DIARRHEA


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  Notes
 
 
1 : DIARREAHA Presented By Dr Zaheer Iqbal MBBS, DPH FCPS (Med)
2 : 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
3 : CLASSIFICATION Acute Diarrhea Non-inflammatory Inflammatory Chronic Diarrhea Osmotic Secretary Malabsorption Inflammatory Infectious Motility disorders factitious
4 : ACUTE DIARRHEA Sudden onset Persists < 2weeks Most commonly due to infections toxins drugs
5 : AC NON-INFLAMMATORY DIARRHEA Watery No blood No fever Involves small intestine Voluminous/nausea/vomiting Peri-umblical pain Cause hypokalemia & acidosis No fecal leukocytes
6 : 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
7 : AC INFLAMMATORY DIARRHEA Bloody Fever Large bowel involvement Small in quantity - < 1litre Left lower quadrant cramps Urgency Tenesmus Faecal leukocytes/lactoferrin
8 : 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
9 : DIAGNOSIS OF ACUTE DIARRHEA HISTORY See under chronic diarrhea PHYSICAL EXAMINATION See under chronic diarrhea INVESTIGATIONS
10 : ACUTE DIARRHOEA - INVESTIGATIONS Stools Microscopy Antigen Giardia E histolytica Acid staining Cryptosporidium Cyclospora Culture sensitivity – not usually required
11 : TREATMENT Diet Avoid high fiber diet, caffeine, alcohol Rehydration – oral or intravenous 50-200ml/kg/day of ORS or Ringer’s lactate Antidiarrheal agents In non-inflammatory diarrhea Loperamide in mild/moderat diarrhea Anticholinergic agents are CONTRAINDICATED – Toxic Megacolon Antibiotics In inflammatory diarrhea only
12 : 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
13 : 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
14 : CHRONIC DIARRHEA Inflammatory Diarrhea Fever Hematochazia Examples are Ulcerative colitis Crohen’s disease Microscopic colitis
15 : CHRONIC DIARRHEA Malabsorptive Weight loss prominent feature Deficiency diseases Vitamins Minerals Due to Intestinal mucosal disease Lymphatic obstruction Bacterial overgrowth
16 : CHRONIC DIARRHEA Motility Disorders Rapid transit of food Stasis of intestinal contents Example Irritable Bowel Syndrome
17 : CHRONIC DIARRHEA Chronic Infections Parasitic Protozoal – giardia, E. histolytica Cyclospora Bacterial Aeromonas Plesiomonas Immunocompromised CMV MAC Isospora Cryptosporidium
18 : CHRONIC DIARRHEA Factitious Diarrhea Dilution of stools with Urine Water Laxatives
19 : DIAGNOSIS/EVALUATION History Physical Examination Investigations
20 : 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
21 : 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
22 : 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
23 : 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
24 : INVESTIGATIONS Other tests CBC S.Electrolytes LFT’s Ca++/phosphate TSH Albumin – malabsorption,protein losing enteropathy PTH Folate/B12 Decreased Na+ & nonanion gap met acidosis – secretary diarrhea
25 : 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
26 : INVESTIGATIONS Specific tests Endoscopy & Biopsy Upper GI tract Lower GI tract Breath test Bacterial overgrowth X ray abdomen Pancreatic calcification – Ch. Pancreatitis Barium Radiology
27 : TREATMENT TREATMENT OF CHRONIC DIARRHEA IS ACCORDING TO THE UNDERLYING CAUSE
28 : PRESENTATION ENDS

 

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CLASSIFICATION & DIAGNOSIS OF DIARRHEA
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