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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 .

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Approach to the patient with diarrhea

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

  2. 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

  3. Frequency of bowel movement in general population Mean number of bowel movement /day

  4. 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

  5. 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

  6. Mechanism of Diarrhea 1. Osmotic diarrhea 2. Secretory diarrhea 3. Inflammatory diarrhea 4. Abnormal gastrointestinal motility

  7. Osmotic Diarrhea สาเหตุ 1. Unabsorbable osmotic load 2. Malabsorption or maldigestion กลไก 1. Unabsorbable solute load ---> more fluid transport to lumen

  8. Osmotic Diarrhea

  9. Raised CI Secretion

  10. Clinical approach to diarrhea Diarrhea Pseudodiarrhea Acute Chronic

  11. Acute Diarrhea Infectious Non infectious

  12. Non infectious acute diarrhea • Drug induced • Diet • Poisoning

  13. Acute Infective Diarrhea Clinical Evaluation • Severity of illness Special • Underlying disease Consideration and management Clinical setting Diagnosis + treatment

  14. Bacteria Enteroadherant E.coli Parasites Cryptosporidia Giardia Parasite Viruses Bacteria Helminths

  15. 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)

  16. Viral • Norwalk • Rotavirus • Enteric adenovirus • Cytomegalovirus • Herpes simple virus • Fungal • Candida Sp. • Histoplasma Sp. • Parasite • Entamoeba histolytica • Giardia lamblia • Strongyloides • Cryptosporidium • Cyclospora Cayetanensis

  17. Severity of Diarrhea • Sunken eyeballs • Poor skin turgor • Orthostatic hypotension • Tachycardia • Oliguria or Anuria • Alteration of consciousness

  18. Underlying diseases • AIDS • Hyperthyroidism

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. Treatment 1. Supportive 2. Symptomatic 3. Specific

  25. Antimicrobial treatment • Fecal WBC • Severe volume depletion • Community out break • Impaired host

  26. 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

  27. Chronic Diarrhea Functional Organic HIV Non-HIV

  28. 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.

  29. Chronic organic diarrhea (Non HIV) Inflammatory Secretory Malabsorption

  30. Chronic Inflammatory Diarrhea • Infection • Inflammatory bowel • Radiation • Ischemic

  31. Malabsorption syndrome • Diarrhea • Malnutrition

  32. 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

  33. The intestine has a very large surface area for absorption

  34. Malabsorption syndrome • Strongyloidiasis • Giardiasis • Capillariasis • Lymphoma

  35. Chronic secretory diarrhea • Vipoma • Carcinoid syndrome • ZE syndrome

  36. Constipation วัตถุประสงค์ • ทราบ Definition • รู้กลไกการเกิด Constipation • ทราบสาเหตุ • เรียนรู้แนวทางการวินิจฉัยและแยกโรค • เรียนรู้แนวทางการวางแผนการรักษา

  37. Definition Acute Chronic Patient review Clinical review

  38. 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

  39. Pathogenesis Drugs (opiates, phenothiazines) Obstruction Pseudo-obstruction

  40. Cause of constipation Extrinsic Structural Systemic Neurological Drugs

  41. Extrinsic • Inadequate dietary fiber, fluid • Ignoring urge to defecate

  42. Structural • Colorectal : neoplasms, stricture, ischemia , volvulus, diverticular disease • Anorectal : inflammations, prolapse, rectocele,fissure, stricture

  43. Systemic • Hypokalemia • Hypercalcemia • Hyperparathyroidism • Hypothyroidism • Hyperthyroidism • Diabetes mellitus

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