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Approach to the patient with diarrhea . วัตถุประสงค์ 1. ทราบ Definition ของ Diarrhea 2. ทราบ กลไกการเกิด Diarrhea 3. เรียนรู้แนวทางการวินิจฉัยและแยกโรคของภาวะ Diarrhea 4. เรียนรู้แนวทางการวางแผนการรักษา. Definition of Diarrhea .

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approach to the patient with diarrhea
Approach to the patient with diarrhea

วัตถุประสงค์

1. ทราบ Definition ของ Diarrhea

2. ทราบ กลไกการเกิด Diarrhea

3. เรียนรู้แนวทางการวินิจฉัยและแยกโรคของภาวะ Diarrhea

4. เรียนรู้แนวทางการวางแผนการรักษา

definition of diarrhea
Definition of Diarrhea

Pathophysiology :- Stool weight > 200 g/day

(infant stool weight > 10 g/kg/day)

Clinical : Frequency , Liquidity,

Changing character

Form water

mucous - bloody

slide3

Frequency of bowel movement in general population

Mean number of bowel movement /day

slide4

Daily intake and endogenous secretion and absorption

Oral intake 2000

Net balance 2000-200=1800

Salivary 1500

Glands

Stomach 2500

Endogenous secretions 7000 ml

Bile 500

Pancreas 1500

% absorbed 8800/9000=98%

Intestine 1000

9000

- 8800

Stool

200

slide5

The amount of fluid absorbed differs throughout the intestine

Duodenum / jejunum

~5.5 L

Ileum

~ 2 L

Colon – Rectum

~ 1.3 L

Intake

2 liter

Stool <200 ml

mechanism of diarrhea
Mechanism of Diarrhea

1. Osmotic diarrhea

2. Secretory diarrhea

3. Inflammatory diarrhea

4. Abnormal gastrointestinal motility

osmotic diarrhea
Osmotic Diarrhea

สาเหตุ

1. Unabsorbable osmotic load

2. Malabsorption or maldigestion

กลไก

1. Unabsorbable solute load ---> more fluid

transport to lumen

clinical approach to diarrhea
Clinical approach to diarrhea

Diarrhea Pseudodiarrhea

Acute Chronic

acute diarrhea
Acute Diarrhea

Infectious Non infectious

non infectious acute diarrhea
Non infectious acute diarrhea
  • Drug induced
  • Diet
  • Poisoning
acute infective diarrhea
Acute Infective Diarrhea

Clinical Evaluation

  • Severity of illness Special
  • Underlying disease Consideration and management

Clinical setting

Diagnosis + treatment

slide14

Bacteria

Enteroadherant E.coli

Parasites

Cryptosporidia

Giardia

Parasite Viruses Bacteria

Helminths

slide15
Etiology of infectious diarrhea
  • Bacterial
      • Shigella Sp.
      • Aeromonas Shigelloides
      • Salmonella Sp.
      • Vibrio Sp.
      • Compylobactor Sp.
      • Clostridium difficile
      • E.coli (ETEC, EPEC, EIEC, EAEC and EHEC)
slide16

Viral

      • Norwalk
      • Rotavirus
      • Enteric adenovirus
      • Cytomegalovirus
      • Herpes simple virus
  • Fungal
      • Candida Sp.
      • Histoplasma Sp.
  • Parasite
      • Entamoeba histolytica
      • Giardia lamblia
      • Strongyloides
      • Cryptosporidium
      • Cyclospora Cayetanensis
slide17
Severity of Diarrhea
  • Sunken eyeballs
  • Poor skin turgor
  • Orthostatic hypotension
  • Tachycardia
  • Oliguria or Anuria
  • Alteration of consciousness
underlying diseases
Underlying diseases
  • AIDS
  • Hyperthyroidism
history of diet
History of Diet

ชนิดของอาหาร สาเหตุของ diarrhea

เห็ด Amanita phelloides

อาหารกระป๋อง Botulism

นม Lactose deficiency

Samonella Campylobacter

ขนมจีน, แป้งหมัก , ข้าวผัด Bacillus cereus

อาหารทะเล Vibrio cholerae

Vibiro pararhemolyticus

Vibrio non-O-group I

Norwalk virus

history of diet1
History of Diet

ชนิดของอาหาร สาเหตุของ diarrhea

เนื้อไก่ และเครื่องในสัตว์ Samonella , Campylobacter

ไข่ดิบ Salmonella , S aureus

น้ำไม่สะอาด Giardia , Aeromonas

ผักและผลไม้ไม่สะอาดShigilla , Salmonella

E histolytica

E coli (EHEC)

เนื้อ, หมูV. cholera , E coli

น้ำแข็งNorwalk Virus

slide21
ยา

Antacid

Lactose containing drugs

Cancer chemotherapy

Neomycin

Cadiovascular drugs : digitalis , quinidine , ganglionic - blocking agent

Antibiotics

สาเหตุของ diarrhea

Magnesium induce osmotic diarrhea

Osmotic diarrhea

Mucosal Injury

Malabsorption

Increase motility

Antibiotic associated enterocolitis (Clostridium difficile)

ประวัติการกินยา
clinical setting
Clinical Setting

Food poisoning Water Diarrhea Dysentery

(entero/neuro (non-Invasive (Invasive organism)

toxin producing) Organism)

Fever Rare Non or Low Grade Common

Incubation < 6 hours 6 hours-3 days 1-3 days

Peroid

Mucous-bloody stool Non Non Common

Nausea vomiting ++ + +

Tenesmus - - +

Voluminous stool + ++ +

Etiology Staphylococcus EPEC, ETEC, EAEC Shigella

aureus, C.perfringens Aeromonas, P.shigelloides

B, ceceus Vibrio Cholerae EIEC EHEC

Salmonella Giardia, Salmonella

Cryptospodium Campylobactor

Salmonella C.difficile, virus E.Histolytica

V.Parahemolyticus

stool leukocyte
Stool Leukocyte

Present stool leukocyte Absent stool leukocyte

HSV Adenovirus

CMV Norwalk virus

Aeromonas Rotavirus

Campylobacter Bacillus cereus

EIEC, EHEC Staphylococcus aureus

Shigella ETEC, EPEC, EAEC

Salmonella Giardia lamblia

V.parahemolyticus Cryptosporidium

Plesiomenas Shigiloides V. cholerae

E.Histolytica Cyclospora sp.

Microsporidium

Strongyloides

treatment
Treatment

1. Supportive

2. Symptomatic

3. Specific

antimicrobial treatment
Antimicrobial treatment
  • Fecal WBC
  • Severe volume depletion
  • Community out break
  • Impaired host
slide28
การรักษา

เชื้อ Drug of choice Alternative

Shigella sp. Norfloxacin , ofloxacin Ciprofloxacin, ceftriaxone

Areomonas sp. Amlnoglycoside TMP/SMX, loramphenical

Ceftriaxone

Campylobacter Erythromycin Ciprofloxacin

Norfloxacin

Clostridium difficile Metronidazole Bacitacin

Vancomycin

Vibrio cholerae Tetracycline Doxycycline , TMP/SMX

E. histolytica Metronidazole Emitine

Giardia lamblia Metronidazole Quinacrine hydrochloride

Strongyloides Thiabendazole Albendazole

slide29

Chronic Diarrhea

Functional Organic

HIV Non-HIV

causes of chronic diarrhea in thai aids
Causes of chronic diarrhea in Thai-AIDS

29/45 Found causative organism %

Cryptosporidium 20 TB 17.8

Salmomella spp. 15.5

CMV 11.1

MAC 6.6

Strongyloidiasis 4.4

Giardiasis 4.4

Cryptococcus 2.2

Histoplasma carsulatum 2.2

Campylobacter 2.2

Cyclospora 2.2

Manatsathit S. et al. J Gastroenterol.1996;31(4):533-7.

chronic organic diarrhea non hiv
Chronic organic diarrhea (Non HIV)

Inflammatory Secretory

Malabsorption

slide32

Chronic Inflammatory Diarrhea

  • Infection
  • Inflammatory bowel
  • Radiation
  • Ischemic
slide33

Malabsorption syndrome

  • Diarrhea
  • Malnutrition
slide34

Intestinal epithelial cells are continually renewed

Cell death

And sloughing

Villus

Region

Turn over time ~ 48 – 72hr

Crypt

Region

Diving cells

Paneth cells

Normally : # Cells entering villus = # Cells dying

slide38

Malabsorption syndrome

  • Strongyloidiasis
  • Giardiasis
  • Capillariasis
  • Lymphoma
slide42

Chronic secretory diarrhea

  • Vipoma
  • Carcinoid syndrome
  • ZE syndrome
constipation
Constipation

วัตถุประสงค์

  • ทราบ Definition
  • รู้กลไกการเกิด Constipation
  • ทราบสาเหตุ
  • เรียนรู้แนวทางการวินิจฉัยและแยกโรค
  • เรียนรู้แนวทางการวางแผนการรักษา
slide44
Definition

Acute

Chronic

Patient review

Clinical review

rome ii criteria for chronic constipation at least 2 of following
Rome II Criteria for chronic constipation (At least 2 of following)
  • Fever than 3 bowel movement/week
  • Hard stool in more than 25% of BM
  • A sense incomplete evaluation in more than 25% of BM
  • Excessive staining in more than 25% of BM
  • The necessity of digital manipulation to facilitate evaluation
  • Any 12 week period in the least 12 months
pathogenesis
Pathogenesis

Drugs

(opiates, phenothiazines)

Obstruction Pseudo-obstruction

cause of constipation
Cause of constipation

Extrinsic

Structural

Systemic

Neurological

Drugs

extrinsic
Extrinsic
  • Inadequate dietary fiber, fluid
  • Ignoring urge to defecate
structural
Structural
  • Colorectal : neoplasms, stricture, ischemia , volvulus, diverticular disease
  • Anorectal : inflammations, prolapse, rectocele,fissure, stricture
systemic
Systemic
  • Hypokalemia
  • Hypercalcemia
  • Hyperparathyroidism
  • Hypothyroidism
  • Hyperthyroidism
  • Diabetes mellitus
neurological
Neurological
  • CNS : Parkinson’s disease, multiple sclerosis, trauma, ischemia, tumor
  • Sacral nerves : trauma, tumor
  • Autonomic neuropathy
  • Aganglionosis (Hirschsprung’s disease)
drugs
Drugs
  • Analgesics
      • Opiates, non-steroidal anti-inflammatory
  • Anticholinergics
      • Atropine agent, antidepressants, neuroleptics
drugs1
Drugs
  • Metal ions
      • Aluminum (antacids, sucralfate), barium sulfate , bismuth, calcium, iron, heavy metals (arsenic, mercury)
  • Resins
      • Cholestyramine, polystyrene
diagnosis and differential
Diagnosis and differential
  • History taking
  • Physical examination
  • Diagnostic techniques
history taking
History taking
  • How many stools per week?
  • Chronic constipation or not?
  • Is there concomitant abdominal pain?
  • Dietary history
  • Lifestyle
  • Use of laxative
  • Use of other drugs
physical examination
Physical examination
  • Percussion (check for gas)
  • Palpable feces (‘loaded colon’)

Rectal palpation

      • Consistency / impaction
      • Presence of non fecal masses pr abnormalities (tumor, hemorrhoid, fissures, fistulas, prolapse, neoplasms)
      • Presence of blood
      • Sphincter tone
diagnostic techniques
Diagnostic techniques
  • Stool analysis (assess seriousness)
      • weighing 3 days ; < 100 g average means constipation
      • Abdominal Xray (assess seriousness)
      • Radiological or Endoscopic investigation (to assess/exclude obstructions) :
        • megacolon
        • redundant sigmoid colon
        • pattern of haustral folds
          • IBS patients ---> normal length haustral colon
          • Colon inertia ---> longer length less haustral colon
major alarm symptoms especially in patients 50 yr
Major Alarm symptoms especially in patients > 50 yr
  • New onset constipation
  • Anemia
  • Weight loss
  • Anal blood loss
  • Positive occult blood test
  • Sudden change in defecation pattern and appearance of stool
slide59

Stepped Treatment of Constipation

change lifestyle and diet

Stop medications which cause constipation

Bulk-forming agent

Osmotic laxatives

Pelvic floor

physiotherapy

Contact laxatives

Enema

Prokinetics

laxatives
Laxatives
  • Bulk laxative
      • Psyllium
      • Polycarbophil
      • Methylcellulose
  • Lubricating agents
      • Mineral oil
laxatives1
Laxatives
  • Osmotic agents
      • Magnesium and phosphate salts
      • Lactulose
      • Sorbitol
      • Polyethylene glycol
  • Glycerin suppositories
laxatives2
Laxatives
  • Stimulant laxatives
      • Surface acting agents
        • Ducusate
        • Bile acids
      • Diphenymethane derivates
        • Phenolphtalein
        • Bisacodyl
        • Sodium picosulfate
      • Ricinoleic acid
      • Anthraquinones
        • Senna
        • Cascara sagrada
        • Aloe
        • Rhubarb