Table 40-2 Association between Pathobiology of Causative Agents and Clinical Features in Acute Infectious Diarrhea

Pathobiology/Agents Toxin producers Preformed toxin Bacillus cereus, Staphylococcus aureus, Clostridium perfringens Enterotoxin

Incubation Vomiting Abdominal Fever Diarrhea Period Pain

18 h 824 h

34+

12+

01+ 34+, watery

Vibrio cholerae, 872 h enterotoxigenic Escherichia coli, Klebsiella pneumoniae, Aeromonas species Enteroadherent Enteropathogenic and enteroadherent E. coli, Giardia organisms, cryptosporidiosis, helminths Cytotoxin-producers Clostridium difficile 13 d 18 d

24+

12+

01+ 34+, watery

01+

13+

02+ 12+, watery, mushy

01+

34+

12+ 13+, usually watery, occasionally bloody 12+ 13+, initially watery, quickly bloody

Hemorrhagic E. coli

1272 h

01+

34+

Invasive organisms Minimal inflammation Rotavirus and Norwalk agent Variable inflammation Salmonella, 12 h11 d Campylobacter, and Aeromonas species, Vibrio parahaemolyticus, Yersinia 03+ 24+ 34+ 14+, watery or bloody 13 d 13+ 23+ 34+ 13+, watery

Pathobiology/Agents Severe inflammation Shigella species, enteroinvasive E. coli, Entamoeba histolytica

Incubation Vomiting Abdominal Fever Diarrhea Period Pain 12 h8 d 01+ 34+ 34+ 12+, bloody

Table 40-3 Major Causes of Chronic Diarrhea According to Predominant PathophysiologicMechanism

Secretory causes Exogenous stimulant laxatives Chronic ethanol ingestion Other drugs and toxins Endogenous laxatives (dihydroxy bile acids) Idiopathic secretory diarrhea Certain bacterial infections Bowel resection, disease, or fistula ( absorption) Partial bowel obstruction or fecal impaction Hormone-producing tumors (carcinoid, VIPoma, medullary cancer of thyroid, mastocytosis, gastrinoma, colorectal villous adenoma) Addison's disease Congenital electrolyte absorption defects Osmotic causes Osmotic laxatives (Mg2+, PO43, SO42) Lactase and other disaccharide deficiencies Nonabsorbable carbohydrates (sorbitol, lactulose, polyethylene glycol) Steatorrheal causes Intraluminal maldigestion (pancreatic exocrine insufficiency, bacterial overgrowth, bariatric surgery, liver disease) Mucosal malabsorption (celiac sprue, Whipple's disease, infections, abetalipoproteinemia, ischemia) Post-mucosal obstruction (1 or 2 lymphatic obstruction)

Inflammatory causes Idiopathic inflammatory bowel disease (Crohn's, chronic ulcerative colitis) Lymphocytic and collagenous colitis Immune-related mucosal disease (1 or 2 immunodeficiencies, food allergy, eosinophilic gastroenteritis, graft-vs-host disease) Infections (invasive bacteria, viruses, and parasites, Brainerd diarrhea) Radiation injury Gastrointestinal malignancies Dysmotile causes Irritable bowel syndrome (including post-infectious IBS) Visceral neuromyopathies Hyperthyroidism Drugs (prokinetic agents) Postvagotomy Factitial causes Munchausen Eating disorders Iatrogenic causes Cholecystectomy Ileal resection Bariatric surgery Vagotomy, fundoplication

Table 40-4 Physical Examination in Patients with Chronic Diarrhea

1. Are there general features to suggest malabsorption or inflammatory bowel disease (IBD) such as anemia, dermatitis herpetiformis, edema, or clubbing? 2. Are there features to suggest underlying autonomic neuropathy or collagen-vascular disease in the pupils, orthostasis, skin, hands, or joints? 3. Is there an abdominal mass or tenderness? 4. Are there any abnormalities of rectal mucosa, rectal defects, or altered anal sphincter functions? 5. Are there any mucocutaneous manifestations of systemic disease such as dermatitis herpetiformis (celiac disease), erythema nodosum (ulcerative colitis), flushing (carcinoid), or oral ulcers for IBD or celiac disease?