DIARRHEA

Presented by Ezza Nur Adzliyanni Binti Azali 082013100005

DIARRHEA
Diarrhea is defined as passage of abnormally liquid or unformed stools at an increased frequency. Stool weight >200 g/d. It is further defined
i. Acute if <2 weeks ii. Persistent if 24 weeks iii. Chronic if >4 weeks

PATHOPHYSIOLOGY

Osmotic Diarrhea Absorption of water in the intestine is dependent on adequate absorption of solutes.
Excessive amounts of solutes are retained in the intestinal lumen

Water will not be absorbed

i. Ingestion of a poorly absorbed substrate: ii. Malabsorption

Secretory Diarrhea
Diarrhea occurs when secretion of water into the intestinal lumen exceeds absorption.

ACUTE DIARRHEA
Diarrhea that comes on suddenly and goes away over a period of a couple of weeks. >90% caused by infectious agents. Remaining 10%
i. Medications ii. Toxic ingestions iii. Ischemia

A. Infectious Agents
Feco-oral transmission Systemic manifestations
Reiter's syndrome
Arthritis Urethritis Conjuctivitis
Salmonella, Campylobacter, Shigella, and Yersinia. Enterohemorrhagic E. coli and Shigella

Hemolytic-uremic syndrome - High mortality rate

Others:
Viral hepatitis Listerosis Toxic shock syndrome

Five high-risk groups

Travelers

Enterotoxigenic or Enteroaggregative E.coli Campylobacter Shigella Giardia

Chicken

Consumers of certain foods

: Salmonella, Shigella, Campylobacter Undercooked hamburger : Enterohemorrhagic E. coli Fried rice or reheated food : Bacillus cereus Mayonnaise or creams : Staph.aureus/Salmonella Eggs : Salmonella Uncooked foods : Listeria Seafood (esp raw) : Vibrio sp, Salmonella, Acute hepatitis A

Immunodeficient persons

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

Day care attendees and their family members

Institutionalized persons

Shigella Giardia Cryptosporidium

C.difficile

CLINICAL FEATURES

Pathogen
Bacillus cereus Staph.aureus Clostridium perfringens Vibrio cholerae Enterotoxigenic Escherichia coli Klebsiella pneumoniae Aeromonas species Enteropathogenic E.coli Enteroadherent E. coli Giardia C. difficile Hemorrhagic E. coli Rotavirus and norovirus Salmonella Campylobacter Aeromonas species Vibrio parahaemolyticus Yersinia

Incubation Period
1-8 hr 8-24 hr 872 h

1-8 days

13 d 1272 h 13 d 12 h11 d

B. Medications
Antibiotics Anti hypertensives Antidepressants Antacids Bronchodilators Chemotherapeutic agents Cardiac antidysrhythmics NSAIDs Laxatives

C. Ischemic colitis
Acute lower abdominal pain preceding watery then bloody diarrhea
Acute inflammatory changes in the sigmoid or left colon while sparing the rectum.

D. Toxins
i. Organophosphate insecticides ii. Amanita and other mushrooms iii. Arsenic

APPROACH TO PATIENT WITH ACUTE DIARRHEA

 Mild and self-limited.

Indications for evaluation include :

Abdominal pain (severe) in patients >50 years Antibiotic use (recent) Bloody stools (grossly) New Community outbreaks Duration >48 h without improvement Profuse diarrhea with Dehydration Elderly (>70 years) Fever 38.5C (101F)
Immunocompromised patients

INVESTIGATIONS
Microbiologic analysis of the stool :
i. Cultures for bacterial and viral pathogens. ii. Direct inspection for ova and parasites. iii. Immunoassays for certain - Bacterial toxins (C. difficile) - Viral antigens (rotavirus) - Protozoal antigens (Giardia, E. histolytica)

 Flexible sigmoidoscopy with biopsies and upper endoscopy with duodenal aspirates and biopsies may be indicated.
Structural examination by sigmoidoscopy, colonoscopy or abdominal CT scanning i. To exclude IBD ii. Initial approach in patients with suspected non-infectious acute diarrhea.

MANAGEMENT

Fluid and electrolyte replacement

Mild case : Fluid alone Severe case : Oral sugar-electrolytes solutions

IV rehydration

Dehydrated patients, especially infants and the elderly.

Antimotility and Antisecretory agents

Moderately severe non febrile and non bloody diarrhea. To control symptoms. Avoided with febrile dysentery, which may be exacerbated or prolonged by them.

Quinolone (500 mg bid for 35 d) Metronidazole (250 mg qid for 7 d)

Reduce severity and duration of diarrhea. Treat empirically without diagnostic evaluation.

Antibiotic prophylaxis

If travelling to high-risk countries Immunocompromised Hemochromatosis IBD

**Antibiotic is indicated whether or not causative org is discovered in patients who are i. Immunocompromised ii. Have mechanical heart valve or recent vascular grafts iii. Elderly

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