IMS : Diarrhoea

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IMS Diarrhoea

• By Semester 6 and Smester 7

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Agenda of the day

• Overview of diarrhoea
• -Ambiga and Hui Yan
• Acute Diarrhoea (Acute Gastroenteritis)
• -Wen Jiun and Vanessa

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Epidemiology of Diarrhoea

• Leading cause of illness and death among children
  in developing countries.
• estimated 1.3 thousand million episodes and 4
  million deaths occur each year in under-fives.
• Main cause of death from acute diarrhoea is
  dehydration. Other important causes of death are
  dysentery and undernutrition.

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Definitions

• Acute Diarrhoea
• sudden onset and lasts less than two weeks
• 90 are infectious in etiology
• 10 are caused by medications, toxin ingestions,
  and ischemia
• Chronic Diarrhoea
• Diarrhoea which lasts for more than 4 weeks
• Most of the causes are non-infectious
• Persistent Diarrhoea
• -Diarrhoea lasting between 2 to 4 weeks

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Clinical Features

• Stools
• Loose
• Blood stained
• Offensive smell
• Steatorrhea (floating, oily, difficult to flush)
• Sudden onset of bowel frequency
• Crampy abdominal pain
• Urgency
• Fever
• Loss of appetite
• Loss of weight

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Classifications of Diarrhoea

• Duration-
• ( Acute, Chronic)
• Causes-
• ( infectious, post-infectious, drugs,
  endocrine, factitious)
• Chronic Dirrhoea-
• Pathophysiologic mechanism
• (osmotic, secretory, inflammatory, abnormal
  motility)

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• Acute Diarrhoea
• Viral,Bacterial,
• Protozoa (90)
• Medications
• Laxatives or diuretic abuse
• Ingestion of environmental preformed toxin
  such as seafood
• Ischemic Colitis
• Graft versus Host

• Chronic Diarrhoea
• Irritable Bowel Syndrome
• Diverticular disease
• Colorectal Cancer
• Bowel Resection
• Malabsorption
• Inflammatory Bowel Disease
• Celiac Disease
• Carcinoid tumour

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Mechanism of Diarrhoea

• Osmotic Diarrhoea
• Secretory Diarrhoea
• Inflammatory Diarrhoea
• Abnormal Motility Diarrhoea

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Osmotic Diarrhoea

• Mechanism
• -retention of water in the bowel as a result
  of an accumulation of non-absorbable
  water-soluble compounds
• -cease with fasting, discontinue oral agents
• Causes
• -Purgatives like magnesium sulfate or magnesium
  containing antacids
• -especially associated with excessive intake of
  sorbitol and mannitol.
• -Disaccharide intolerance
• -Generalized malabsorption

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Secretory Diarrhoea

• Mechanism
• Active intestinal secretion of fluid and
  electrolytes as well as decreased absorption.
• Large volume, painless, persist with fasting
• Causes
• Cholera enterotoxin, heat labile E.coli
  enterotoxin
• Vasoactive Intestinal Peptide hormone in
  Verner-Morrison syndrome
• Bile salts in colon following ileal resection
• Laxatives like docusate sodium
• Carcinoid tumours

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Inflammatory Diarrhoea

• Mechanism
• -damage to the intestinal mucosal cell
  leading to a loss of fluid and blood
• -pain, fever, bleeding, inflammatory
  manifestations
• Causes
• -- Immunodeficiency patient
• Infective conditions like Shigella dysentary
• Inflammatory conditions
• Ulcerative colitis and Crohns disease

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Abnormal Motility Diarrhoea

• Mechanism
• -Increased frequency of defecation due to
  underlying diseases
• -large volume, signs of malabsorption
  (steatorrhoea)
• Causes
• Diabetes mellitus- autonomic neuropathy
• Post vagotomy
• Hyperthyroid diarrhoea
• Irritable Bowel Syndrome

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ACUTE GASTROENTERITIS
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Acute Gastroenteritis

• Gastroenteritis is the inflammation of the lining
  of stomach, small and large intestine.
• gt90 of cases are infectious, although acute
  gastroenteritis may follow ingestion of drugs and
  chemical toxins (10).
• Acute gastroenteritis is common among children,
  elderly, and those who are immunocompromised.

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Infectious Agents

• Acquired by
• fecal-oral route via direct personal contact
• ingestion of food or water contaminated with
  pathogens from human or animal feces
• Acute infection occurs when the ingested agent
  overwhelms the hosts mucosal immune and
  non-immune (gastric acid, digestive enzymes,
  mucus secretion, peristalsis, and suppressive
  resident flora) defenses.

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Aetiology Causative Pathogens

• Bacteria
• Viral
• Protozoa

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Bacterial

• Campylobacter jejuni
• Salmonella sp.
• Shigella
• Escherichia coli
• Staphylococcal enterocolitis
• Bacillus cereus
• Clostridium perfringens
• Clostridium botulinum
• Gastrointestinal tuberculosis

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Viral
Protozoa

• Rotavirus
• Norovirus
• Adenovirus

• Entamoeba histolytica
• Cryptosporidium
• Giardia intestinalis
• Schistosomiasis

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High Risk Groups

1. Travelers
2. Consumers of certain foods
3. Immunodeficient person
4. Daycare participants
5. Institutionalized person

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1. Travelers

• Tourists to Latin America, Africa, and Asia
  develop traveler's diarrhea commonly due to
  enterotoxigenic Escherichia coli, Campylobacter,
  Shigella, and Salmonella.
• Visitors to Russia may have increase risk of
  Giardia-associated diarrhea.
• Visitors to Nepal may acquire Cyclospora.
• Campers, backpackers, and swimmers in wilderness
  areas may become infected with Giardia.

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2. Consumers of Certain Food

• Diarrhea closely following food consumption may
  suggest infection with
• Salmonella or Campylobacter from chicken
• Enterohemorrhagic Escherichia coli (O157H7) from
  undercooked hamburger
• Bacillus aureus from fried rice
• S. aureus from mayonnaise or creams
• Salmonella from eggs
• Vibro species, acute hepatitis A or B from (raw)
  seafood

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3. Immunodeficiency Persons

• Primary immunodeficiency
• IgA deficiency, common variable
  hypogammaglobulinemia, chronic granulomatous
  disease
• Secondary immunodeficiency
• AIDS, senescence, pharmacologic suppression

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4. Daycare Participants

• Infections with Shigella, Giardia,
  Cryptosporidium, rotavirus, and other agents are
  very common and should be considered.

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5. Institutionalized Persons

• Most frequent cause of nosocomial infections in
  many hospitals and long-term care facilities
• The causes are a variety of microorganisms but
  most commonly Clostridium difficile.

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Pathophysiology

• Infectious agents cause diarrhoea in 3 different
  ways as follows
• Mucosal adherence
• Mucosa Invasion
• Toxin Production

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Mucosal adherence

• Bacteria adhere to specific receptors on the
  mucosa, e.g. adhesions at the tip of the pili or
  fimbriae
• Mode of action effacement of intestinal mucosa
  causing lesions, produce secretory diarrhoea as a
  result of adherence
• Causing moderate watery diarrhoea
• e.g. enteropathogenic E.coli

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Mucosa Invasion

• The bacteria penetrate into the intestinal
  mucosa, destroying the epithelial cells and
  causing dysentery
• e.g. Shigella spp.
• Enteroinvasive E.coli
• Campylobacter spp

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Toxin Production

• Enterotoxins
• - toxin produced by bacteria adhere to the
  intestinal epithelium, induce excessive fluid
  secretion into the bowel lumen, results in watery
  diarrhoea without physically damaging the mucosa.
• Some enterotoxin preformed in the food can cause
  vomiting
• e.g Staph.aureus (enterotoxin B)
• Bacillus cereus
• Vibrio cholerae
• Cytotoxins
• - damage the intestinal mucosa and sometimes
  vascular endothelium, leads to bloody diarrhoea
  with inflammatory cells, decreased absorptive
  ability.
• e.g. Salmonella spp.
• Campylobacter spp.
• Enterohaemorrhagic E.coli 0157

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Bacterial causes of watery diarrhoea and
dysentery

• Watery diarrhoea Dysentery
• Vibrio cholerae - Shigella spp
• Enterotoxigenic E.coli (ETEC) - Yersinia
  enterocolitica
• Enteropathogenic E.coli (EPEC) - Campylobacter
  spp
• Salmonella spp. - Salmonella spp.
• Clostridium difficile - Clostridium difficile
• Clostridium perfringens - Enteroinvasive E.coli
• Campylobacter jejuni - Enterohaemorrhagic
• Bacillus cereus E.coli (EHEC)
• Staphylococus aureus

profuse vomiting
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Clinical Features

• Diarrhoea
• Watery
• Bloody
• Cramping abdominal pain
• Nausea, /- Vomiting
• Fever
• Loss of appetite
• Lethargy
• Shock

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Investigations

• FBC
• UE, BUN
• Stool culture
• Stool examination, microscopy for ova, cysts,
  parasites and fecal WBC
• ELISA test
• For unresolved diarrhoea sigmoidoscopy,
  rectal biopsy and radiological studies to rule
  out other organic causes

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Management

• Aims/Goals of management
• Prevent, identify and treat dehydration
• Eradicate causative pathogens
• Tetracycline, Ciprofloxacin
• Prevent spread by early recognition and
  institution of infection-control measures
• immunization, chemoprophylaxis, good hygiene,
  improve sanitation

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Prevent, Identify Treat Dehydration

• Moderate to severe dehydration need referral to
  hospital
• Oral Rehydration Solution (ORS)
• Glucose, Na, Cl, K, bicarbonate or citrate
• encourage fluid intake e.g. salt glucose drink
  to assist in co-transport of sodium into the
  epithelial cells via the SGLT1 protein, which
  enhances water and sodium re-absorption in small
  intestines.
• IV fluids (lactate Ringers solution) are
  preferred in those with severe dehydration.

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Chronic Diarrhea
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Causes

• Chronic Fatty Diarrhea (Diarrhea due to
  Malabsorption)
• Chronic Inflammatory Diarrhea
• Chronic Watery Diarrhea
• Secretory Diarrhea
• Osmotic Diarrhea
• Drug-Induced Diarrhea
• Infectious Diarrhea
• Malignancy
• Functional Diarrhea (diagnosis of exclusion)
• Irritable Bowel Syndrome

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History

• Age
• Diarrhea pattern
• Differentiating small bowel from large bowel
• Stool characteristics
• Diurnal variation
• Weight Loss
• Medication and dietary intakes
• Recent travel to undeveloped areas

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Age

• Young patients
• Inflammatory Bowel Disease
• Tuberculosis
• Functional bowel disorder (Irritable bowel)
• Older patients
• Colon Cancer
• Diverticulitis

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Diarrhea pattern

• Diarrhea alternates with Constipation
• Colon Cancer
• Laxative abuse
• Diverticulitis
• Functional bowel disorder (Irritable bowel)
• Intermittent Diarrhea
• Diverticulitis
• Functional bowel disorder (Irritable bowel)
• Malabsorption
• Persistent Diarrhea
• Inflammatory Bowel Disease
• Laxative abuse

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Differentiating small bowel from large bowel

• Small intestine or proximal colon involved
• Large stool Diarrhea
• Abdominal cramping persists after Defecation
• Distal colon involved
• Small stool Diarrhea
• Abdominal cramping relieved by Defecation

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Stool characteristics

• Water Chronic Watery Diarrhea
• Blood, pus or mucus Chronic Inflammatory
  Diarrhea
• Foul, bulky, greasy stools Chronic Fatty
  Diarrhea

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Diurnal variation

• No relationship to time of day Infectious
  Diarrhea
• Morning Diarrhea and after meals
• Gastric cause
• Functional bowel disorder (e.g. irritable bowel)
• Inflammatory Bowel Disease
• Nocturnal Diarrhea (always organic)
• Diabetic Neuropathy
• Inflammatory Bowel Disease

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Weight Loss

• Despite normal appetite
• Hyperthyroidism
• Malabsorption
• Associated with fever
• Inflammatory Bowel Disease
• Weight loss prior to Diarrhea onset
• Pancreatic Cancer
• Tuberculosis
• Diabetes Mellitus
• Hyperthyroidism
• Malabsorption

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Medication and dietary intakes

• Drug-Induced Diarrhea
• Food borne Illness
• Waterborne Illness
• High fructose corn syrup
• Excessive Sorbitol or mannitol
• Excessive coffee or other caffeine

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Recent travel to undeveloped areas

• Traveler's Diarrhea
• Infectious Diarrhea

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Colorectal Carcinoma

• Colorectal carcinoma
• Colorectal cancer is second commonest cancer
  causing death in the UK
• 20,000 new cases per year in UK - 40 rectal and
  60 colonic
• 3 patients present with more than one tumour
  (synchronous tumours)
• A previous colonic neoplasm increases the risk of
  a second tumour (metachronous tumour)
• Some cases are hereditary
• Most related to environmental factors - dietary
  red fat and animal fat
• Adenoma - carcinoma sequence
• Of all adenomas - 70 tubular, 10 villous and
  20 tubulovillous
• Most cancers believed to arise within
  pre-existing adenomas
• Risk of cancer greatest in villous adenoma
• Series of mutations results in epithelial changes
  from normality, through dysplasia to invasion
• Important genes - APC, DCC, k-ras, p53.

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Colorectal Carcinoma

• Clinical presentation
• Right-sided lesions present with
• Iron deficiency anaemia due occult GI Blood loss
• Weight loss
• Right iliac fossa mass
• Left-sided lesions present with
• Abdominal pain
• Alteration in bowel habit
• Rectal bleeding
• 40 of cancers present as a surgical emergency
  with either obstruction or perforation

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Colorectal Carcinoma

• Developed by Cuthbert Duke in 1932 for rectal
  cancers
• Dukes staging of colorectal cancer
• Stage A - Tumour confined to the mucosa
• Stage B - Tumour infiltrating through muscle
• Stage C - Lymph node metastases present
• Five year survival - 90, 70 and 30 for Stages
  A, B and C respectively

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Chronic Inflammatory Diarrhea

• Inflammatory Bowel Disease
• Ulcerative Colitis
• is a form of colitis, a disease of the intestine,
  specifically the large intestine or colon
• usually present with diarrhea mixed with blood
  and mucus, of gradual onset
• also may have signs of weight loss, and blood on
  rectal examination
• Crohn's Disease
• is an inflammatory disease which may affect any
  part of the gastrointestinal tract from mouth to
  anus, causing a wide variety of symptoms.
• It primarily causes abdominal pain, diarrhea
  (which may be bloody), vomiting, or weight loss,
  but may also cause complications outside of the
  gastrointestinal tract such as skin rashes,
  arthritis and inflammation of the eye
• Diverticulitis

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Drug-induced diarrhea
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• Diarrhea - common side effect of many classes of
  medications.
• Accounts for 7 of all adverse drug effects.
• Over 700 drugs have been implicated.

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Medications commonly involved

• Antibiotics
• Laxatives
• Antihypertensives
• Lactulose
• Antineoplastics
• Antiretroviral drugs
• Magnesium containing compounds

• Anti arrhythmics
• NSAIDs
• Colchicine
• Antacids
• Acid reducing agents
• Prostaglandin analogs

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Medication Mechanism
Laxatives Osmotic diarrhea (osmotically active solutes)
Stimulant laxatives Secretory diarrhea (excess of fluids electrolytes)
Erythromycin, cisapride Motility diarrhea (shortened transit time)
Antimicrobials Pseudomembranous colitis (bacterial proliferation)
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Medication Mechanism
Antineoplastics Exudative diarrhea (protein losing enteropathy)
NSAIDS Lymphocytic or collagenous colitis
Alpha-glucosidase inhibitor Malabsorption of carbohydrates (osmotic diarrhea)
Lipase inhibitors (Orlistat) Malabsorption of fat (steatorrhea)
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Antibiotic-induced diarrhea

• unexplained onset of diarrhea that occurs with
  the administration of any antibiotic
• due to disruption of normal intestinal flora,
  which leads to
• either proliferation of pathogenic microorganisms
  or impairment of the metabolic functions of the
  microflora

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Types

• Simple antibiotic associated diarrhea
• Erythromycin induced diarrhea
• Clostridium difficile associated diarrhea

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Simple antibiotic associated diarrhea

1. disturbance in the normal colonic flora, leading
   to impaired fermentation of carbohydrates and
   osmotic diarrhea
2. reduced production of short-chain fatty acids
   which by reducing colonic absorption of fluid
   causes secretory diarrhea
3. reduced digestion of bile salts by normal colonic
   flora and the resultant increased colonic
   concentration can stimulate secretion of fluid by
   the colon and cause a secretory diarrhea

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• Occurs in dose-related fashion
• more common in drugs given orally rather than
  parenterally, except with drugs excreted in the
  bile
• generally resolves within days of discontinuing
  the offending antibiotic
• typically have a larger impact on anaerobic
  bacteria in the normal fecal flora

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Common antibiotics involved

• Clindamycin
• Ampicillin
• Amoxicillin-clavulanate
• Cefixime
• Cephalosporins
• Fluoroquinolones
• Azithromycin
• Clarithromycin,
• Erythromycin
• Tetracyclines

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Erythromycin induced diarrhea

• Caused by erythromycin
• Increased motility through stimulation of motilin
  receptors

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Clostridium difficile associated diarrhea (CDAD)

• not dose related
• symptoms can last weeks to months after the
  offending antibiotic has been discontinued,
• often until treatment for the infection is
  administered

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antibiotic therapy
disturbance in the normal flora of the colon
colonization of the individual by the organism
(faecal-oral route)
majority
asymptomatic
Symptomatic (1st day of antibiotic to 6 weeks
after stopping the drug)
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Common antibiotics involved

• Clindamycin
• Ampicillin
• Amoxicillin
• Quinolones
• Cephalosporins

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Clostridium difficile

• gram-positive bacillus
• spore-former, allowing it to survive under harsh
  conditions and during antibiotic therapy
• development of infection caused by Clostridium
  difficile involves several steps

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• Clostridium difficile demonstrate production of 2
  toxins
• Toxin A bind to specific receptors in the brush
  border of the intestinal epithelium
• Toxin B site of binding has not yet been
  described

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Toxin A B
Release of inflammatory mediators cytokines
Chemotaxis of inflammatory cells Increased fluid
secretion by the epithelium
Patchy necrosis with production of an exudate
composed fibrin and neutrophils
Pseudomembrane fomation (necrotic cellular
debris, fibrin, mucin leucocytes)
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Contributing factors to CDAD

• Host susceptibility to infection
• Virulence of the infecting strain
• Type of antibiotic used
• Timing of exposure

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Spectrum of disease

• Asymptomatic colonization
• Simple antibiotic associated diarrhea
• Pseudomembranous colitis
• Fulminant colitis

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Clinical features

• Lethargy
• Abdominal pain
• Nausea
• Anorexia
• Water diarrhea
• Low-grade fever
• Peripheral leucocytosis
• Pseudomembranous colitis more profuse diarrhea,
  occult bleeding, high fever.

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Fulminant colitis

• 1-3 of patients with Clostridium difficile
  infection
• Presentation severe abdominal pain, distension,
  high fever, marked leucocytosis
• Complications colonic perforation, toxic
  megacolon

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Diagnosis of Clostridium difficile infection

• Tissue culture assay for toxin B
• ELISA for toxin A/B
• Latex agglutination assays (detect enzyme
  glutamate dehydrogenase)

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Treatment of CDAD

• Discontinuation of the offending antibiotic
• Supportive fluids and electrolytes replacement
• Enteric isolation precautions
• Aviod antiperistaltic agents and opiates

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• Antibiotic is indicated for moderate to severe
  cases
• 1st line Vancomycin 125mg qds and
• metronidazole 250mg tds or
• bacitracin 25,000 units qds
• Parenteral metronidazole 500mg qds may be used if
  oral agents are not tolerated

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• Used of probiotics in recurrent relapses of
  Clostridium difficile infection
• Saccharomyces boulardii 1g od during concurrent
  antibiotic treatment

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Endocrine causes
76

• Diabetic autonomic neuropathy
• Thyrotoxicosis
• Neuroendocrine tumours
• Zollinger Ellison syndrome
• VIPoma
• Somatostatinoma
• Carcinoid syndrome
• Medullary carcinoma of thyroid

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Diabetic autonomic neuropathy

• Reduces small bowel motility
• affects enterocyte secretion
• Bacterial overgrowth
• Watery, continuous/interrupted by constipation
  diarrhoea, worse at night(nocturnal diarrhoea)

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Other clinical features

• Postural hypotension
• Gastroparesis ( nausea and vomitting)
• Difficulty in micturition ( bladder atony)
• Erectile dysfunction
• Gustatory sweating

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Treatment

• Broad spectrum antibiotics
• Antidiarrhoeal- Loperamide
• Alpha 2 adrenergic agonist- Clonidine
• Somatostatin analogue- Octreotide

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Thyrotoxicosis

• Increase motility of GIT
• Shortened transit time
• Reduced time for action of bile on fat digestion
• Malabsorption of nutrients
• Increased bowel movement, diarrhoea, mild
  steatorrhoea

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Other clinical features

• Symptoms
• Weight loss
• Increase appetitite
• Heat intolerance
• Palpitations
• Tremor
• Irritability

• Signs
• Tachycardia
• Goitre
• Lid retraction
• Lid lag
• Graves
• ophthalmoplegia (diplopia)
• pretibial myxoedema
• thyroid acropachy

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Investigations

• Serum T4 TSH
• Treatment
• Carbimazole
• Propranolol

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Neuroendocrine tumours of pancreas

• Zollinger Ellison syndrome
• Severe peptic ulceration
• Gastric acid hypersecretion
• Non beta cell islet tumour of pancreas
  (gastrinoma)

84

• Gastrinoma
• Increase gastrin levels
• Increase acid production by parietal cells of
  stomach
• Small intestine pH low acidic
• Pancreatic lipase inactivated, bile acids
  precipitated
• Diarrhoea steatorrhoea
• Treatment High dose proton pump inhibitors

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VIPoma

• Vasoactive intestinal peptide (VIP)
• Stimulate adenyl cyclase in enterocytes
  (stimulate secretion of water and electrolytes)
• Secretory diarrhoea
• Clinical syndrome watery diarrhoea, hypokalemia,
  metabolic acidosis

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Somatostatinoma

• Function of somatostatin suppress GI hormones,
  pancreatic hormones, pancreatic enzymes
• Increase levels of somatostatin
• Diabetes mellitus and diarrhoea/steatorrhoea

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Investigations

• Fasting blood sample for
• Chromogranin A
• Hormones ( gastrin, VIP, somatostatin)
• Ultrasound scan, CT, MRI to look for tumours
• Treatment
• Surgically resect solitary tumours
• Somatostatin analogue (Octreotide)

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Carcinoid tumour

• Most commonly found in small bowel
• Local mass effect (obstruction, appendicitis) or
• Hormone excess
• ectopic ACTH or 5-HT (serotonin)
• Carcinoid syndrome- when vasoactive hormones
  reach systemic circulation

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Carcinoid syndrome

• Flushing
• Wheezing ( bronchoconstriction)
• Diarrhoea
• Facial telangiectasia
• Cardiac involvement
• Investigations
• 24 hour urine collection of 5HIAA (5
  hydroxyindoleacetic acid)

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Medullary carcinoma of thyroid

• Parafollicular C cells
• Produce calcitonin also 5HT
• diarrhoea

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Post Gut Resection Diarrhoea
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Pathophysiology
Mesenteric vascular occlusion
Crohns disease
Injury/ trauma to the gut
Tumours of the small intestine
Necrotising enterocolitis
Volvulus
Gut resection
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• Short Bowel Syndrome (SBS)

Impaired absorption of fluid and nutrients
Diarrhoea
Normally, length of small intestine 6m in
SBS, lt2m
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Factitious diarrhoea
95

• 1. Purgative abuse
• High diarrhoea volume, low serum potassium
• Sigmoidoscope shows pigmented mucosa (melanosis
  coli)
• Barium enema shows dilated colon
• May be associated with eating disorders
• 2. Dilutional diarrhoea
• dilute stools on purpose
• Check stool osmolality and electrolytes

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Investigation of diarrhoea
97

• Acute-self limiting diarrhoea-
• No investigations are necessary
• Investigations are indicated when
• -Signs of Dehydration (electrolytes
  imbalances)
• -Chronic or persistent diarrhoea
• -Bloody Diarrhoea
• -Anemia, Weight loss, abdominal mass or
  
• suspicion of neoplasia
• -Patients with IBS with significant
  change of
• symptoms

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Irritable Bowel Syndrome
99

• Functional bowel disorder
• Absence of any organic causes

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Epidemiology

• Young
• lt35 years old
• Female

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Clinical Features

• Abdominal pain or discomfort
• Abdominal bloating/ distension
• Change in bowel habits (constipation alternating
  with diarrhoea)
• Urgency of bowel movements
• Tenesmus

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Diagnosis

• no specific laboratory or imaging test
• Diagnosis of exclusion
• Rome Criteria

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Rome III Criteria (2006)

• Recurrent abdominal pain or discomfort at least 3
  days per month during the previous 3 months that
  is associated with 2 or more of the following
• Relieved by defecation
• Onset associated with a change in stool frequency
• Onset associated with a change in stool form or
  apperance.

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Cont.

• Supporting symptoms
• Altered stool frequency
• Altered stool form
• Altered stool passage (straining and/or urgency)
• Mucorrhoea
• Abdominal bloating or subjective distention

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Etiology

• Currently unknown.
• Thought to result from
• an interplay of abnormal gastrointestinal(GI)
  tract movements
• Increased awareness of normal bodily functions
• Change in the nervous system communication
  between the brain and the GI tract,

106
Cont.

• Has also developed after episodes of
  gastroenteritis
• Dietary allergies or food sensitivities (not yet
  proven)
• Symptoms worsen during periods of stress or menses

107
Management

• Exclusion diet
• Fiber supplements
• Laxatives
• Anti-diarrhoea medication
• Antispasmodic
• Antidepressants

108
Blood Tests

• 1. Full Blood Count
• - Anemia? MCH? (iron deficiency? Anemia of
  chronic illness?)
• - MCV (inc in Crohns, celiac disease dec in
  iron defi anemia)

109

• 2. Renal Profile
• - Electrolyte imbalances (dec K)
• 3. Arterial Blood Gas
• - Acid-Base balance (loss of alkali in
  diarrhoea)

110

• 4. HIV serology (?opportunistic infection of the
  gut?chronic diarrhoea)
• 5. ESR (cancer, IBD)
• 6. CRP (IBD)
• 7. Thyroid function test (hyperthyroidism)
• 8. Celiac Serology
• 9. Tumor Markers (eg CEA)
• Depends on your differential diagnosis

111

• Stool
• ( must be collected fresh on three occasions)
• Microscopy for parasites and red and white cells
  ( warm specimen for amoebiasis)
• Cultures Pathogens, Campylobacter sp.,
  C.difficile (pseudomembranous colitis, Yersinia,
  sp

112

• Stool
• For occult blood
• For ova and cyst (eg Cryptosporidiosis,
  Blastocystis)
• For fat excretion (steatorrhoea)

113

• Imaging and Scope
• Barium Studies Barium enema, Barium
  follow-through
• Ultrasound
• Abdominal X-Ray (chronic pancreatitis)
• CT scan
• MRI

114

• Imaging and Scope
• Small Bowel Endoscopy (for malabsorption
  disorders) and Capsule Endoscopy
• Colonoscopy/ Barium enema
• To exclude malignancy and in colitis
• Rigid / Flexible sigmoidoscopy
• Biopsy of normal and abnormal looking mucosa

115
Complications of Diarrhoea
116

• Hypokalaemia
• Depletional hyponatraemia
• Hypernatraemia
• Hypophosphataemia
• Hypomagnesemia
• Dehydration
• Hypovolaemic shock

117
Principles of Management of Acute Diarrhoea
118
Acute Diarrhoea Management

• Access Hydration Status
• Encourage fluids intake
• Consider antibiotics if ill or frail
• Consider referring if very ill, diabetic on
  insulin or metformin

119

• Symptomatic relief with antimotility drugs
• Advice on how to reduce spread by hand washing.
• Food-handlers and staff in health care services
  should be symptom free for 48 hours before
  return.

120

• Drink glucose containing liquids and soups
• Carbohydrates e.g. pasta and bread, assist the
  co-transport of glucose and sodium, so the amount
  of diarrhoea lost will be less than if water is
  used alone

121

• Particular care should be taken when dealing with
  the following patients
• The very young or elderly
• Those with co-morbidity e.g.diabetes,
  immunodeficiency, inflammatory bowel disorder or
  gastric hypochlorhydria
• Patients taking systemic corticosteroids,
  ACE-inhibitors, diuretics or acid suppressants

122

• Antibiotic therapy is usually only indicated for
  patients with positive stool cultures, who are
  systemically unwell and whose condition fails to
  improve within a few days.

123
Dehydration Management

• Children and Elderly are especially prone to
  dehydration.
• A child should be encouraged by their preferred
  diet.
• Breastfeeding should be continued and alternate
  with ORS

124
Oral Rehydration Therapy

• The use of Oral Rehydration Therapy (ORT) is
  advisable for all cases with dehydration seen.
• Oral Rehydration Salt standard or reduced
  osmolarity
• Home solutions

125

• Oral Rehydration Therapy
• Sodium chloride 3.5 g
• Trisodium citrate dehydrate 2.9 g
• (or sodium bicarbonate 2.5g)
• Potassium chloride 1.5g
• Glucose 20 g
• To be dissolved in one litre of clean drinking
  water
• encourage fluid intake e.g. salt glucose drink
  to assist in co-transport of sodium into the
  epithelial cells via the SGLT1 protein, which
  enhances water and sodium re-absorption in small
  intestines.

126

• Adults should receive 2 litres of ORT in the
  first 24 hours, followed by unrestricted normal
  fluids with 200 ml of ORT for every loose stool
  or vomit.
• Mild dehydration (lt5) can be treated in a
  primary care, by giving ORS.
• Moderate (5-10) or severe (greater than
  10)dehydration is an indication for admission.

127
Fluid management of Moderate to Severe Dehydration

• Treat Shock
• Rehydrate
• Maintainance
• Ongoing Losses

128

• Treat Shock
• 20 ml /kg 0.9 saline over 10 to 15 mins
• Rehydration
• fluid deficit of dehydration X body weight
• 0.45 saline/2.5 dextrose
• over 24 hours-low or normal plasma sodium
• over 48 hours-high plasma sodium

129

• Maintenance
• First 10 kg 100 ml/kg/24 hours
• Second 10 kg 50 ml/kg/24 hours
• Subsequent kg 20 ml/kg/24 hours
• Close monitoring clinical condition (vomiting,
  diarrhoea), plasma creatinine, and electrolytes.

130
Principles of Management of Chronic Diarrhoea
131
1. Rehydration

• Oral rehydration therapy
• Oral Rehydration Salt standard or reduced
  osmolarity
• Home solutions
• Intravenous therapy
• Ringers Lactate solution (Hartmanns soln)
• Normal saline/ Half normal saline with 5-10
  glucose
• Half strength Darrows soln

132
2. Stop diarrhoea

• Anti-motility agents Codeine, Loperamide,
  Diphenoxylate, Bismuth subsalicylate
• Adsorbents Zaldaride Maleate
• Anti-spasmodic agents Propantheline,
  Dicyclomine, Mebeverine
• Antibiotics? Cholera, Dysentery, Giardiasis

133
3. Treat the underlying cause
134
4. Symptomatic Management

• Blood transfusion
• Analgesics
• Rehydration and electrolyte replacement
• Diet modification (malabsorption disorders)
• Treat accordingly

135
References

• Harrisons Principal of Internal Medicine.2005,
  pg 225-233
• Kumar and Clark,
• Rehydration Project
• http//rehydrate.org/diarrhoea/tmsdd/1med.htmintr
  o
• Kochars Clinical Medicine for Students, Fifth
  edition.pg41-47
• Murtaghs Family Practicespg467-483

136
References

• http//www.patient.co.uk/showdoc/40025020/
• Emedicinehealth.Dehydration
• Medication Induced Constipation and Diarrhea May
  2008 issue Practical Gastroenterology
• Medication Induced Constipation and Diarrhea May
  2008 issue Practical Gastroenterology