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DIARRHEA

DIARRHEA. WHAT TO ORDER. Criteria for Conducting Stool Studies:. Perform a complete history which includes the following: Travel history Sexual practices Antibiotics in the past 2 months or usage any other medications

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DIARRHEA

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  1. DIARRHEA WHAT TO ORDER

  2. Criteria for Conducting Stool Studies: • Perform a complete history which includes the following: • Travel history • Sexual practices • Antibiotics in the past 2 months or usage any other medications • Attendance of large group gatherings where others have become ill with same symptoms • Recent surgeries or procedures • Recent meals • Water source • Pets (high risk are snakes, turtles) • Onset and duration of illness

  3. Criteria for Conducting Stool Studies: • Does the patient have the following: • Fever >101.3 F • Bloody stools • Symptoms of dehydration • Worsening diarrhea after 48 hours • Six or more stool samples in 24 hours • Advanced age (>70 years of age) • Compromised immune system • Age greater than 50 with severe abdominal pain

  4. DIARRHEA • Definition: • To most patients, diarrhea means an increased frequency and/or decreased consistency of bowel movements.

  5. Diarrhea • Diarrhea occurs because more fluid passes through the large intestine than can be absorbed. • Caused by: • Infections or illnesses • Excess production of fluids • Inability to absorb fluids • Certain substances in the colon, such as fats and bile acids • Interfere with water absorption • Rapid passage of material through the colon

  6. Diarrhea Cont… • Diarrhea can be classified as: • Acute, which lasts one or two weeks • Chronic, which continues for longer than 2 or 3 weeks. • The most common causes of acute diarrhea are: • Infections (viral or bacterial) • Food poisoning • Frequently overlooked: • Medications especially antibiotics, antacids, laxatives • various sugar free foods • sometimes contain poorly absorbable materials

  7. Causes of Acute Diarrhea • Bacterial Infection • Indications for stool culture: • Bloody diarrhea • Fever • Tenesmus • Persistent or severe symptoms • Recent travel to a third world country • Known exposure to bacterial agent • Presence of fecal leukocytes • Stool Culture • Campylobacter, Salmonella, Shigella, E. coli 0157:H7 • Coming soon: Shiga toxins

  8. Causes of Acute Diarrhea • Shiga toxin • Produced by enterohemorrhagic E. coli strains • Most famous serotype is O157:H7 • Others include O26, O103, O111, O145 • Shiga toxin 1 (ST1) and Shiga toxin 2 (ST2) • Only one may be present, or both • CDC recommendation

  9. Causes of Acute Diarrhea • Yersinia Culture • Not included in routine stool culture • Primarily affects young adults and immunocompromised individuals • Indicators for Yersinia culture • Exposure to contaminated pork, milk, water, tofu • Exposure to contaminated blood via blood transfusions • Sheds for 90 days after symptoms are resolved • Early detection key in prevention of transmission and outbreaks

  10. Causes of Acute Diarrhea Cont… Bacterial cont…. • CDA Toxin (caused by Clostridium difficle) • 10x more likely to affect >65 year olds than any other age group • Indicators • Extended hospital or nursing home stay post treatment with antibiotics accompanied with the following: • Watery diarrhea (>3 times a day for >3 days) • Fever • Severe abdominal cramps/pain • Presence of fecal blood

  11. C. difficile toxin (CDA) • Most often diarrhea is caused by antibiotics or nosocomial infection • Rapid kits test for toxin A and toxin B • Do not order C. difficile culture • Not all strains of C. difficile produce toxin • Test of cure is NOT a negative toxin assay • Toxin is shed for period of time after diarrhea is resolved • Hard, non liquid stool will be rejected

  12. Causes of Acute Diarrhea Cont… • Viral Infection • Rotavirus • Most common cause of viral diarrhea in infants and young children (up to 3 years of age) • May affect all ages, especially the elderly and the immunocompromised • Extremely contagious • Indications for performing test: • Fever >101 F • Vomiting • Watery stools lasting 5 to 7 days

  13. Causes of Acute Diarrhea Cont… • Parasitic Infection • Giardia/Cryptosporidium Screen • Giardia and Cryptosporidium are the most common causes of diarrhea • Indicators • Exposure to contaminated water, food, or soil • Acute, watery diarrhea accompanied with • Excess gas • Stomach/abdominal pain • Nausea

  14. Chronic Diarrhea • Chronic diarrhea is frequently due to many of the same things (infections, medications, etc.); symptoms just last longer. • Parasitic Infections • AIDS • colon cancer and other bowel tumors • endocrine or hormonal abnormalities (thyroid, diabetes mellitus, etc.) • food allergy • inflammatory bowel disease (Crohn's disease and ulcerative colitis) • lactose intolerance • malabsorption syndromes (celiac and Whipple's disease) • other (alcohol, microscopic colitis, radiation, surgery)

  15. Chronic Diarrhea Cont… • Parasitic Infection • Ova and Parasite • 3 samples over 10 day period recommended • Indicators for ordering • Suspected parasitic infection • Prolonged diarrhea with unknown origin • Diarrhea with few leukocytes present • Immunocompromised individuals • History of foreign travel or travel to mountainous areas of North America • Children in daycare • Not typically indicated for acute diarrhea

  16. Causes of Chronic Diarrhea Cont… • Ova and Parasite Cont… • Test includes: • Fecal Concentration Exam, • Fecal Trichrome Stain: • Giardia/Cryptospiridium Antigen Assay • Does not include exam for: • Cyclospora, Isospora • Most common in our area is Giardia • History is extremely important

  17. Complete Stool Exam • At Salina Regional, Complete Stool Exam includes: • Stool Color & Consistency • Presence of gross blood • Occult blood • Stool pH • Giardia/Cryptosporidium antigen assays • Presence of charcot-leydon crystals, meat fibers, neutral fat, split fat, RBCs, & WBCs • Wet mount exam for parasites

  18. Complete Stool Exam Cont… Tests not included: • C. Diff Toxin (CDA) or Culture • Stool Culture • Yesinia Culture • O&P • Reducing substances

  19. Occult Blood vs. Fecal RBC Occult Blood: Detects hemoglobin in stool Fecal RBC: Tests for intact RBCs in stool Associated with: Gastrointestinal bleeding Hemorrhoids Colon cancer Ulcers Parasitic infections Celiac Disease, Crohns Disease Occult Blood and/or Fecal RBC

  20. Fecal pH • Results vary with specific age groups • 7-7.5 for adults and children • 5-7 for neonates • Acidic stools are typically associated with the following: • Carbohydrate intolerance, such as lactose intolerances • Fat malabsorbtion • E. coli infections • Rotavirus infections • Strongly alkaline stools may indicate cholerheic enteropathy

  21. Fecal WBC • Evaluates acute, inflammatory cause of diarrhea • Indicates need for a stool culture

  22. Fecal Meat Fibers • Indicator of malabsorption and pancreatic insufficiency

  23. Charcot-Leyden Crystals • What are they? • Crystals found in stool that result from an enzyme released by damaged eosinophil cells which are present due to an allergy or parasitic infection. • Diagnostic uses • Indicator of possible parasitic infection • Other inflammatory or allergic condition such as eosinophilic gastroenteritis

  24. Complete Stool Exam w/Ova and Parasite • Includes all tests found in a complete stool exam plus the following: • Fecal Concentration • Fecal Trichrome Stain

  25. Qualitative Fecal Fat • Steatorrhea • Possible biological causes • Olestra: not since 2003 • Orlistat • Patient preparation: • Patient should not use suppositories, mineral oils, or any other oil based products before collection of sample. • Patient should also avoid taking castor oil, bismuth, Metamucil and oily salad dressings for 1 week prior to testing.

  26. Qualitative Fecal Fat Cont…. • Test Includes: • Neutral Fecal Fat • Positive results indicate: • Deficiency of pancreatic enzymes • Small bowel disease • Aids in diagnosis of malabsorption and/or maldigestion • Split Fecal Fat • Positive results indicate: • Impaired bile secretion • Inadequate adsorption of nutrients

  27. Fecal Reducing Substance • Test is not performed at SRHC • sent out to Labcorp of America • Reference Range: • Normal: <0.25 g/dL • Trace: 0.25-0.50 g/dL • Increased: >0.50 g/dL • Use: Detect malabsorption of primarily sucrase and lactase

  28. Total cost of testing • Complete stool exam • $600.40 • Complete stool exam with Ova and Parasite • $828.70 • How much will insurance pay? • Depends on insurance and diagnosis • What if patient has no insurance? • Payment is usually patient’s responsibility

  29. Laboratory recommendations • A complete stool exam is not indicated in every instance of diarrhea • Pick and choose what tests are necessary when dealing with acute diarrhea based on patient history • Often see orders for CDA, WBC, culture • Do not order C. difficile culture • Tell the outpatient to disregard orders for stool testing if he/she no longer has diarrhea

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