Diarrhea & Constipation

Piyanant Chonmaitree, MD. Department of Medicine Srinakharinwirot University

Diarrhea

Diarrhea
3 bowel movement/D or stool weight >200 g/D acute : duration <4wks chronic : duration >4wks

Acute Diarrhea

Acute Diarrhea
3 24 . 1 2 1 24 .

Acute Diarrhea
infection : bacteria, virus, protozoa, parasites food poisoning food allergies medications initial presentation of chronic diarrhea

Infectious Diarrhea
Bacteria
E. coli Campylobacter spp Salmonella spp Shigella spp Clostridium difficile Aeromonas spp Plesiomonas spp Vibrio spp

Virus
Adenovirus Rotavirus Norovirus

Parasites
Entamoeba histolytica Giardia lamblia Cryptosporidium Microsporidia Cyclospora

Host
uncontrolled DM, cirrhosis : Vibrios, Aeromonas uremia, metastatic malignancy, aortic aneurysm, prosthetic heart valve, vascular graft, orthopedic prosthesis : Salmonella spp.

Medications
antiarrhythmics antibiotic antihypertensive : -blocker anti-inflammatory : NSAIDs, gold salts, 5-ASA antineoplastic antiretroviral antacids acid-reducing : H2RA, PPI colchicine PG : misoprostol theophylline vitamin and mineral supplements herbal products

History
, , , , , , , . , , , , , , , , (V. parahaemolyticus) (S. aureus B. cereus) , HIV, immunosuppressive, chemotherapy

DDx Acute diarrhea

Appendicitis Adnexitis Diverticulitis Peritonitis from bowel perforation Systemic infections: malaria, measles Inflammatory enterocolitis Mesenteric artery/venous occlusion

Physical Examination
signs of dehydration :
pulse BP JVP skin turgor dry lips and mucosa sunken eye balls capillary filling BW

fever abd : light palpation, deep palpation PR

Approach Acute Diarrhea

diarrhea as major presentation
watery diarrhea mucous bloody diarrhea

vomiting as major presentation

bacterial preformed toxin-induced food poisoning viral gastroenteritis

Watery diarrhea
Enterotoxin induced diarrhea
Vibrio cholerae ETEC, EPEC Vibrio parahaemolyticus Salmonella Aeromonas Plesiomonas Shigella Campylobacter jejuni Yersinia enterocolitica Clostridium difficile

Mucous-Bloody Diarrhea
Invasive bacteria
Shigella Salmonella Campylobacter jejuni Yersinia enterocolitica EIEC, EHEC Entamoeba histolytica Balantidium coli

Noninvasive bacteria (late)

Vibrio parahaemolyticus, Aeromonas, Plesiomonas

fever, headache, abdominal pain, tenesmus, frequent defecation, small volume stool WBC+, RBC+ antiperistaltics-contraindicated

Bacterial preformed toxininduced food poisoning

Staphylococcus aureus, Bacillus cereus heat stable toxin onset 6-24 hr : severe vomiting, abdominal pain, watery diarrhea (not severe) fever (infrequent) improved within 24-48 hr replacement Rx, antiemetics, antispasmodics

Viral gastroenteritis
adult < children Norwalk virus*, Rotavirus, Adenovirus, Astrovirus, Calicivirus, Coronavirus, Enterovirus, small round virus-like particles ICP 18-72 hr low grade fever, URI symptoms vomiting, abdominal pain, headache, myalgia watery diarrhea-varing severity improve within 3-4 D (7-10 D) replacement Rx

Acute Diarrhea toxic prolonged course blood in stools dehydrated nontoxic short duration no bleeding not tender symptomatic Rx ORS antidiarrheal drugs fluid & electrolyte repletion stool WBC, culture if WBC+ CBC : hemoconcentration, WBC, differential count blood chemistries : electrolytes, BUN, Cr stool tests : ova and parasite, C.difficile toxin (amoebic serology) sigmoidoscopy or colonoscopy not improved improved

Stool Examination and C/S

indication
watery diarrhea with clinical dehydration bloody diarrhea suspect cholera or cholera-like >3-5 D fever >2 D suspect epidemic or outbreak

Stool Examination and C/S

fresh stool (< 2 hr) shooting star bacteria WBC, RBC ova and parasite esp. Entamoeba histolytica cyst and/or trophozoites

case 1
25 3 1 10-15 5 T 38C P 100/min R 20/min BP 100/70mmHg not pale, no pitting edema abd: not distend, soft, liver and spleen not palpated problem list 3

Watery diarrhea
Enterotoxin induced diarrhea
Vibrio cholerae ETEC, EPEC Vibrio parahaemolyticus Salmonella Aeromonas Plesiomonas Shigella Campylobacter jejuni Yersinia enterocolitica Clostridium difficile

History
, , , , , , , . , , , , , , , , (V. parahaemolyticus) (S. aureus B. cereus) , HIV, immunosuppressive, chemotherapy

Physical Examination
signs of dehydration :
pulse BP JVP skin turgor dry lips and mucosa sunken eye balls capillary filling BW

fever abd : light palpation, deep palpation PR

case 1
25 3 1 10-15 5 T 38C P 100/min R 20/min BP 100/70mmHg not pale, no pitting edema abd: not distend, soft, liver and spleen not palpated BP drop stool exam : shooting star organisms pathogenesis

watery diarrhea dehydration no/mild ORT improved not improved moderate/severe ORS or IV fluid stool exam, C/S

antibiotic if pathogen identified

Cholera
severe watery diarrhea with severe dehydration, rice water, abrupt onset, rapid progression, muscle cramp fever, abdominal pain-uncommon endemic area : epidemics in summer toxin act on intestinal epithelial cells cAMP intestinal secretion stool exam : shooting star organisms

Cholera
replacement Rx antibiotics (shorten course) tetracycline (250 mg) 2 x 4 3 D doxycycline (100 mg) 1 x 2 3 D cotrimoxazole (80/400 mg) 2 x 2 3 D norfloxacin (400 mg) 1 x 2 3 D

S/S GA radial pulse respiration systolic BP skin turgor eyes mucosa urine BW loss (%) estimate fluid deficit (mL/kg)

Mild thirsty, alert normal normal normal normal normal normal normal 4-5 40-50

Moderate giddiness with postural change rapid & weak deep + rapid normal - low pinch retract slowly sunken dry reduced amount , dark 6-9 60-90

Severe cold, sweaty, restless, cyanotic, wrinkled skin rapid, may be impalpable deep & rapid < 80 mmHg pinch retracts > 2 sec deeply sunken very dry no urine > 10 100-110

Oral Replacement Rx
Oral Rehydration Salts (ORS) Solution
Na 90, K 20, Cl 80, HCO3 30, glucose 111 mmol/L moderate to severe dehydration

Oral Rehydration Therapy (ORT)

Na < 90 mmol/L mild dehydration

Cochrane Database of Systemic Review

reduced osmolarity ORS and rice-based ORD benefit > WHO-ORS decrease stool volume, IV replacement and safe

Antiperistaltics
loperamide, diphenoxylate, codeine, tincture opium decrease frequency and stool volume Loperamide not more than 1-2 tab/D (2 mg) abdominal discomfort, myalgia C/I : mucous bloody diarrhea, high grade fever, diarrhea in septicemic prone conditions

Adsorbents
low efficacy : activated charcoal, aluminium hydroxide, kaolin, pectin, tannic acid high efficacy : dioctahedral smectite, attapulgite (anhydrous aluminium silicate), bismuth salts absorb enterotoxin and block bile acids interact with mucosa should administered within 24-48 hr stool consistency, not shorten course

Diet

lactase deficiency lactose 1/3 375 .

case 2
30 3 1 5-6 T 37.8C P 70/min R 20/min BP 120/70mmHg not pale, no pitting edema abd: not distend, soft, liver and spleen not palpated problem list 3

Mucous-Bloody Diarrhea
Invasive bacteria
Shigella Salmonella Campylobacter jejuni Yersinia enterocolitica EIEC, EHEC Entamoeba histolytica Balantidium coli

Noninvasive bacteria (late)

Vibrio parahaemolyticus, Aeromonas, Plesiomonas

fever, headache, abdominal pain, tenesmus, frequent defecation, small volume stool WBC+, RBC+ antiperistaltics-contraindicated

case 2
30 3 1 5-6 T 37.8C P 70/min R 20/min BP 120/70mmHg not pale, no pitting edema abd: not distend, soft, liver and spleen not palpated stool exam : WBC 20-30 RBC 20-30 stool C/S : pending

mucous bloody diarrhea stool exam, C/S Norfloxacin improved not improved repeat stool exam C/S result change antibiotic FS or colonoscopy with biopsy Metronidazole (E. Histolytica)

Antibiotics in Acute Diarrhea

proven efficacy Cholera Shigella ETEC Giardia lamblia Entameba histolytica severe Salmonellosis Yersinia septicemia

Acute Diarrrhea Requiring Special Consideration

age >65 yr outbreak diarrhea travelers diarrhea AAD/AAC EHEC, Shiga-toxin producing E. coli nosocomial diarrhea institutional diarrhea HIV-related diarrhea immunocompromised host septicemic prone conditions

Chronic Diarrhea

Chronic Diarrhea
Watery diarrhea Osmotic diarrhea Osmotic laxatives CHO malabsorption Secretory diarrhea Bacterial toxins Ileal bile acid malabsorption IBD Diverticulitis Vasculitis Medication and toxins Laxative abuse Disordered motility/regulation Postvagotomy diarrhea Postsympathectomy diarrhea Diabetic autonomic neuropathy IBS Endocrinopathies Hyperthyroidism Addisons disease Gastrinoma VIPoma Somatostatinoma Carcinoid syndrome Medullary CA of thyroid Mastocytosis Pheochromocytoma Neoplasia Colon CA lymphoma Villous adenoma Idiopathic secretory diarrhea Inflammatory IBD Diverticulitis Infectious disease PMC Invasive bacterial infection : TB, yersiniosis Ulcerating viral infections : CMV, HSV Invasive parasite infections : amebiasis, strongyloides Ischemic colitis Radiation colitis Neoplasia Colon CA Lymphoma Fatty diarrhea Malabsorption syndrome Mucosal disease : celiac sprue, Whipples disease Short bowel disease Small bowel bacterial overgrowth Chronic mesenteric ischemia Maldigestion Pancreatic exocrine insufficiency Inadequate luminal bile acid concentration

History
ask about incontinence general history of diarrhea: onset, duratn, freq., amount & vol., stool character, relationship with meals, nocturnal diarrhea, episodic & varying diarrhea (CHO malabs., SBBO), abd. pain ass. with defecation (IBS), baseline bowel movement associated symptoms : N/V, tenesmus, abd. pain, constipatn, excess flatus etc. symptoms of malnutrition : anemia, edema, bruise systemic enquiry : fever, weight loss, amenorrhea, impotence, change of voice, polyuria, polydipsia, arthralgia/arthritis, rashes, eye symptoms, paresthesia, difficulty walking, sweating, tremor, proteinuria, bone pain, etc. social history: diet (lactose, food allergy), occupation, environment, travelling, contact with diarrhea past Hx & underlying illness : DM, PU, thyrotoxicosis, autoimmune disease, unsafe sex, RT, previous Sx, pancreatitis, etc. family history : IBD, polyposis syndrome, MEN1, MEN2 drugs : antibiotics, magnesium compounds, laxatives, etc. 2 gain, Hx of attempted wt. loss & fixation on body image

History
abrupt onset infectious, toxin induced incidious onset non-infectious watery secretory, toxin induced mucus LB bloody inflammatory, ulcerative, invasive steatorrhea fat malabsorption, SBO undigested materials malabsorption, increased motility large stool volume SB small volume LB fever inflammatory, infection vomiting toxin induced

PE
GA : anemia, edema, orthostatic hypotension, tachycardia, sign of hyperthyroidism & HIV, peripheral pulse HEENT : grey hair, glossitis, cheilitis, angular stomatitis, oral ulcer, macroglossia, pinch purpura, goiter, exophthalmos, uveitis, episcleritis, bruise Skin : urticaria pigmentosa (mastocytosis), waxy papule, increased pigmentation (Addisons disease), eczema, dermatitis herpetiformis (celiac sprue), PG, vasculitis, migratory necrotizing erythema (glugagonoma), flushing, malignant atrophic papulosis (Degoss disease) CVS : right-sided heart murmur Abd. : ascites, enlarge, hard liver (carcinoid synd.), abdominal bruit, PR* esp. fecal incontinence, perianal lesions NS : muscle wasting, PN (amyloidosis) Musculoskeletal : arthritis-IBD, WD, some enteric infection

Stool Analysis
WBC, RBC, parasite, FOBT, laxatives, fat, C.difficile toxin assay special stains: G/S, iodine stains, AFB stain, modified AFB stain, modified trichrome stain, dark field microscopy stool pH
pH < 6 CHO malabsorption

stool fat : Sudan 3 (qualitative), Van de Kamer (quantitative)

Approach to Chronic Diarrhea

Functional VS Organic <6m. VS >6m.<2yr. VS >2yr. Infectious VS Non-infectious Small bowel VS Large bowel Secretory VS Osmotic Steatorrhea VS Loose watery VS Mucous/bloody HIV VS Non-HIV Any clinical clues/hints Algorythms

Criteria Suggestive of Organic Diarrhea

shorter duration of diarrhea (often < 3 m.) predominant nocturnal diarrhea continual rather than intermittent sudden onset weight loss > 5 kg. high ESR low Hb level low albumin level average daily stool weight > 400 gm

sensitivity of > 3 criteria is poor, specificity is > 90 %

Duration of Chronic Diarrhea

< 6 months
Infections : bacterial (include C. difficile), viral (include CMV) Post infectious colitis

>6 m.< 2 y.
Infection: parasites, TB, fungus Any organic chronic diarrhea causes

> 2 years
Possibly organic Probably functional

Small bowel diarrhea

Large volume stool Moderate frequency Minimal urgency No tenesmus Little mucus Periumbilical pain Weight loss Signs of malnutrition

Large bowel diarrhea

Small amount of stool High frequency Urgency Tenesmus Large mucus & blood LIF pain Little or no weight loss Little or no signs of malnutrition

Chronic diarrhea
History and PE CBC, ESR, E lyte, LFT, Ca, P, PT stool parasite, WBC, RBC, C/S, fat, FOBT

Watery

Generalized Inflammatory malabsorption

Severe or Elusive

Generalized Malabsorption (Fatty Diarrhea)

Generalized malabsorption
elevated stool fat

IL maldigestion Mucosal malabs. Pancreatic exo. insuff. Celiac sprue WD Tropical sprue

Mixed Postmucosal obs. SBS SBO Intestinal lymphangiectasia

Fatty Diarrhea
Malabsorption voluminous diarrhea (cathartic action of FFA in the colon) lower fecal fat conc.* mucosal dis. (celiac, WD), SBS, SBBO, chronic mesenteric ischemia Maldigestion may not be very loose (intact TG have little effect on colonic electrolyte abs.) higher fecal fat conc. pancreatic exocrine insufficiency, inadequate luminal bile acid conc.

Impaired luminal digest Test Stool fat Intestinal biopsy PT Serum chol Serum albumin Serum iron Serum folate Serum B12 D-xylose test Schilling test Breath test decreased decreased decreased normal decreased normal normal or abn. Mucosal elevated abnormal Pancreatic very elevated normal may be increased decreased normal normal normal normal normal decreased normal May be decreased normal normal may be decreased may be decreased decreased abnormal decrease d normal normal normal normal normal normal SBO slight elevated mildly abn. Lymph Obs. elevated abnormal

Watery Diarrhea

Osmotic VS Secretory
Osmotic stool volume stool osmolality stool osmotic gap stool Na stool pH stool reducing substance effect of fasting <300 ml/day >[Na+K]x2 >100 mOsm < 60 Qmol/L <5 Positive Improve Secretory > 1000 ml/day <[Na+K]x2 <50 mOsm > 90 Qmol/L >6 Negative Not improve

stool osmotic gap = 290 2(Na+K) mOsm/kg H2O

Stool osmotic gap

Osmotic Diarrhea
ingestion of osmotic laxatives (Mg) consumption of poorly absorbable CHO
candy, chewing gum (sorbitol, mannitol, xylitol)

drugs
colchicine, cholestyramine, neomycin, lactulose, PAS

CHO malabsorption

Secretory Diarrhea
congenital bacterial toxin ileal bile acid malabsorption IBD microscopic colitis diverticulitis vasculitis medication & toxin laxative abuse disordered motility endocrinopathy neoplasia, villous adenoma diabetic diarrhea BA diarrhea idiopathic

Inflammatory diarrhea

Inflammatory Diarrhea
IBD infectious disease : TB, Yersiniosis, C. difficile, CMV, HSV, strongyloidiasis diverticulitis ischemic colitis radiation colitis neoplasia (CRC, lymphoma)

case 3
50 3 4-5 7-8 5 kg T 37C P 80/min R 20/min BP 110/70mmHg mildly pale, pitting edema 1+ both legs, coarse hair, glossitis abd: not distend, soft, liver and spleen not palpated stool exam

Paracapillaria philippinensis Capillaria philippinensis

albendazole 200 mg x2 10 D mebendazole 200 mg x2 20 D

case 4
30 2 5-6 T 37.8C P 80/min R 20/min BP 110/70mmHg mildly pale, no pitting edema abd: not distend, soft, liver and spleen not palpated stool exam

E. histolytica

Treatment
Metronidazole 750 mg x 3 5-10 D (cure rate > 90%) or Tinidazole or Chloroquine oral luminal amebicide Iodoquinol 650 mg x 3 20 D Diloxanide furoate 500 mg x 3 10 D Paramomycin 25-35 mg/kg/D x 7 D

Hints
Flushing carcinoid syndrome Tachycardia thyrotoxicosis, carcinoid syndrome PN DM, amyloidosis Proteinuria amyloidosis, SLE Postural hypotension DM, Addisons disease Dermatitis herpetiformis coeliac disease

Chronic Diarrhea with Eosinophilia

Parasites: strongyloidiasis, gnathostomiasis, giardia, capillaria etc. Eosinophillic gastro/entero/colitis Lymphoma Autoimmune disease: SLE, vasculitis Drugs induced: sulphonamide, aspirin, cephalosporins Food allergy

Chronic Diarrhea with Generalized Lymphadenopathy

Dissiminated tuberculosis IPSID, lymphoma, hematologic malignancy AIDS related diarrhea Whipples disease

Chronic Diarrhea with Remarkable Weight Loss

Malignancy eg. Pancreatic tumor TB intestine IPSID, lymphoma Malabsorption syndrome Thyrotoxicosis Parasitic diseases eg. Capillaria Inflammatory bowel disease AIDS related diarrhea

Chronic Diarrhea with Prolonged Fever

Infectious diarrhea
Amoebiasis TB enteritis CMV colitis C. difficile associated diarrhea Actinomycosis, histoplasmosis

Lymphoma IBD AIDS related diarrhea Autoimmune disease: SLE

case 5
40 3 2-3 7-8 10 kg T 38.3C P 100/min R 20/min BP 100/70mmHg cachexia, mildly pale, pitting edema 1+ both legs, oral thrush, OHL abd: not distend, soft, liver and spleen not palpated problem list differential diagnosis 3

Diarrhea in Well-Defined Patient groups

Travelers
bacterial infection protozoal infection : amebiasis, giardiasis tropical sprue

Diabetic patients
altered motility drugs : metformin, acarbose associated disease : celiac sprue, pancreatic exocrine insufficiency, SBO

Epidemics and Outbreaks

bacterial infection viral infection protozoal infection idiopathic secretory

Hospitalized patients
drug C.difficile toxin-mediated colitis tube feeding ischemic colitis fecal impaction with overflow diarrhea

AIDS
opportunistic infections drug lymphoma

DDx of Diarrhea in AIDS

Protozoa
Microsporidium Cryptosporidium Isospora belli Toxoplasma Giardia lamblia Entamoeba histolytica Blastocystis hominis Cyclospora spp Pneumocystis carinii

Fungi
Histoplasmosis Coccidiomycosis Cryptococcosis Candidiasis Lymphoma Kaposis sarcoma AIDS enteropathy Protease inhibitor : nelfinavir Pancreatic insufficiency Chronic pancreatitis Infectious pancreatitis : CMV, MAC Drug-induced pancreatitis

Neoplasms

Idiopathic Drug-induced Pancreatic disease

Bacteria C.difficile
Salmonella Shigella Campylobacter MAC M.tuberculosis SBO Vibrio spp CMV HSV Adenovirus Rotavirus Norovirus

Virus

Diarrhea in AIDS
etiology -most often drug induced or disorders unrelated to HIV infection protozoa : most common pathogens Cryptosporidium most common protozoa identified most common site-small bowel diarrhea typically severe with stool volumes of several liters per day CMV most common virus identified

Diarrhea in AIDS
Giardia lamblia and E. histolytica not increase frequency or virulence in AIDS Ancylostoma duodenale and Strongyloides stercoralis not altered clinical syndrome and recurrent rate enteric bacteria more frequent and more virulent in AIDS
Salmonella, Shigella, Campylobacter -higher rates bacteremia and antibiotic resistant

C.difficile not differ clinical presentation, response to Rx, relapse rate

Approach Diarrhea in AIDS

all patients
stool exam., ova and parasite stool specimen for bacterial C/S : Salmonella, Shigella, Campylobacter C. difficile toxin in stool

rectal bleeding, tenesmus, or fecal WBC+

FS or colonoscopy with biopsy, C/S for bacteria, virus

weight loss persist and above evaluation is negative

upper endoscopy with SB mucosal biopsy

Stool Examination
acid fast bacilli (AFB) stain modified AFB stain modified trichrome stain for microsporidia

case 5
40 3 2-3 7-8 10 kg T 38.3C P 100/min R 20/min BP 100/70mmHg cachexia, mildly pale, pitting edema 1+ both legs, oral thrush, OHL abd: not distend, soft, liver and spleen not palpated stool AFB

Cyclospora spp

Cryptosporidium spp

Isospora belli

Treatment
Organisms Cryptosporidia Cyclospora Isospora belli Treatment Paramomycin Nitazoxanide+Azithromycin TMP-SMZ Ciprofloxacin TMP-SMZ Ciprofloxacin Pyrimethamine Encephalitozoon intestinalis: Albendazole Enterocytozoon bienusi: Metronidazole, Atovaquone

Microsporidia

Constipation

Constipation
3 bowel movements per week organic VS functional

Cause of Secondary Constipation

Mechanical obstruction Metabolic and endocrinologic disorders Medication Neurologic and myopathic disorders

Mechanical obstruction
colon CA rectocele or sigmoidocele stricture extrinsic compression anal stenosis

Metabolic and endocrinologic disorders

hypothyroidism hyperthyroidism hypoK hyperCa heavy metal poisoning (lead, mercury, arsenic) DM pregnancy pheochromocytoma panhypopituitarism porphyria

Neurologic and myopathic disorders

spinal cord injury stroke parkinsonism multiple sclerosis autonomic neuropathy progressive systemic sclerosis amyloidosis dermatomyositis Chagas disease intestinal pseudoobstruction Shy-Drager syndrome

ROME III : Functional Constipation

1. must include 2 of the following :
a) b) c) d) straining during 25% of defecations lumpy or hard stool 25% of defecations sensation of incomplete evacuation 25% of defecations manual maneuvers to facilitate 25% of defecations (eg, digital evacuation, support of the pelvic floor) e) <3 defecations per wk

2. loose stools are rarely present without the use of laxatives 3. there are insufficient criteria for IBS criteria fulfilled for the last 3 mo. with symptom onset 6 mo. prior to Dx

ROME III : IBS

recurrent abdominal pain or discomfort 3 D per mo. in the last 3 mo. associated with 2 of the following: improvement with defecation onset associated with a change in frequency of stool onset associated with a change in form (appearance) of stool criteria fulfilled for the last 3 mo. with symptom onset at least 6 mo. prior to Dx

1. 2. 3.

History
duration of symptoms
long duration refractory to conservative Rx functional disorder

frequency of bowel movements associated symptoms

abdominal discomfort, distention

stool consistency and size degree of straining during defecation diet

skip breakfast exacerbate constipation

neurologic disorders, obstetric and surgical history drug social history

Warning symptoms
unintentional weight loss rectal bleeding family history of colon CA change in caliber of stool severe abdominal pain

Physical examination
sign of hypothyroidism CNS abd : distention, hard feces in palpable colon PR
perineum at rest and after strain
> 4 cm. : descending perineum syndrome

scars, fistulas, fissures, external hemorrhoids DRE

fecal impaction, anal stricture, rectal mass patulous anal sphincter : trauma, neurologic disorder inability to insert finger : elevated anal sphincter pressure

case 6
60 3 T 37C P 80/min R 20/min BP 110/70mmHg mildly pale, no pitting edema, abd: not distend, soft, liver and spleen not palpated problem list differential diagnosis 3

case 6
60 3 T 37C P 80/min R 20/min BP 110/70mmHg mildly pale, no pitting edema, abd: not distend, soft, liver and spleen not palpated

Diagnostic tests
Tests to exclude systemic disease
Hb, ESR, TFT, Ca, glucose

Tests to exclude structural disease

Barium enema
width and length of colon exclude obstructing lesion

GIFT
suspected pseudo-obstruction or small bowel obstruction

Diagnostic tests
all > 50 years or alarm symptoms
colonoscopy BE + flexible sigmoidoscopy

< 50 years without alarm symptoms

flexible sigmoidoscopy

case 7
70 3 T 37C P 80/min R 20/min BP 110/70mmHg not pale, no pitting edema, abd: not distend, soft, liver and spleen not palpated problem list differential diagnosis 3

Medications
anticholinergic : antispasmodics, antipsychotics, TCA, antiparkinsonian anticonvulsants : phenobarbital, CBZ, phenytoin antacids antineoplastic : vinca derivatives CCB -opioid agonists : loperamide, Mo, fentanyl 5-HT antagonists : alosetron Fe supplements NSAIDs : ibuprofen diuretics : furosemide

case 7
70 3 T 37C P 80/min R 20/min BP 110/70mmHg not pale, no pitting edema, abd: not distend, soft, liver and spleen not palpated verapamil FeSO4