • Young patients
    • Inflammatory Bowel Disease
    • Tuberculosis
    • Functional bowel disorder (Irritable bowel)
  • Older patients
    • Colon Cancer
    • Diverticulitis
diarrhea pattern
Diarrhea pattern
  • Diarrhea alternates with Constipation
    • Colon Cancer
    • Laxative abuse
    • Diverticulitis
    • Functional bowel disorder (Irritable bowel)
  • Intermittent Diarrhea
    • Diverticulitis
    • Functional bowel disorder (Irritable bowel)
    • Malabsorption
  • Persistent Diarrhea
    • Inflammatory Bowel Disease
    • Laxative abuse
differentiating small bowel from large bowel
Differentiating small bowel from large bowel
  • Small intestine or proximal colon involved
    • Large stool Diarrhea
    • Abdominal cramping persists after Defecation
  • Distal colon involved
    • Small stool Diarrhea
    • Abdominal cramping relieved by Defecation
stool characteristics
Stool characteristics
  • Water: Chronic Watery Diarrhea
  • Blood, pus or mucus: Chronic Inflammatory Diarrhea
  • Foul, bulky, greasy stools: Chronic Fatty Diarrhea
diurnal variation
Diurnal variation
  • No relationship to time of day: Infectious Diarrhea
  • Morning Diarrhea and after meals
    • Gastric cause
    • Functional bowel disorder (e.g. irritable bowel)
    • Inflammatory Bowel Disease
  • Nocturnal Diarrhea (always organic)
    • Diabetic Neuropathy
    • Inflammatory Bowel Disease
weight loss
Weight Loss
  • Despite normal appetite
    • Hyperthyroidism
    • Malabsorption
  • Associated with fever
    • Inflammatory Bowel Disease
  • Weight loss prior to Diarrhea onset
    • Pancreatic Cancer
    • Tuberculosis
    • Diabetes Mellitus
    • Hyperthyroidism
    • Malabsorption
medication and dietary intakes
Medication and dietary intakes
  • Drug-Induced Diarrhea
  • Food borne Illness
  • Waterborne Illness
  • High fructose corn syrup
  • Excessive Sorbitol or mannitol
  • Excessive coffee or other caffeine
recent travel to undeveloped areas
Recent travel to undeveloped areas
  • Traveler's Diarrhea
  • Infectious Diarrhea
colorectal carcinoma
Colorectal Carcinoma
  • Colorectal carcinoma
    • Colorectal cancer is second commonest cancer causing death in the UK
    • 20,000 new cases per year in UK - 40% rectal and 60% colonic
    • 3% patients present with more than one tumour (=synchronous tumours)
    • A previous colonic neoplasm increases the risk of a second tumour (=metachronous tumour)
    • Some cases are hereditary
    • Most related to environmental factors - dietary red fat and animal fat
  • Adenoma - carcinoma sequence
    • Of all adenomas - 70% tubular, 10% villous and 20% tubulovillous
    • Most cancers believed to arise within pre-existing adenomas
    • Risk of cancer greatest in villous adenoma
    • Series of mutations results in epithelial changes from normality, through dysplasia to invasion
    • Important genes - APC, DCC, k-ras, p53.
colorectal carcinoma47
Colorectal Carcinoma
  • Clinical presentation
    • Right-sided lesions present with
      • Iron deficiency anaemia due occult GI Blood loss
      • Weight loss
      • Right iliac fossa mass
    • Left-sided lesions present with
      • Abdominal pain
      • Alteration in bowel habit
      • Rectal bleeding
    • 40% of cancers present as a surgical emergency with either obstruction or perforation
colorectal carcinoma48
Colorectal Carcinoma
  • Developed by Cuthbert Duke in 1932 for rectal cancers
  • Dukes staging of colorectal cancer
    • Stage A - Tumour confined to the mucosa
    • Stage B - Tumour infiltrating through muscle
    • Stage C - Lymph node metastases present
    • Five year survival - 90%, 70% and 30% for Stages A, B and C respectively
chronic inflammatory diarrhea
Chronic Inflammatory Diarrhea
  • Inflammatory Bowel Disease
    • Ulcerative Colitis
      • is a form of colitis, a disease of the intestine, specifically the large intestine or colon
      • usually present with diarrhea mixed with blood and mucus, of gradual onset
      • also may have signs of weight loss, and blood on rectal examination
    • Crohn's Disease
      • is an inflammatory disease which may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms.
      • It primarily causes abdominal pain, diarrhea (which may be bloody), vomiting, or weight loss, but may also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis and inflammation of the eye
    • Diverticulitis
slide51
Diarrhea - common side effect of many classes of medications.
  • Accounts for 7% of all adverse drug effects.
  • Over 700 drugs have been implicated.
medications commonly involved
Antibiotics

Laxatives

Antihypertensives

Lactulose

Antineoplastics

Antiretroviral drugs

Magnesium containing compounds

Anti arrhythmics

NSAIDs

Colchicine

Antacids

Acid reducing agents

Prostaglandin analogs

Medications commonly involved
antibiotic induced diarrhea
Antibiotic-induced diarrhea
  • unexplained onset of diarrhea that occurs with the administration of any antibiotic
  • due to disruption of normal intestinal flora, which leads to
  • either proliferation of pathogenic microorganisms or impairment of the metabolic functions of the microflora
types
Types
  • Simple antibiotic associated diarrhea
  • Erythromycin induced diarrhea
  • Clostridium difficile associated diarrhea
simple antibiotic associated diarrhea
Simple antibiotic associated diarrhea
  • disturbance in the normal colonic flora, leading to impaired fermentation of carbohydrates and osmotic diarrhea
  • reduced production of short-chain fatty acids which by reducing colonic absorption of fluid causes secretory diarrhea
  • reduced digestion of bile salts by normal colonic flora and the resultant increased colonic concentration can stimulate secretion of fluid by the colon and cause a secretory diarrhea
slide58
Occurs in dose-related fashion
  • more common in drugs given orally rather than parenterally, except with drugs excreted in the bile
  • generally resolves within days of discontinuing the offending antibiotic
  • typically have a larger impact on anaerobic bacteria in the normal fecal flora
common antibiotics involved
Common antibiotics involved
  • Clindamycin
  • Ampicillin
  • Amoxicillin-clavulanate
  • Cefixime
  • Cephalosporins
  • Fluoroquinolones
  • Azithromycin
  • Clarithromycin,
  • Erythromycin
  • Tetracyclines
erythromycin induced diarrhea
Erythromycin induced diarrhea
  • Caused by erythromycin
  • Increased motility through stimulation of motilin receptors
clostridium difficile associated diarrhea cdad
Clostridium difficile associated diarrhea (CDAD)
  • not dose related
  • symptoms can last weeks to months after the offending antibiotic has been discontinued,
  • often until treatment for the infection is administered
slide62

antibiotic therapy

disturbance in the normal flora of the colon

colonization of the individual by the

organism (faecal-oral route)

majority

asymptomatic

Symptomatic

(1st day of antibiotic to 6 weeks after stopping the drug)

common antibiotics involved63
Common antibiotics involved
  • Clindamycin
  • Ampicillin
  • Amoxicillin
  • Quinolones
  • Cephalosporins
clostridium difficile
Clostridium difficile
  • gram-positive bacillus
  • spore-former, allowing it to survive under harsh conditions and during antibiotic therapy
  • development of infection caused by Clostridium difficile involves several steps
slide65
Clostridium difficile demonstrate production of 2 toxins
  • Toxin A – bind to specific receptors in the brush border of the intestinal epithelium
  • Toxin B – site of binding has not yet been described
slide66

Toxin A & B

Release of inflammatory mediators & cytokines

Chemotaxis of inflammatory cells

Increased fluid secretion by the epithelium

Patchy necrosis with production of an exudate composed fibrin and neutrophils

Pseudomembrane fomation

(necrotic cellular debris, fibrin, mucin & leucocytes)

contributing factors to cdad
Contributing factors to CDAD
  • Host susceptibility to infection
  • Virulence of the infecting strain
  • Type of antibiotic used
  • Timing of exposure
spectrum of disease
Spectrum of disease
  • Asymptomatic colonization
  • Simple antibiotic associated diarrhea
  • Pseudomembranous colitis
  • Fulminant colitis
clinical features69
Clinical features
  • Lethargy
  • Abdominal pain
  • Nausea
  • Anorexia
  • Water diarrhea
  • Low-grade fever
  • Peripheral leucocytosis

Pseudomembranous colitis – more profuse diarrhea, occult bleeding, high fever.

fulminant colitis
Fulminant colitis
  • 1-3% of patients with Clostridium difficile infection
  • Presentation –severe abdominal pain, distension, high fever, marked leucocytosis
  • Complications – colonic perforation, toxic megacolon
diagnosis of clostridium difficile infection
Diagnosis of Clostridium difficile infection
  • Tissue culture assay for toxin B
  • ELISA for toxin A/B
  • Latex agglutination assays (detect enzyme glutamate dehydrogenase)
treatment of cdad
Treatment of CDAD
  • Discontinuation of the offending antibiotic
  • Supportive fluids and electrolytes replacement
  • Enteric isolation precautions
  • Aviod antiperistaltic agents and opiates
slide73
Antibiotic is indicated for moderate to severe cases
  • 1st line : Vancomycin 125mg qds and

metronidazole 250mg tds or

bacitracin 25,000 units qds

  • Parenteral metronidazole 500mg qds may be used if oral agents are not tolerated
slide74
Used of probiotics in recurrent relapses of Clostridium difficile infection
  • Saccharomyces boulardii 1g od during concurrent antibiotic treatment
slide76
Diabetic autonomic neuropathy
  • Thyrotoxicosis
  • Neuroendocrine tumours

~ Zollinger Ellison syndrome

~ VIPoma

~ Somatostatinoma

~ Carcinoid syndrome

~ Medullary carcinoma of thyroid

diabetic autonomic neuropathy
Diabetic autonomic neuropathy
  • Reduces small bowel motility

&

  • affects enterocyte secretion

Bacterial overgrowth

Watery, continuous/interrupted by constipation diarrhoea, worse at night(nocturnal diarrhoea)

other clinical features
Other clinical features
  • Postural hypotension
  • Gastroparesis ( nausea and vomitting)
  • Difficulty in micturition ( bladder atony)
  • Erectile dysfunction
  • Gustatory sweating
treatment
Treatment
  • Broad spectrum antibiotics
  • Antidiarrhoeal- Loperamide
  • Alpha 2 adrenergic agonist- Clonidine
  • Somatostatin analogue- Octreotide
thyrotoxicosis
Thyrotoxicosis
  • Increase motility of GIT
  • Shortened transit time
  • Reduced time for action of bile on fat digestion
  • Malabsorption of nutrients

Increased bowel movement, diarrhoea, mild steatorrhoea

other clinical features81
Symptoms

Weight loss

Increase appetitite

Heat intolerance

Palpitations

Tremor

Irritability

Signs

Tachycardia

Goitre

Lid retraction

Lid lag

Graves’

+ ophthalmoplegia (diplopia)

+ pretibial myxoedema

+ thyroid acropachy

Other clinical features
investigations82
Investigations
  • Serum T4 & TSH

Treatment

  • Carbimazole
  • Propranolol
neuroendocrine tumours of pancreas
Neuroendocrine tumours of pancreas

Zollinger Ellison syndrome

  • Severe peptic ulceration
  • Gastric acid hypersecretion
  • Non beta cell islet tumour of pancreas (gastrinoma)
slide84
Gastrinoma
  • Increase gastrin levels
  • Increase acid production by parietal cells of stomach
  • Small intestine pH low &acidic
  • Pancreatic lipase inactivated, bile acids precipitated
  • Diarrhoea & steatorrhoea

Treatment: High dose proton pump inhibitors

vipoma
VIPoma
  • Vasoactive intestinal peptide (VIP)
  • Stimulate adenyl cyclase in enterocytes (stimulate secretion of water and electrolytes)
  • Secretory diarrhoea

Clinical syndrome: watery diarrhoea, hypokalemia, metabolic acidosis

somatostatinoma
Somatostatinoma
  • Function of somatostatin: suppress GI hormones, pancreatic hormones, pancreatic enzymes
  • Increase levels of somatostatin
  • Diabetes mellitus and diarrhoea/steatorrhoea
investigations87
Investigations
  • Fasting blood sample for:

~ Chromogranin A

~ Hormones ( gastrin, VIP, somatostatin)

  • Ultrasound scan, CT, MRI to look for tumours

Treatment

  • Surgically resect solitary tumours
  • Somatostatin analogue (Octreotide)
carcinoid tumour
Carcinoid tumour
  • Most commonly found in small bowel
  • Local mass effect (obstruction, appendicitis) or
  • Hormone excess

~ ectopic ACTH or 5-HT (serotonin)

Carcinoid syndrome- when vasoactive hormones reach systemic circulation

carcinoid syndrome
Carcinoid syndrome
  • Flushing
  • Wheezing ( bronchoconstriction)
  • Diarrhoea
  • Facial telangiectasia
  • Cardiac involvement

Investigations

  • 24 hour urine collection of 5HIAA (5 hydroxyindoleacetic acid)
medullary carcinoma of thyroid
Medullary carcinoma of thyroid
  • Parafollicular C cells
  • Produce calcitonin & also 5HT
  • diarrhoea
pathophysiology92
Pathophysiology

Mesenteric vascular occlusion

Crohn’s disease

Injury/ trauma to the gut

Tumours of the small intestine

Necrotising enterocolitis

Volvulus

Gut resection

slide93
Short Bowel Syndrome (SBS)

Impaired absorption of fluid and nutrients

Diarrhoea

* Normally, length of small intestine: 6m; in SBS, <2m *

slide95
1. Purgative abuse
  • High diarrhoea volume, low serum potassium
  • Sigmoidoscope shows pigmented mucosa (melanosis coli)
  • Barium enema shows dilated colon
  • May be associated with eating disorders

2. Dilutional diarrhoea

  • dilute stools on purpose
  • Check stool osmolality and electrolytes
slide97
Acute-self limiting diarrhoea-

No investigations are necessary

  • Investigations are indicated when:

-Signs of Dehydration (electrolytes imbalances)

-Chronic or persistent diarrhoea

-Bloody Diarrhoea

-Anemia, Weight loss, abdominal mass or

suspicion of neoplasia

-Patients with IBS with significant change of

symptoms

slide99
Functional bowel disorder
  • Absence of any organic causes
epidemiology
Epidemiology
  • Young
  • <35 years old
  • Female
clinical features101
Clinical Features
  • Abdominal pain or discomfort
  • Abdominal bloating/ distension
  • Change in bowel habits (constipation alternating with diarrhoea)
  • Urgency of bowel movements
  • Tenesmus
diagnosis
Diagnosis
  • no specific laboratory or imaging test
  • Diagnosis of exclusion
  • Rome Criteria
rome iii criteria 2006
Rome III Criteria (2006)
  • Recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months that is associated with 2 or more of the following:
    • Relieved by defecation
    • Onset associated with a change in stool frequency
    • Onset associated with a change in stool form or apperance.
slide104
Cont.
  • Supporting symptoms:
    • Altered stool frequency
    • Altered stool form
    • Altered stool passage (straining and/or urgency)
    • Mucorrhoea
    • Abdominal bloating or subjective distention
etiology
Etiology
  • Currently unknown.
  • Thought to result from
    • an interplay of abnormal gastrointestinal(GI) tract movements
    • Increased awareness of normal bodily functions
    • Change in the nervous system communication between the brain and the GI tract,
slide106
Cont.
  • Has also developed after episodes of gastroenteritis
  • Dietary allergies or food sensitivities (not yet proven)
  • Symptoms worsen during periods of stress or menses
management107
Management
  • Exclusion diet
  • Fiber supplements
  • Laxatives
  • Anti-diarrhoea medication
  • Antispasmodic
  • Antidepressants
blood tests
Blood Tests

1. Full Blood Count

- Anemia? MCH? (iron deficiency? Anemia of chronic illness?)

- MCV (inc in Crohn’s, celiac disease; dec in iron defi anemia)

slide109

2. Renal Profile

- Electrolyte imbalances (dec K)

3. Arterial Blood Gas

- Acid-Base balance (loss of alkali in diarrhoea)

slide110

4. HIV serology (opportunistic infection of the gutchronic diarrhoea)

5. ESR (cancer, IBD)

6. CRP (IBD)

7. Thyroid function test (hyperthyroidism)

8. Celiac Serology

9. Tumor Markers (eg: CEA)

……

Depends on your differential diagnosis~

slide111
Stool
  • ( must be collected fresh on three occasions)
    • Microscopy for parasites and red and white cells ( warm specimen for amoebiasis)
    • Cultures: Pathogens, Campylobacter sp., C.difficile (pseudomembranous colitis, Yersinia, sp
slide112
Stool
  • For occult blood
  • For ova and cyst (eg: Cryptosporidiosis, Blastocystis)
  • For fat excretion (steatorrhoea)
slide113
Imaging and Scope:
  • Barium Studies: Barium enema, Barium follow-through
  • Ultrasound
  • Abdominal X-Ray (chronic pancreatitis)
  • CT scan
  • MRI
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Imaging and Scope:
  • Small Bowel Endoscopy (for malabsorption disorders) and Capsule Endoscopy
  • Colonoscopy/ Barium enema
    • To exclude malignancy and in colitis
  • Rigid / Flexible sigmoidoscopy
    • Biopsy of normal and abnormal looking mucosa
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Hypokalaemia
  • Depletional hyponatraemia
  • Hypernatraemia
  • Hypophosphataemia
  • Hypomagnesemia
  • Dehydration
  • Hypovolaemic shock
acute diarrhoea management
Acute Diarrhoea : Management
  • Access Hydration Status
  • Encourage fluids intake
  • Consider antibiotics if ill or frail
  • Consider referring if very ill, diabetic on insulin or metformin
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Symptomatic relief with antimotility drugs
  • Advice on how to reduce spread by hand washing.
  • Food-handlers and staff in health care services should be symptom free for 48 hours before return.
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Drink glucose containing liquids and soups
  • Carbohydrates e.g. pasta and bread, assist the co-transport of glucose and sodium, so the amount of diarrhoea lost will be less than if water is used alone
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Particular care should be taken when dealing with the following patients:
  • The very young or elderly
  • Those with co-morbidity e.g.diabetes, immunodeficiency, inflammatory bowel disorder or gastric hypochlorhydria
  • Patients taking systemic corticosteroids, ACE-inhibitors, diuretics or acid suppressants
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Antibiotic therapy is usually only indicated for patients with positive stool cultures, who are systemically unwell and whose condition fails to improve within a few days.
dehydration management
Dehydration: Management
  • Children and Elderly are especially prone to dehydration.
  • A child should be encouraged by their preferred diet.
  • Breastfeeding should be continued and alternate with ORS
oral rehydration therapy
Oral Rehydration Therapy
  • The use of Oral Rehydration Therapy (ORT) is advisable for all cases with dehydration seen.
    • Oral Rehydration Salt –standard or reduced osmolarity
    • Home solutions
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Oral Rehydration Therapy

  • Sodium chloride 3.5 g
  • Trisodium citrate dehydrate 2.9 g

(or sodium bicarbonate 2.5g)

  • Potassium chloride 1.5g
  • Glucose 20 g
  • To be dissolved in one litre of clean drinking water
  • encourage fluid intake e.g. salt + glucose drink to assist in co-transport of sodium into the epithelial cells via the SGLT1 protein, which enhances water and sodium re-absorption in small intestines.
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Adults should receive 2 litres of ORT in the first 24 hours, followed by unrestricted normal fluids with 200 ml of ORT for every loose stool or vomit.
  • Mild dehydration (<5%) can be treated in a primary care, by giving ORS.
  • Moderate (5-10%) or severe (greater than 10%)dehydration is an indication for admission.
fluid management of moderate to severe dehydration
Fluid management of Moderate to Severe Dehydration

Treat Shock

Rehydrate

Maintainance

Ongoing Losses

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Treat Shock:

20 ml /kg 0.9% saline over 10 to 15 mins

  • Rehydration

fluid deficit: % of dehydration X body weight

0.45% saline/2.5 % dextrose

over 24 hours-low or normal plasma sodium

over 48 hours-high plasma sodium

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Maintenance :

First 10 kg : 100 ml/kg/24 hours

Second 10 kg : 50 ml/kg/24 hours

Subsequent kg : 20 ml/kg/24 hours

  • Close monitoring : clinical condition (vomiting, diarrhoea), plasma creatinine, and electrolytes.
1 rehydration
1. Rehydration
  • Oral rehydration therapy
    • Oral Rehydration Salt –standard or reduced osmolarity
    • Home solutions
  • Intravenous therapy
    • Ringer’s Lactate solution (Hartmann’s soln)
    • Normal saline/ Half normal saline with 5-10% glucose
    • Half strength Darrow’s soln
2 stop diarrhoea
2. Stop diarrhoea

Anti-motility agents: Codeine, Loperamide, Diphenoxylate, Bismuth subsalicylate

Adsorbents: Zaldaride Maleate

Anti-spasmodic agents: Propantheline, Dicyclomine, Mebeverine

Antibiotics? Cholera, Dysentery, Giardiasis

4 symptomatic management
4. Symptomatic Management
  • Blood transfusion
  • Analgesics
  • Rehydration and electrolyte replacement
  • Diet modification (malabsorption disorders)

Treat accordingly~

references
References
  • Harrison’s Principal of Internal Medicine.2005, pg 225-233
  • Kumar and Clark,
  • Rehydration Project
  • http://rehydrate.org/diarrhoea/tmsdd/1med.htm#intro
  • Kochar’s Clinical Medicine for Students, Fifth edition.pg41-47
  • Murtagh’s Family Practicespg467-483
references136
References
  • http://www.patient.co.uk/showdoc/40025020/
  • Emedicinehealth.Dehydration
  • Medication Induced Constipation and Diarrhea; May 2008 issue; Practical Gastroenterology
  • Medication Induced Constipation and Diarrhea; May 2008 issue; Practical Gastroenterology