DIARRHEA

Presented
By
Dwi aprila putri
12-083
DEFINITION
Diarrhea may be defined on the basis of
quantity, frequency and consistency of the
Stools

>200-300 gm/day
>3 stools/day
Unformed liquid stools
CLASSIFICATION
Acute Diarrhea
- Non-inflammatory
- Inflammatory
Chronic Diarrhea
- Osmotic
- Secretary
- Malabsorption
- Inflammatory Infectious Motility disorders
factitious
ACUTE DIARRHEA
Sudden onset
Persists < 2weeks
Most commonly due to
- infections
- toxins
- drugs
AC NON-INFLAMMATORY DIARRHEA
Watery
No blood
No fever Involves small intestine
Voluminous/nausea/vomiting
Peri-umblical pain
Cause hypokalemia & acidosis
No fecal leukocytes
AC NON-INFLAMMATORY DIARRHEA
Caused by
Toxin producing bacteria
- Staph aureus
- Bacillus cereus
- Cl perfrengens
- ETEC (Enterotoxigenic E coli)
Viruses Rotavirus, Norovirus
Protozoal Giardia,Cryposporidium,Cyclospora
AC INFLAMMATORY DIARRHEA
Bloody
Fever
Large bowel involvement
Small in quantity - < 1litre
Left lower quadrant cramps
Urgency
Tenesmus
Faecal leukocytes/lactoferrin
AC INFLAMMATORY DIARRHEA
Viral CMV
Protozoal Entamoeba histolytica
Cytotoxin producing bacteria
- EHEC (Enterohemorrhagic E coli)
- Vibrio parahaemolyticus
- Clostridium difficile
Mucosal invading bacteria
- Shigella
- Salmonella
- Campylobacter jejuni
- EIEC (Enteroinvasive E coli)
- Aeromonas
- Plesiomonas
- Yersinia
- Chlamydia
DIAGNOSIS OF ACUTE DIARRHEA
HISTORY
- See under chronic diarrhea
PHYSICAL EXAMINATION
- See under chronic diarrhea
INVESTIGATIONS
ACUTE DIARRHOEA - INVESTIGATIONS
Stools
- Microscopy
- Antigen
* Giardia
* E histolytica
- Acid staining
* Cryptosporidium
* Cyclospora
- Culture sensitivity not usually required
TREATMENT
Diet
- Avoid high fiber diet, caffeine, alcohol
Rehydration oral or intravenous
- 50-200ml/kg/day of ORS or Ringers lactate
Antidiarrheal agents
- In non-inflammatory diarrhea
- Loperamide in mild/moderat diarrhea
- Anticholinergic agents are CONTRAINDICATED
Toxic Megacolon
Antibiotics
- In inflammatory diarrhea only
CHRONIC DIARRHEA
Osmotic Diarrhea
- Increased osmotic gap > 125mosm/kg (N= up to
50mosm/kg)
- Due to
* Ingestion of osmotically active substance
* Malabsorption
- Resolves during fasting
- Occurs with
* Disaccharidase deficiency viral infection,GIT
surgery
* Laxatives
* Malabsorption syndrome
CHRONIC DIARRHEA
Secretary
Diarrhea
Increased GI secretions
Decreased absorption
Normal osmotic gap
Fasting does not improve condition
Due to
- Endocrine tumours
- Bile salt malabsorption
- Laxatives
CHRONIC DIARRHEA
Inflammatory Diarrhea
- Fever
- Hematochazia
- Examples are
* Ulcerative colitis
* Crohens disease
* Microscopic colitis
CHRONIC DIARRHEA
Malabsorptive
- Weight loss prominent feature
- Deficiency diseases
* Vitamins
* Minerals
- Due to
* Intestinal mucosal disease
* Lymphatic obstruction
* Bacterial overgrowth
CHRONIC DIARRHEA
Motility Disorders
- Rapid transit of food
- Stasis of intestinal contents
- Example Irritable
* Bowel
* Syndrome
CHRONIC DIARRHEA
Chronic Infections
- Parasitic
*Protozoal giardia, E. histolytica
* Cyclospora
- Bacterial
* Aeromonas
* Plesiomonas
- Immunocompromised
* CMV
* MAC
* Isospora
* Cryptosporidium
CHRONIC DIARRHEA
Factitious Diarrhea
- Dilution of stools with
* Urine
* Water
- Laxatives
DIAGNOSIS/EVALUATION
History
Physical Examination
Investigations
HISTORY TAKING
What is the complaint
Onset sudden? Gradual?
Duration days ? Weeks? Chronic?
Frequency of stools
Consistency of stools
Any mucus or blood in stools
Fever
Tenesmus
Abdominal cramps peri-umblical? Left lower quadrant?
Food taken
History of gastroenteritis in others sharing same food
Water source
Related to any special food or history of food allergy
History of weight loss
History of abdominal surgery
Any known systemic disease
Features of systemic diseases like
- Relating to thyroid gland
- Relating to carcinoid syndrome
- Relating to malabsorption
- Anxiety / depression
PHYSICAL EXAMINATION
Demeanor
Level of hydration
- Look for tongue
- Sunken eyes
- Skin turger
Temperature, Blood pressure, Pulse rate
Anxious / Depressed / Fidgety
Pallor
Cachexia
Other features of malnourishment
Tremors
Tachycardia
Flushing of face
Abdominal tenderness
Features of liver / pancreatic disease
Other features of relevant systemic diseases
INVESTIGATIONS
24 Hour Stool
- > 300gm indicates diarrhea
- > 500gm excludes IBS
- >1000-1500gm suggests secretary diarrhea
- > 10gm of faecal fat - malabsorption
Stool Osmolality
- < Serum osmolality factitious diarrhea
INVESTIGATIONS
Stool pH < 5.6 - carbohydrate malabsorption
Faecal leukocytes/lactoferin inflammatory
Fecal ova/parasites
- Giardia/E.histolytica
Fecal antigen
- Giardia/E.histolytica
Acid fast staining
- Cryptosporidium/cyclospora
INVESTIGATIONS
Other tests
- CBC
- S.Electrolytes
- LFTs
- Ca++/phosphate
- TSH
- Albumin malabsorption,protein losing
enteropathy
- PTH
- Folate/B12
- Decreased Na+ & nonanion gap met acidosis
secretary diarrhea
INVESTIGATIONS
Specific tests
- Ig G/Ig A antigliadin antibodies celiac sprue
- T tG antibodies celiac sprue
- Serum VIP VIPoma
- Calcitonin medulary thyroid carcinoma
- Gastrin Zollinger-Ellison Syndrome
- Urine for 5HIAA Carcinoid syndrome
- Urine for VMA/Metanephrine -
pheochromocytoma
INVESTIGATIONS
Specific tests
- Endoscopy & Biopsy
* Upper GI tract
* Lower GI tract
- Breath test
* Bacterial overgrowth
- X ray abdomen
* Pancreatic calcification Ch. Pancreatitis
- Barium Radiology
TREATMENT
TREATMENT OF CHRONIC DIARRHEA


IS ACCORDING TO


THE UNDERLYING CAUSE
PRESENTATION ENDS