Lecture 2 Infections Gi Tract (2)

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Gastroenteritis, Infections of Gastroenteritis, Infections of
the GI Tract, and Diarrheathe GI Tract, and Diarrhea

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GastroenteritisGastroenteritis
Gastroenteritis is a nonspecific term for various Gastroenteritis is a nonspecific term for various
pathologic states of the gastrointestinal tract. pathologic states of the gastrointestinal tract.
The primary manifestation is diarrhea, but it may The primary manifestation is diarrhea, but it may
be accompanied by nausea, vomiting, and be accompanied by nausea, vomiting, and
abdominal pain. abdominal pain.
A universal definition of diarrhea does not exist, A universal definition of diarrhea does not exist,
although patients seem to have no difficulty although patients seem to have no difficulty
defining their own situation. defining their own situation.
Although most definitions center on the frequency, Although most definitions center on the frequency,
consistency, and water content of stools consistency, and water content of stools

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GastroenteritisGastroenteritis
Defined as- Defined as- Inflammation of the mucous Inflammation of the mucous
membrane of both the stomach and membrane of both the stomach and
intestine, usually causing intestine, usually causing nausea, nausea,
vomiting, and diarrhea.vomiting, and diarrhea.
Acute gastroenteritis usually causes profuse Acute gastroenteritis usually causes profuse
watery diarrhea, often c nausea and watery diarrhea, often c nausea and
vomiting, but vomiting, but withoutwithout localized findings. localized findings.
Between cramps, the abdomen is completely Between cramps, the abdomen is completely
relaxed. relaxed.

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Cause of GastroenteritisCause of Gastroenteritis
Infectious agents usually cause acute gastroenteritis. Infectious agents usually cause acute gastroenteritis.
These agents cause diarrhea by adherence, mucosal These agents cause diarrhea by adherence, mucosal
invasion, enterotoxin production, and/or cytotoxin invasion, enterotoxin production, and/or cytotoxin
production. production.
These mechanisms result in increased fluid secretion These mechanisms result in increased fluid secretion
and/or decreased absorption. and/or decreased absorption.
This produces an increased luminal fluid content that This produces an increased luminal fluid content that
cannot be adequately reabsorbed, leading to cannot be adequately reabsorbed, leading to
dehydration and the loss of electrolytes and nutrients. dehydration and the loss of electrolytes and nutrients.

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Infantile Gastroenteritis-Infantile Gastroenteritis-
An endemic An endemic viralviral infection of young children infection of young children
(6 mo-12 yrs) (6 mo-12 yrs)
is especially widespread during winter, is especially widespread during winter,
caused by strains of caused by strains of rotavirusrotavirus; ;
the incubation period is 2-4 days, the incubation period is 2-4 days,
with symptoms lasting 3-5 days, with symptoms lasting 3-5 days,
including abd. pain, diarrhea, fever, and vomiting.including abd. pain, diarrhea, fever, and vomiting.
Tx = Fluids (PO vs. IV)Tx = Fluids (PO vs. IV)

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Epidemic Gastroenteritis-Epidemic Gastroenteritis-
An epidemic, highly communicable but rather An epidemic, highly communicable but rather
mild disease of sudden onset, mild disease of sudden onset,
caused by the epidemic gastroenteritis caused by the epidemic gastroenteritis virusvirus
(especially (especially NorwalkNorwalk agent), agent),
with an incubation period of 16-48 hrs with an incubation period of 16-48 hrs
and a duration of 1-2 days, and a duration of 1-2 days,
affects all age groups; affects all age groups;
infection is associated with some fever, abd. infection is associated with some fever, abd.
cramps, nausea, vomiting, diarrhea, and cramps, nausea, vomiting, diarrhea, and
headache, headache,

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Causes of Vomiting and DiarrheaCauses of Vomiting and Diarrhea
GASTROENTERITIS GASTROENTERITIS MNEUMONICMNEUMONIC
GGastrointestinal- Obstruction, Dymotility, Inflammation, Malabsorption, Lactose astrointestinal- Obstruction, Dymotility, Inflammation, Malabsorption, Lactose
Intolerance, GI bleedingIntolerance, GI bleeding
AAppendicitis or aortappendicitis or aorta
SSpecific diseases- Glaucoma, Torsion (ovary/testicle)pecific diseases- Glaucoma, Torsion (ovary/testicle)
TTraumarauma
RRx (prescription)-medication side effectsx (prescription)-medication side effects
OObstetrics and Gynecology-pregnancy, preeclampsia, Hyperemesis gravidarumbstetrics and Gynecology-pregnancy, preeclampsia, Hyperemesis gravidarum
EEndocrine or metabolic-thyrotoxicosis, DKA, Adrenal insufficiencyndocrine or metabolic-thyrotoxicosis, DKA, Adrenal insufficiency
NNeurologic-Vestibular, Migraine, encephalopathy, Hydrocephalus, Increased ICP eurologic-Vestibular, Migraine, encephalopathy, Hydrocephalus, Increased ICP
(neoplasms, subdural, epidural, or subarrachnoid hemorrhage, cerebral edema)(neoplasms, subdural, epidural, or subarrachnoid hemorrhage, cerebral edema)
TToxicologyoxicology
EEnvironmental-Food poisoning, envenomation, high altitude, acute radiationnvironmental-Food poisoning, envenomation, high altitude, acute radiation
RRenal-Obstructive uropathy, renal colicenal-Obstructive uropathy, renal colic
IInfection- gastroenteritis (viral, bacterial, parasitic), pyelonephritis, pneumonia nfection- gastroenteritis (viral, bacterial, parasitic), pyelonephritis, pneumonia
(pertussis, Legionella), PID, Meningitis, Hepatitis, colitis, HIV(pertussis, Legionella), PID, Meningitis, Hepatitis, colitis, HIV
TTumors-gastrinoma, thyroid ca, villous adenomaumors-gastrinoma, thyroid ca, villous adenoma
IIschemia- MI, Mesenteric ischemia, ischemia colitisschemia- MI, Mesenteric ischemia, ischemia colitis
SSupratentorial- Bulemia, psychosocial stressupratentorial- Bulemia, psychosocial stress

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GastroenteritisGastroenteritis
Causes:Causes:
Viral 50-70%Viral 50-70%
Norwalk virus Norwalk virus
CalicivirusesCaliciviruses
RotavirusRotavirus
Adenovirus Adenovirus
Parvovirus Parvovirus
Astrovirus Astrovirus
Bacterial 15-20%Bacterial 15-20%
Salmonella, Shigella,Salmonella, Shigella, and and CampylobacterCampylobacter species are the top 3 species are the top 3
leading causes of bacterial diarrhea worldwide, followed leading causes of bacterial diarrhea worldwide, followed
closely by closely by AeromonasAeromonas species species
Parasitic 10-15%Parasitic 10-15%
OthersOthers

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GastroenteritisGastroenteritis
Acute symptoms may follow a wide variety of Acute symptoms may follow a wide variety of
infectious & chemical agentsinfectious & chemical agents
Ingestion may occur as a result of person to Ingestion may occur as a result of person to
person contact, more commonly via water or person contact, more commonly via water or
foodfood
The majority of food borne illnesses are caused The majority of food borne illnesses are caused
by by staphylococcus aureusstaphylococcus aureus from contaminated from contaminated
food being allowed to stand, producing food being allowed to stand, producing
endotoxins.endotoxins.
Salmonella & ClostridiumSalmonella & Clostridium follow staph poisoning follow staph poisoning
as most common. They are found in meats.as most common. They are found in meats.

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GastroenteritisGastroenteritis
Invasive InfectionInvasive Infection: The organism enters the : The organism enters the
mucosal cells, destroys them, causing diarrhea mucosal cells, destroys them, causing diarrhea
usually with blood in the stool.usually with blood in the stool.
Enterotoxic syndromes:Enterotoxic syndromes: The organisms do not The organisms do not
invade the mucosa, but produce enterotoxins of invade the mucosa, but produce enterotoxins of
which act as chemical mediators causing which act as chemical mediators causing
hypersecretion of the fluid. Little damage to the hypersecretion of the fluid. Little damage to the
tissue is done.tissue is done.

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GastroenteritisGastroenteritis
Key SymptomsKey Symptoms
ViralViral
Abdominal cramps (#1)Abdominal cramps (#1)
VomitingVomiting
Profuse Profuse waterywatery stools stools
MyalgiasMyalgias
FeverFever
HeadachesHeadaches
ArthralgiasArthralgias
Bacterial DysenteryBacterial Dysentery
Small volume stoolsSmall volume stools
Fever Fever
TenesmusTenesmus
BloodyBloody mucoid stools mucoid stools
Suprapubic pain relieved Suprapubic pain relieved
by BMby BM

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Gastroenteritis (cont.)Gastroenteritis (cont.)
Historical InformationHistorical Information
History of suspicious food eaten within the last 48 History of suspicious food eaten within the last 48
hrs, eating an unusual food (special fish) in a hrs, eating an unusual food (special fish) in a
restaurant, or preparing food in an unconventional restaurant, or preparing food in an unconventional
container (copper). Or a hx of similar illness in container (copper). Or a hx of similar illness in
others who ate with the patient.others who ate with the patient.

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Gastroenteritis (cont.)Gastroenteritis (cont.)
Physical Exam FindingsPhysical Exam Findings
Minimally helpfulMinimally helpful
Abdominal tendernessAbdominal tenderness
Diarrhea causing dehydrationDiarrhea causing dehydration
Fever- usually indicates organism invasionFever- usually indicates organism invasion
Hypotension- usually indicates dehydration and Hypotension- usually indicates dehydration and
electrolyte imbalanceelectrolyte imbalance
Rectal Exam- “to bleed or not to bleed”Rectal Exam- “to bleed or not to bleed”

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Gastroenteritis (cont.)Gastroenteritis (cont.)
Laboratory:Laboratory:
Stool Culture Stool Culture
Hemoccult of stoolHemoccult of stool
Fecal leukocytesFecal leukocytes
CBC; If WBC count is elevated increased likelyhood of CBC; If WBC count is elevated increased likelyhood of
bacterial infection. bacterial infection.
(If eosinophils present r/o parasitic infection).(If eosinophils present r/o parasitic infection).
If C. Difficile is suspected request cytotoxin of stoolIf C. Difficile is suspected request cytotoxin of stool
Treatment:Treatment:
With the exception of Giardiasis, amebiasis, C. difficile, With the exception of Giardiasis, amebiasis, C. difficile,
salmonellosis, & shigellosis, practically all only need fluid salmonellosis, & shigellosis, practically all only need fluid
replacement, glucose, and electrolyte control (IV NS, pedialyte)replacement, glucose, and electrolyte control (IV NS, pedialyte)

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Gastroenteritis (cont.)Gastroenteritis (cont.)
Incubation periodIncubation period
Chemical poisonsChemical poisons: onset immediate after ingestion : onset immediate after ingestion
of food like Ciguatera or scromboid (scrombotoxin of food like Ciguatera or scromboid (scrombotoxin
found in fish)found in fish)
Staphylococcal food poisoningStaphylococcal food poisoning: onset within hrs : onset within hrs
after eating contaminated foodafter eating contaminated food
Salmonella & Shigella infectionSalmonella & Shigella infection: onset usually : onset usually
within 24-48 hrs (bacillary dysentery)within 24-48 hrs (bacillary dysentery)
Giardiasis infectionGiardiasis infection: onset of symptoms after one : onset of symptoms after one
week with recurrent diarrhea. week with recurrent diarrhea.

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Gastroenteritis (cont.)Gastroenteritis (cont.)
Incubation period (cont.)Incubation period (cont.)
Clostridium difficile:Clostridium difficile: Antimicrobial use within the Antimicrobial use within the
last 2 weekslast 2 weeks
BotulismBotulism: Associated Neurological symptoms after : Associated Neurological symptoms after
eating canned food. Symptoms within 24 hrs.eating canned food. Symptoms within 24 hrs.
A h/o homosexualityA h/o homosexuality: r/o AIDS, : r/o AIDS, Shigella, Shigella,
Campylobacter jejuni, Salmonella,Campylobacter jejuni, Salmonella, protozoalike protozoalike
Entamoeba, cryptosproidia, candida, giardiasis, and Entamoeba, cryptosproidia, candida, giardiasis, and
many othersmany others

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Gastrointestinal Infectious DisordersGastrointestinal Infectious Disorders
ViralViral
StaphlococcalStaphlococcal
CholeraCholera
ShigellosisShigellosis
SalmonellaSalmonella
Hemorrhagic Colitis (E. coli O157:H7)Hemorrhagic Colitis (E. coli O157:H7)
Pseudomembranous Colitis (C. difficile)Pseudomembranous Colitis (C. difficile)
Enterotoxigenic E. coliEnterotoxigenic E. coli

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Viral GastroenteritisViral Gastroenteritis
N/V/D/ abd crampsN/V/D/ abd cramps
NorwalkNorwalk- -
common year-roundcommon year-round
This is the leading cause of viral gastroenteritis in the United States This is the leading cause of viral gastroenteritis in the United States
CalicivirusesCaliciviruses
Various caliciviruses, other than Norwalk virus, are likely responsible for many Various caliciviruses, other than Norwalk virus, are likely responsible for many
outbreaks of previously unidentified viral gastroenteritis. outbreaks of previously unidentified viral gastroenteritis.
RotavirusRotavirus
This is the leading cause of gastroenteritis in children (> in winter), but can also be This is the leading cause of gastroenteritis in children (> in winter), but can also be
found in adults. Rotavirus may cause severe dehydration.found in adults. Rotavirus may cause severe dehydration.
OthersOthers
Enterovirus, Coxsackie virus A1, echovirus, adenovirusEnterovirus, Coxsackie virus A1, echovirus, adenovirus
Often occur in epidemic fashion in closed environments (eg, cruise Often occur in epidemic fashion in closed environments (eg, cruise
ships, schools)ships, schools)
Viral cultures rarely indicated; ELISA and PCR assaysViral cultures rarely indicated; ELISA and PCR assays
Fecal Leukocytes absentFecal Leukocytes absent
Self limiting; although, hospitalization and rehydration may be needed in Self limiting; although, hospitalization and rehydration may be needed in
severe casessevere cases

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Staphylococcal GastroenteritisStaphylococcal Gastroenteritis
From foods left @ room temperature, particularly milk, From foods left @ room temperature, particularly milk,
cream products, and some meat and fish.cream products, and some meat and fish.
Within 8 hrs p eating, N/V/D/F/HA, crampsWithin 8 hrs p eating, N/V/D/F/HA, cramps
Completely recovering p 24 hrsCompletely recovering p 24 hrs
h/o similar illness in others eating same food.h/o similar illness in others eating same food.
Fecal leukocytes are usually absent.Fecal leukocytes are usually absent.
Laboratory studies to distinguish b/t this and viral do Laboratory studies to distinguish b/t this and viral do
not change management and are usually not done.not change management and are usually not done.
Tx: fluids and electrolyte maintenanceTx: fluids and electrolyte maintenance

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CholeraCholera
Vibrio CholeraeVibrio Cholerae
Secretory Diarrhea Secretory Diarrhea
Spread by fecal contamination of water, seafood, and other products.Spread by fecal contamination of water, seafood, and other products.
Endemic in Gulf Coast of US, Asia, Africa, Middle East.Endemic in Gulf Coast of US, Asia, Africa, Middle East.
Epidemics, contaminated water supplies effects all in all seasonsEpidemics, contaminated water supplies effects all in all seasons
““Rice-Water”Rice-Water” stools, painless, non-bloody diarrhea stools, painless, non-bloody diarrhea
Severe Dehydration=thirst, oliguria, anuria, cramps, weakness, decrease Severe Dehydration=thirst, oliguria, anuria, cramps, weakness, decrease
turgorturgor
Circulatory collapse= cyanosis, stupor, renal tubular necrosis, deathCirculatory collapse= cyanosis, stupor, renal tubular necrosis, death
Metabolic Acidosis may be severe b/c of lost bicarbinateMetabolic Acidosis may be severe b/c of lost bicarbinate
Dx: stool cx, Dx: stool cx,
Fecal Leukocytes (WBC’s) absentFecal Leukocytes (WBC’s) absent
Tx: Maintain fluid and electrolyte balance.Tx: Maintain fluid and electrolyte balance.
Tetracycline or doxycycline reduces duration of symptomsTetracycline or doxycycline reduces duration of symptoms

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ShigellosisShigellosis
ShigellaShigella
Dysentery (bloody diarrhea)Dysentery (bloody diarrhea)
Only need to ingest small inoculumOnly need to ingest small inoculum
Fecal-Oral spread, and contaminated foods, also flies act as mechanical Fecal-Oral spread, and contaminated foods, also flies act as mechanical
vectorsvectors
Epidemics occur c overcrowding and insufficient sanitation, and Epidemics occur c overcrowding and insufficient sanitation, and
reinfection possible.reinfection possible.
Young children- acute onset of sx: f/n/v/d/abd pain/distentionYoung children- acute onset of sx: f/n/v/d/abd pain/distention
Within 3 days diarrhea becomes severe and bloody, often with pus, and Within 3 days diarrhea becomes severe and bloody, often with pus, and
mucus.mucus.
Dehydration can cause death; otherwise acute ds. resolves within several Dehydration can cause death; otherwise acute ds. resolves within several
days. (Adults have milders sx)days. (Adults have milders sx)
Dx: stool cx, proctoscopy, Dx: stool cx, proctoscopy,
Fecal Leukocytes (WBC’s) PRESENTFecal Leukocytes (WBC’s) PRESENT
Tx: Tx:
Fluid replacement is criticalFluid replacement is critical
Bactrim or Cipro can shorten course of severe dsBactrim or Cipro can shorten course of severe ds
DO NOT GIVE ANTI-DIARRHEALS, may prolong courseDO NOT GIVE ANTI-DIARRHEALS, may prolong course

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SalmonellaSalmonella
3 types3 types
1. Gastroenteritis is most common form of Salmonellosis1. Gastroenteritis is most common form of Salmonellosis
2. Enteric Fever- Typhoid Fever2. Enteric Fever- Typhoid Fever
3. Bacteremia3. Bacteremia
Eating foods produced from infected animals; meat, milk, poultry, eggs, Eating foods produced from infected animals; meat, milk, poultry, eggs,
and drinking contaminated water; and from fecal-oral trans.and drinking contaminated water; and from fecal-oral trans.
Incubation period 8-48 hrsIncubation period 8-48 hrs
Asymptomatic or symptoms develop within 2 days of eating infected Asymptomatic or symptoms develop within 2 days of eating infected
food.food.
N/cramps/watery or N/cramps/watery or bloodybloody diarrhea/fever/ and sometimes vomiting diarrhea/fever/ and sometimes vomiting
lasting 1-4 dayslasting 1-4 days
Dx: stool cx, Presence of fecal WBC’s variableDx: stool cx, Presence of fecal WBC’s variable
Tx: Tx:
supportive (IV hydration)supportive (IV hydration)
Antibiotics usually not necessary for Salmonella gastroenteritis (Bactrim, Amp, or Antibiotics usually not necessary for Salmonella gastroenteritis (Bactrim, Amp, or
Cipro indicated in pt’s c increased risk of mortality, Typhoid fever, or Bacteremia)Cipro indicated in pt’s c increased risk of mortality, Typhoid fever, or Bacteremia)

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Hemorrhagic ColitisHemorrhagic Colitis
Escherichia coliEscherichia coli O157:H7 O157:H7
Produces a toxin that damages GI mucosa and vascular Produces a toxin that damages GI mucosa and vascular
endothelial cells (vessels), other organs, particularly the endothelial cells (vessels), other organs, particularly the
kidneys.kidneys.
Organism has bovine reservoir: unpasteurized milk and Organism has bovine reservoir: unpasteurized milk and
undercooked beef; Fecal-oral transmission also possibleundercooked beef; Fecal-oral transmission also possible
S/S: Acute, severe abd cramps and watery diarrhea S/S: Acute, severe abd cramps and watery diarrhea
progresses to progresses to bloody bloody diarrhea; low grade fever, diarrhea; low grade fever,
uncomplicated lasts ~1wk; but complicated cases=high fever, uncomplicated lasts ~1wk; but complicated cases=high fever,
hemolytic uremic syndrome (HUS) or thrombocytopenic hemolytic uremic syndrome (HUS) or thrombocytopenic
purpura (TTP)purpura (TTP)
Dx: Stool cx; fecal leuks usually absentDx: Stool cx; fecal leuks usually absent
Tx: Supportive (IV hydration), Tx: Supportive (IV hydration), Abx do not helpAbx do not help; ;
complications require aggressive managementcomplications require aggressive management

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Pseudomembranous ColitisPseudomembranous Colitis
Clostridium difficileClostridium difficile
Caused by antibiotic therapyCaused by antibiotic therapy which changes balance of which changes balance of
normal intestinal flora, causing overgrowth of pathogen normal intestinal flora, causing overgrowth of pathogen
(most common causes clindamycin, ampicillin, and (most common causes clindamycin, ampicillin, and
cephalosporins, although any can be cause)cephalosporins, although any can be cause)
Hospitalized pt’s on Abx at greatest riskHospitalized pt’s on Abx at greatest risk
Usually within 2 wks after starting Abx, but may be as long as 6 Usually within 2 wks after starting Abx, but may be as long as 6
wks after.wks after.
Illness often mild, but severe bloody diarrhea with abd Illness often mild, but severe bloody diarrhea with abd
cramps, fever, and dehydration may occur.cramps, fever, and dehydration may occur.
Dx: C. difficile toxin in stool is diagnostic; stool cx or Dx: C. difficile toxin in stool is diagnostic; stool cx or
sigmoidoscopy with visualization of pseudomembranessigmoidoscopy with visualization of pseudomembranes
Tx: Tx: D/C Abx if possibleD/C Abx if possible, may be sufficient, may be sufficient
Metronidazole or PO vancomycinMetronidazole or PO vancomycin in more severe cases in more severe cases

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Traveler’s DiarrheaTraveler’s Diarrhea
Most commonly caused by bacteria (80%), Most commonly caused by bacteria (80%), Enterotoxigenic E. coli, Enterotoxigenic E. coli,
Shigella, Campylobacter jejuniShigella, Campylobacter jejuni being the most common pathogens. being the most common pathogens.
Chronic Chronic watery diarrheawatery diarrhea
Up to 10 or more loose stools per day, usually without blood or Up to 10 or more loose stools per day, usually without blood or
mucus.mucus.
Fever is rareFever is rare
Self limiting within 1-5 daysSelf limiting within 1-5 days
Dx: stool cx for pt’s c f/dysentery, and those that don’t respond to Dx: stool cx for pt’s c f/dysentery, and those that don’t respond to
abx abx
Tx: mostly Tx: mostly symptomaticsymptomatic therapy (IV hydration) therapy (IV hydration)
If high fever, or dysentery tx c Cipro (not antidiarrheals) If high fever, or dysentery tx c Cipro (not antidiarrheals)
Prevention: Prophylaxis is recommended for those with significant Prevention: Prophylaxis is recommended for those with significant
underlying ds.underlying ds.
CiproCipro
Pepto-bismol is effective, but may interfere with the absorption of other Pepto-bismol is effective, but may interfere with the absorption of other
medications (tetracycline/doxycycline) used for malaria prophylaxis, and it also medications (tetracycline/doxycycline) used for malaria prophylaxis, and it also
carries the same toxicity as other salicylates (Reyes Syndrome) and turns the carries the same toxicity as other salicylates (Reyes Syndrome) and turns the
tongue and stool black, so it is rarely used.tongue and stool black, so it is rarely used.

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General Bacterial OvergrowthGeneral Bacterial Overgrowth
TreatmentTreatment
Usually self limitingUsually self limiting
IV hydrationIV hydration
Correct the anatomic defect when possible.Correct the anatomic defect when possible.
Empiric antibiotic trial can be used as a Empiric antibiotic trial can be used as a
diagnostic and therapeutic maneuver.diagnostic and therapeutic maneuver.
Ciprofloxacin (or combo c Metronidazole)Ciprofloxacin (or combo c Metronidazole)
(However often not necessary, unless dysenteric) (However often not necessary, unless dysenteric)

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Protozoal InfectionProtozoal Infection

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Protozoal infection signs/symptomsProtozoal infection signs/symptoms
Abdominal painAbdominal pain
Wheezing or hemoptysis Wheezing or hemoptysis
due to pulmonary due to pulmonary
migration of larva migration of larva
(lofflers syndrome)(lofflers syndrome)
DermatitisDermatitis
DiarrheaDiarrhea
Dysentery Dysentery
PruritisPruritis
Rectal ProlapseRectal Prolapse
SteatorrheaSteatorrhea
Passage of parasitesPassage of parasites
Bowel obstruction (as Bowel obstruction (as
found in taenia and found in taenia and
ascarisis)ascarisis)

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Protozoal InfectionsProtozoal Infections
HistoryHistory
Travel to underdeveloped Travel to underdeveloped
areasareas
Outbreak of associated Outbreak of associated
illness (Giardia, illness (Giardia,
Trichinella)Trichinella)
Daycare exposure Daycare exposure
(Giardia)(Giardia)
Homosexual behavior Homosexual behavior
(Giardia, Entamoebia)(Giardia, Entamoebia)
Animal ExposureAnimal Exposure
Diet: uncooked foodsDiet: uncooked foods
ImmunocompromisedImmunocompromised
Physical FindingsPhysical Findings
Weight lossWeight loss
Excessive gas or Excessive gas or
abdominal distentionabdominal distention
HyperperistalsisHyperperistalsis
Perianal infectionPerianal infection
WheezingWheezing

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Protozoal InfectionsProtozoal Infections
TestsTests
Fecal smears (look for Fecal smears (look for
WBC’s, RBC’s, WBC’s, RBC’s, ova & ova &
parasites)parasites)
Stool CulturesStool Cultures
CBC: CBC: eosinophiliaeosinophilia, iron , iron
deficiencydeficiency
Graham’s Test: scotch Graham’s Test: scotch
tape testtape test
TreatmentTreatment
Donnagel Donnagel
KaopectateKaopectate
ImmodiumImmodium
Bismuth SubsalicylateBismuth Subsalicylate
Chemotherapeutic agents Chemotherapeutic agents
for each parasitefor each parasite

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PinwormsPinworms
Etiology: Enterobius VermicularisEtiology: Enterobius Vermicularis
Outbreaks Outbreaks common in schoolscommon in schools
Transmission by fecal-oral ingestionTransmission by fecal-oral ingestion
Key symptom is Key symptom is rectal pruritisrectal pruritis
NocturnalNocturnal
Test is Test is scotch tape testscotch tape test
Treatment: Treatment: VermoxVermox, Antiminth (one dose, then , Antiminth (one dose, then
repeat in one week)repeat in one week)

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Giardia (Giardiasis)Giardia (Giardiasis)
Etiology: Etiology: Giardia LambliaGiardia Lamblia
Transmitted: fecal-oralTransmitted: fecal-oral
Most commonMost common water borne infectionwater borne infection
Symptoms: Symptoms:
DiarrheaDiarrhea
Abd. Pain & crampsAbd. Pain & cramps
FlatusFlatus
Fatty, greasy, foul smelling stool (steatorrhea)Fatty, greasy, foul smelling stool (steatorrhea)
Test: Microscopic exam of stool for cysts (also the Test: Microscopic exam of stool for cysts (also the
ELISA antigen test)ELISA antigen test)
It is an upper GI parasite and stool examination can be It is an upper GI parasite and stool examination can be
negativenegative
Treatment: Treatment: Metronidazole (Flagyl)Metronidazole (Flagyl)

33. 12/03/09 33
AmebiasisAmebiasis
Etiology: Entamoeba hitolyticaEtiology: Entamoeba hitolytica
Found in 4% of the populationFound in 4% of the population
Transmitted: fecal-oralTransmitted: fecal-oral
Found mostly in cecum & ascending colon, invading Found mostly in cecum & ascending colon, invading
the mucosa. Can travel to liver, lung, brainthe mucosa. Can travel to liver, lung, brain
Symptoms: Symptoms:
Asymptomatic to diarrheaAsymptomatic to diarrhea
Abd. CrampsAbd. Cramps
Flatus, fever, hepatitisFlatus, fever, hepatitis
Shoulder pain due to hepatitisShoulder pain due to hepatitis

34. 12/03/09 34
Amebiasis (cont.)Amebiasis (cont.)
Signs: rangeSigns: range
No symptoms – no signsNo symptoms – no signs
Bloody diarrheaBloody diarrhea
Perianal ulcersPerianal ulcers
RUQ tendernessRUQ tenderness
Pulmonary (pneumonia- emphysema)Pulmonary (pneumonia- emphysema)
Test: Test:
Examine stool for cyst –trophozoitesExamine stool for cyst –trophozoites
Treatment:Treatment:
Metronidazole (Flagyl)Metronidazole (Flagyl)

35. 12/03/09 35
AscariasisAscariasis
Most common intestinal helminthMost common intestinal helminth
Etiology: Ascaris lumbricoides (the large intestine Etiology: Ascaris lumbricoides (the large intestine
round worm)round worm)
Transmitted by contaminated food Transmitted by contaminated food
Human feces as fertilizerHuman feces as fertilizer
Pulmonary phase (Loffler’s syndrome)Pulmonary phase (Loffler’s syndrome)
Intestinal phase (eggs in stool)Intestinal phase (eggs in stool)
Penetrate the intestine & invade liver, lung, heartPenetrate the intestine & invade liver, lung, heart
Tx: Albendazole and Pyrantel pamoateTx: Albendazole and Pyrantel pamoate

36. 12/03/09 36
TapewormsTapeworms
Cestodes (segmented worms)Cestodes (segmented worms)
Taenia soliumTaenia solium
Adults live in GI tract, larvae can be found in almost Adults live in GI tract, larvae can be found in almost
any organ (neuro, muscle, eye) any organ (neuro, muscle, eye) (cysticercosis )(cysticercosis )
Fish, beef, pork, dog , cats, fleas, snakes, birds, and Fish, beef, pork, dog , cats, fleas, snakes, birds, and
other mammals can carry the tapeworm larva, humans other mammals can carry the tapeworm larva, humans
can be the definitive host or the intermediate hostcan be the definitive host or the intermediate host
From From 5mm to over 25 meters5mm to over 25 meters in length in length

37. 12/03/09 37
Whipworm (Trichuriasis)Whipworm (Trichuriasis)
Humans are the only host for this whipworm and one Humans are the only host for this whipworm and one
of the most common parasitic infections in the U.S.of the most common parasitic infections in the U.S.
The worm lives in the cecum and appendixThe worm lives in the cecum and appendix
One female produces several thousand eggs/dayOne female produces several thousand eggs/day
Fecal-oral transm., uncooked veggies, & waterFecal-oral transm., uncooked veggies, & water
Symptoms: allergic rxns, anemia, vague GI complaints, Symptoms: allergic rxns, anemia, vague GI complaints,
diarrhea & abd. distentiondiarrhea & abd. distention
Diagnosis: stool examinationDiagnosis: stool examination
Tx: Albendazole, MebendazoleTx: Albendazole, Mebendazole

38. 12/03/09 38
DiarrheaDiarrhea

39. 12/03/09 39
DiarrheaDiarrhea
Diarrhea is both a symptom and a sign.Diarrhea is both a symptom and a sign.
SymptomSymptom: Typically considered as an increased : Typically considered as an increased
frequency or volume of stool (i.e., frequency or volume of stool (i.e., 3 or more 3 or more
liquid or semisolid stools dailyliquid or semisolid stools daily for at least 2-3 for at least 2-3
consecutive days).consecutive days).
SignSign: Diarrhea is formally defined as : Diarrhea is formally defined as stool stool
weight >200 g/24h.weight >200 g/24h.

40. 12/03/09 40
DiarrheaDiarrhea
Causes of diarrheaCauses of diarrhea
PsychogenicPsychogenic
SurgicalSurgical
EndocrineEndocrine
Carcinoid tumorsCarcinoid tumors
MechanicalMechanical
NeoplasmNeoplasm
Foreign bodyForeign body
Chemical Chemical
BacterialBacterial
ParasiticParasitic
Saline CatharticsSaline Cathartics
DietaryDietary
AllergicAllergic
MalabsorptionMalabsorption
Tropical sprueTropical sprue
Celiac ds.Celiac ds.
Whipple’s ds.Whipple’s ds.

41. 12/03/09 41
DiarrheaDiarrhea
Acute vs. ChronicAcute vs. Chronic
Acute DiarrheaAcute Diarrhea
Present for Present for less than 2 weeksless than 2 weeks & is usually due to: & is usually due to:
Infectious agent (most common cause) (usually from fecal-oral)Infectious agent (most common cause) (usually from fecal-oral)
Bacterial toxinBacterial toxin
DrugsDrugs
Types of Acute DiarrheaTypes of Acute Diarrhea
Non-inflammatoryNon-inflammatory
InflammatoryInflammatory

42. 12/03/09 42
Acute DiarrheaAcute Diarrhea
Non-inflammatoryNon-inflammatory
WateryWatery
NonbloodyNonbloody
Abd. CrampsAbd. Cramps
BloatingBloating
Nausea-vomitingNausea-vomiting
All of these suggest a small All of these suggest a small
bowel enteritis that disrupts bowel enteritis that disrupts
the normal absorption & the normal absorption &
secretorysecretory process of the process of the
small bowelsmall bowel
The diarrhea can be The diarrhea can be
voluminousvoluminous & cause & cause
electrolyte imbalance.electrolyte imbalance.
InflammatoryInflammatory
FeverFever
Bloody diarrhea (dysentery)Bloody diarrhea (dysentery)
This indicates colonic tissue This indicates colonic tissue
damage caused by invasion damage caused by invasion
of:of:
Bacteria (infectious process)Bacteria (infectious process)
ToxinsToxins
These organisms that are These organisms that are
different from the non-different from the non-
inflammatory organisms inflammatory organisms
involve the involve the coloncolon & the & the
diarrhea is diarrhea is smaller volumesmaller volume
& associated with LLQ pain& associated with LLQ pain
Fecal Leukocytes (WBC’s) can Fecal Leukocytes (WBC’s) can
be presentbe present
Pearl:Don’t give anti-diarrhealsPearl:Don’t give anti-diarrheals

43. 12/03/09 43
Causes of acute diarrheaCauses of acute diarrhea
Non-inflammatory Non-inflammatory
ViralViral
Norwalk virusNorwalk virus
RotavirusRotavirus
ProtozoalProtozoal
Giardia lambliaGiardia lamblia
CryptosporidiumCryptosporidium
BacterialBacterial
Preformed enterotoxinPreformed enterotoxin
Staphylococcus aureusStaphylococcus aureus
Bacillus cereusBacillus cereus
Clostridium perfingensClostridium perfingens
Intra-intestinal Intra-intestinal
enterotoxin productionenterotoxin production
E coli (enterotoxigenic)E coli (enterotoxigenic)
Vibrio choleraVibrio cholera
New MedicationNew Medication
Including Antibiotic useIncluding Antibiotic use
C. difficile C. difficile
severe cases causing severe cases causing
pseudomembranous colitispseudomembranous colitis
Laxative useLaxative use
Fecal ImpactionFecal Impaction
Pancreatic InsufficiencyPancreatic Insufficiency
MalabsorptionMalabsorption

44. 12/03/09 44
Causes of acute diarrheaCauses of acute diarrhea
InflammatoryInflammatory
ViralViral
CytomegalovirusCytomegalovirus
BacterialBacterial
Cytotoxin productionCytotoxin production
E coli (Enterohemorrhagic)E coli (Enterohemorrhagic)
Vibrio parahaemolyticusVibrio parahaemolyticus
Clostridium difficileClostridium difficile
Mucosal InvasionMucosal Invasion
ShigellaShigella
Salmonella sp.Salmonella sp.
Enteroinvasive E coliEnteroinvasive E coli
AeromonasAeromonas
Yersinia enterocoliticaYersinia enterocolitica
Plasmodium (Malaria)Plasmodium (Malaria)
Bacterial ProctitisBacterial Proctitis
ChlamydiaChlamydia
N. gonorrhoeaeN. gonorrhoeae
ProtozoalProtozoal
Entamoeba histolyticaEntamoeba histolytica
Intestinal ischemiaIntestinal ischemia
Inflammatory bowel diseaseInflammatory bowel disease
Radiation ColitisRadiation Colitis

45. 12/03/09 45
Diarrhea HistoryDiarrhea History
OnsetOnset
DurationDuration
Severity (fever, bloody, abd. Severity (fever, bloody, abd.
Pain)Pain)
TravelTravel
Food ingestionFood ingestion
Exposure to sick contactsExposure to sick contacts
SocialSocial
MedicationsMedications
FH of Crohn’s ds. or UCFH of Crohn’s ds. or UC
Diarrhea-constipation Diarrhea-constipation
suggest IBSsuggest IBS
Excessive flatus c diarrhea Excessive flatus c diarrhea
indicates CHO diarrhea indicates CHO diarrhea
which ceases c fastingwhich ceases c fasting
Nocturnal diarrhea indicates Nocturnal diarrhea indicates
autonomic neuropathy or autonomic neuropathy or
anal sphincter ds.anal sphincter ds.
Large volumes indicate sm. Large volumes indicate sm.
BowelBowel
Small volumes are usually left Small volumes are usually left
colon c tensmuscolon c tensmus
Associated c arthritis Associated c arthritis
consider Whipples or IBDconsider Whipples or IBD

46. 12/03/09 46
Physical ExaminationPhysical Examination
Appearance and mental statusAppearance and mental status
Mucous membranes and skin turgorMucous membranes and skin turgor
BP (hypotension)BP (hypotension)
ScarsScars
Abdominal ExamAbdominal Exam
Peritoneal signsPeritoneal signs
Localized tendernessLocalized tenderness
MassesMasses
Bruits-carcinoids &/or renal artery stenosisBruits-carcinoids &/or renal artery stenosis
Rectal exam is neededRectal exam is needed
Sphincter tone- Neurogenic ->DMSphincter tone- Neurogenic ->DM
Blood on stool & appearanceBlood on stool & appearance

47. 12/03/09 47
Diagnostic Studies for Acute Diagnostic Studies for Acute
DiarrheaDiarrhea
Stool exam for blood or WBC’sStool exam for blood or WBC’s
In any patient with fever, abd pain, tenesmus, dehydration, & diarrhea >3 In any patient with fever, abd pain, tenesmus, dehydration, & diarrhea >3
daysdays
Stool cultureStool culture
On all those with WBC’s and blood, mucous in stool with fever, abd pain On all those with WBC’s and blood, mucous in stool with fever, abd pain
(rectal swab if no stool present)(rectal swab if no stool present)
Stool for Ova & ParasitesStool for Ova & Parasites
For severe or persistent diarrhea (if + do HIV test)For severe or persistent diarrhea (if + do HIV test)
Blood testBlood test
CBC c eosinophil count, Electrolytes, calcium, glucose, blood cultures for CBC c eosinophil count, Electrolytes, calcium, glucose, blood cultures for
high fevers, HIV, Vit B12 depending on symptoms and character of high fevers, HIV, Vit B12 depending on symptoms and character of
diarrheadiarrhea
ELISA ELISA
For Giardi lamblia (ameba titers), E. coli, C. Difficile (as a cause of For Giardi lamblia (ameba titers), E. coli, C. Difficile (as a cause of
pseudomembranous colitis) if from day care center, or loosing weight, pseudomembranous colitis) if from day care center, or loosing weight,
traveling, HIV for immunosuppresed.traveling, HIV for immunosuppresed.

48. 12/03/09 48
Management issuesManagement issues
Watch for dehydration and check for electrolyte disturbances Watch for dehydration and check for electrolyte disturbances
(metabolic acidosis, hypokalemia), a common and preventable (metabolic acidosis, hypokalemia), a common and preventable
cause of death in underdeveloped areas.cause of death in underdeveloped areas.
Do a rectal exam, check for occult blood in stool, and examine Do a rectal exam, check for occult blood in stool, and examine
stool for bacteria, ova and parasites, fat content (steatorrhea), stool for bacteria, ova and parasites, fat content (steatorrhea),
and WBC’sand WBC’s
If the cause is not obvious, a trial of NPO status is helpful to see If the cause is not obvious, a trial of NPO status is helpful to see
if the diarrhea stops.if the diarrhea stops.
If the pt has a h/o antibiotic usage c in 2 wks think If the pt has a h/o antibiotic usage c in 2 wks think Clostridium Clostridium
difficiledifficile and test the stool for toxin. If the test is positive, treat and test the stool for toxin. If the test is positive, treat
with metronidazole (or vancomycin).with metronidazole (or vancomycin).
Remember DM (diabetic diarrhea), factitious diarrhea (secret Remember DM (diabetic diarrhea), factitious diarrhea (secret
laxative abuse), hyperthyroidism, and colorectal cancer as causes laxative abuse), hyperthyroidism, and colorectal cancer as causes
of diarrhea.of diarrhea.

49. 12/03/09 49
TreatmentTreatment
Supportive therapy is sufficient for Supportive therapy is sufficient for
most patients with viral or bacterial most patients with viral or bacterial
diarrheadiarrhea
Antibiotics may be indicated for Antibiotics may be indicated for
patients with severe diarrhea and patients with severe diarrhea and
systemic symptoms (e.g., systemic symptoms (e.g., Shigella, Shigella,
Campylobacter, Campylobacter, severe cases ofsevere cases of C. C.
difficiledifficile).).
Treatment of the underlying cause is Treatment of the underlying cause is
required for noninfectious diarrhea. required for noninfectious diarrhea.

50. 12/03/09 50
Treatment for acute diarrheaTreatment for acute diarrhea
1. Nonspecific Antidiarrheals1. Nonspecific Antidiarrheals
These are overusedThese are overused
Unnecessary in most cases of diarrheaUnnecessary in most cases of diarrhea
In chronic diarrhea they are not a substitute for In chronic diarrhea they are not a substitute for
treatment of the underlying pathology.treatment of the underlying pathology.
Examples-Examples-
ParegoricParegoric
Loperamide Loperamide (Imodium(Imodium))
Diphenoxylate Diphenoxylate (Lomotil(Lomotil) has some atropine also) has some atropine also
****These agents may cause Toxic Megacolon with These agents may cause Toxic Megacolon with
patients that have invasive infectionspatients that have invasive infections

51. 12/03/09 51
Treatment for acute diarrhea (cont.)Treatment for acute diarrhea (cont.)
2. Bulk forming agents2. Bulk forming agents
3. Absorbents:3. Absorbents:
Kaopectate after each BMKaopectate after each BM
Aluminum HydroxideAluminum Hydroxide
4. Opiod Agents: should be used cautiously in patients 4. Opiod Agents: should be used cautiously in patients
with asthma, COPD, prostatic hypertophy, and acute with asthma, COPD, prostatic hypertophy, and acute
angle closure glaucoma.angle closure glaucoma.
Paregoric (tinc of opium) (after each BM)Paregoric (tinc of opium) (after each BM)
Codeine Codeine
Diphenoxylate (a meperidine conger) Contraindicated in liver Diphenoxylate (a meperidine conger) Contraindicated in liver
ds. ds.
**Do not use if there is fever, bloody diarrhea, or any **Do not use if there is fever, bloody diarrhea, or any
evidence of toxicity!!**evidence of toxicity!!**

52. 12/03/09 52
Treatment for acute diarrheaTreatment for acute diarrhea
5. Antisecretory agents:5. Antisecretory agents:
Bismuth Subsalicylate (Pepto-Bismol)Bismuth Subsalicylate (Pepto-Bismol)
6. Anticholinergics: (offer no value)6. Anticholinergics: (offer no value)
7. Antimicrobial agents:7. Antimicrobial agents:
**Do stool cultures first**Do stool cultures first
Ova and Parasite studiesOva and Parasite studies
8. Somatostatin: used in severe diarrhea which is 8. Somatostatin: used in severe diarrhea which is
refractory to any therapy. Used in carcinoid refractory to any therapy. Used in carcinoid
syndrome or VIPomas. (IV or SC.)syndrome or VIPomas. (IV or SC.)

53. 12/03/09 53
Treatment for acute diarrheaTreatment for acute diarrhea
9. Special Therapies:9. Special Therapies:
Clonidine is used for withdrawal of diarrhea in Clonidine is used for withdrawal of diarrhea in
patient on opiates (usually used for HTN)patient on opiates (usually used for HTN)
Indocin is used for patients with radiation enteritis (a Indocin is used for patients with radiation enteritis (a
prostaglandin inhibitor)prostaglandin inhibitor)
Traveler’s Diarrhea (all started one week prior or 2 Traveler’s Diarrhea (all started one week prior or 2
days post travel)days post travel)
Pepto-BismolPepto-Bismol
Tetracycline/ DoxycyclineTetracycline/ Doxycycline
BactrimBactrim

54. 12/03/09 54
Chronic DiarrheaChronic Diarrhea
Diarrhea >2-3 weeks, and usually progressively Diarrhea >2-3 weeks, and usually progressively
debilitatingdebilitating
The goal for chronic diarrhea is to make the dx The goal for chronic diarrhea is to make the dx
quicklyquickly
80% diagnosed by H&P80% diagnosed by H&P

55. 12/03/09 55
Mechanisms of Chronic DiarrheaMechanisms of Chronic Diarrhea
1. 1. Osmotic loadOsmotic load: increase in amounts of poorly : increase in amounts of poorly
absorbable osmotic active solutes in the gut of the absorbable osmotic active solutes in the gut of the
lumen.lumen.
Examples:Examples:
#1 #1 Lactose intoleranceLactose intolerance
#2 Milk of magnesia#2 Milk of magnesia
Infectious gastroenteritisInfectious gastroenteritis
LactuloseLactulose
2. Excessive secretion (2. Excessive secretion (secretorysecretory): increase CL & H2O ): increase CL & H2O
w/o sodium resorption:w/o sodium resorption:
Examples:Examples:
Zollinger Ellison syndromeZollinger Ellison syndrome
Seratonins (carcinoid)Seratonins (carcinoid)
Staph toxinStaph toxin

56. 12/03/09 56
Mechanisms of Chronic Diarrhea Mechanisms of Chronic Diarrhea
(cont.)(cont.)
3. Exudation of protein (3. Exudation of protein (InflammatoryInflammatory))
Idiopathic (Crohn’s ds.)Idiopathic (Crohn’s ds.)
Infectious (Shigella, Salmonella, Campylobacter)Infectious (Shigella, Salmonella, Campylobacter)
IschemicIschemic
Vasculitis (blood & mucous in stool)Vasculitis (blood & mucous in stool)
4. Altered intestinal 4. Altered intestinal MotilityMotility (Irritable bowel (Irritable bowel
syndrome)syndrome)

57. 12/03/09 57
Screening test for chronic diarrheaScreening test for chronic diarrhea
BloodBlood
CBCCBC
Sedimentation rateSedimentation rate
AlbuminAlbumin
ElectrolytesElectrolytes
Prothrombin time Prothrombin time
(malabsorption) (malabsorption)
Alkaline phosphataseAlkaline phosphatase
Serum Iron (Fe)Serum Iron (Fe)
Folate & Vitamin B12 Folate & Vitamin B12
(c diarrhea and alt. (c diarrhea and alt.
Mental Mental
status)status)
CaroteneCarotene
StoolStool
Appearance of stoolAppearance of stool
Occult blood testOccult blood test
Ova-ParasitesOva-Parasites
Stool fat Stool fat
Proctoscopy with biopsyProctoscopy with biopsy

58. 12/03/09 58
Treatment for chronic diarrheaTreatment for chronic diarrhea
ParegoricParegoric
ImodiumImodium
LobitolLobitol
MetamucilMetamucil
KaopectateKaopectate
AmphigelAmphigel
**Note in infectious diarrhea **Note in infectious diarrhea  slowing motility slowing motility
can cause Toxic Megacoloncan cause Toxic Megacolon death from death from
necrosis of bowel.necrosis of bowel.

59. 12/03/09 59
Diarrhea TypesDiarrhea Types
SecretorySecretory
Bowel secretes fluid b/c of bacterial Bowel secretes fluid b/c of bacterial
toxinstoxins
Large volume watery stoolsLarge volume watery stools
Danger of dehydrationDanger of dehydration
Persists with fastingPersists with fasting
CholeraCholera
Some strains of E coliSome strains of E coli
Ileal resection (bile acids)Ileal resection (bile acids)
CarcinoidCarcinoid
VIP secreting tumors (pancreatic islet VIP secreting tumors (pancreatic islet
cell tumor)cell tumor)
OsmoticOsmotic
Non absorbable solutes remain in the Non absorbable solutes remain in the
bowel, where they retain waterbowel, where they retain water
Bulky, greasy stoolsBulky, greasy stools
Improves with fastingImproves with fasting
Lactase deficiencyLactase deficiency
Pancreatic insufficiencyPancreatic insufficiency
Short bowel syndromeShort bowel syndrome
InflammatoryInflammatory
Frequent but small stoolsFrequent but small stools
Blood and/or pusBlood and/or pus
Inflammatory bowel dsInflammatory bowel ds
IrradiationIrradiation
Shigella, amebiasisShigella, amebiasis
DysmotilityDysmotility
Diarrhea alternating with Diarrhea alternating with
constipationconstipation
Irritable bowel syndromeIrritable bowel syndrome
Diabetes mellitusDiabetes mellitus

60. 12/03/09 60
Chronic Diarrhea ClassificationChronic Diarrhea Classification
InflammatoryInflammatory- Inflammatory bowel ds., radiation colitis- Inflammatory bowel ds., radiation colitis
SystemicSystemic- any illness can cause diarrhea as a systemic - any illness can cause diarrhea as a systemic
symptom (hyperthyroid, zollinger-ellison, flu)symptom (hyperthyroid, zollinger-ellison, flu)
OsmoticOsmotic- nonabsorbable solutes remain in the bowel, where - nonabsorbable solutes remain in the bowel, where
they retain water (e.g. lactose or other sugar intolerances). they retain water (e.g. lactose or other sugar intolerances).
When the person stops eating the offending substances NPO, When the person stops eating the offending substances NPO,
the diarrhea stops.the diarrhea stops.
SecretorySecretory- bowel secretes fluid b/c of bacterial toxins - bowel secretes fluid b/c of bacterial toxins
(cholera, some strains of E coli), VIPoma (pancreatic islet cell (cholera, some strains of E coli), VIPoma (pancreatic islet cell
tumor), or bile acids (p ileal resection). Diarrhea continues tumor), or bile acids (p ileal resection). Diarrhea continues
with NPO status.with NPO status.
MalabsoptionMalabsoption- (e.g., celiac sprue, Crohn’s ds.) In pt’s c celiac - (e.g., celiac sprue, Crohn’s ds.) In pt’s c celiac
sprue, look for dermatitis herpetiformis, and stop gluten in sprue, look for dermatitis herpetiformis, and stop gluten in
the diet. Diarrhea stops c NPO.the diet. Diarrhea stops c NPO.
ExudativeExudative- inflammation in bowel mucosa causes seepage - inflammation in bowel mucosa causes seepage
of fluid; classically from inflammatory bowel ds. or cancerof fluid; classically from inflammatory bowel ds. or cancer
Altered Intestinal Motility-Altered Intestinal Motility- after bowel resection or after bowel resection or
medications that interfere with bowel functionmedications that interfere with bowel function
FactitiousFactitious- secret laxative abuse (often by medical personnel)- secret laxative abuse (often by medical personnel)

61. 12/03/09 61
Chronic DiarrheaChronic Diarrhea
Chronic diarrhea or recurrent diarrhea should be based Chronic diarrhea or recurrent diarrhea should be based
on etiology & pathophysiology of the disease process.on etiology & pathophysiology of the disease process.
When there is difficulty in making the diagnosis an When there is difficulty in making the diagnosis an
empiric empiric trial of diet restrictiontrial of diet restriction is necessary. is necessary.
LactoseLactose
Gluten (protein in breads)Gluten (protein in breads)
Reduction of long chain fatty acidsReduction of long chain fatty acids
Use of pancreatic enzymesUse of pancreatic enzymes
MetronidazoleMetronidazole
When all else fails use opiatesWhen all else fails use opiates

62. 12/03/09 62
Pearls/ ReviewPearls/ Review
Antidiarrheals often unnecessary (opiods: Antidiarrheals often unnecessary (opiods:
loperamide) b/c they may actually prolong loperamide) b/c they may actually prolong
Salmonella or Shigella infection!Salmonella or Shigella infection!
If chronic or patient very ill (fever, bloody If chronic or patient very ill (fever, bloody
diarrhea): get stool exam for WBC’s, diarrhea): get stool exam for WBC’s,
O&P’s, stool cx, C. difficile toxin and O&P’s, stool cx, C. difficile toxin and
LFT’s.LFT’s.

63. 12/03/09 63
Pearls (cont.)Pearls (cont.)
AID’s patients: diarrhea is often due to AID’s patients: diarrhea is often due to
Cryptosporidium, Isospora or CMVCryptosporidium, Isospora or CMV
Diarrhea of any cause may lead to transient Diarrhea of any cause may lead to transient
lactase deficiency (advise patient to avoid lactase deficiency (advise patient to avoid
milk)milk)
Bismuth subsalicylate (Pepto-Bismol) may Bismuth subsalicylate (Pepto-Bismol) may
prevent infection with enterotoxin producing prevent infection with enterotoxin producing
E. coli. Great for travelers to exotic E. coli. Great for travelers to exotic
countries.countries.

64. 12/03/09 64
PearlsPearls
Diarrhea in elderly patients can indicate an Diarrhea in elderly patients can indicate an
obstruction or fecal impaction.obstruction or fecal impaction.
Acute Diarrhea: Lg amts. of stoolAcute Diarrhea: Lg amts. of stool Small bowel Small bowel
Sm amts. of stoolSm amts. of stool Lg bowel Lg bowel
Gastroenteritis symptomsGastroenteritis symptoms#1. abd. pain #1. abd. pain
#2. #2.
diameterdiameter
Celiac sprueCeliac sprue Gluten sensative enteropathy Gluten sensative enteropathy
proximal small bowelproximal small bowel

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In >90% of cases, acute diarrhea is mild and In >90% of cases, acute diarrhea is mild and
self-limiting, and diagnostic investigation is self-limiting, and diagnostic investigation is
unnecessary.unnecessary.
Prompt sigmoidoscopy for severe proctitis Prompt sigmoidoscopy for severe proctitis
(tenesmus, discharge, rectal pain) or suspected (tenesmus, discharge, rectal pain) or suspected
C. difficile colitis, ulcerative colitis, or ischemic C. difficile colitis, ulcerative colitis, or ischemic
colitiscolitis
When traveling 4 “P’s”, Pepto-bismol, and eat When traveling 4 “P’s”, Pepto-bismol, and eat
only peeled, packaged, and piping hot foods.only peeled, packaged, and piping hot foods.

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Infectious: noninflammatory (nonbloody)Infectious: noninflammatory (nonbloody)
Viruses: Norwalk virus, rotavirus, adenoviruses, Viruses: Norwalk virus, rotavirus, adenoviruses,
astrovirus, coronavirus astrovirus, coronavirus
Preformed toxin (food poisoning): Preformed toxin (food poisoning): Staphylococcus Staphylococcus
aureusaureus, , Bacillus cereusBacillus cereus, , Clostridium perfringensClostridium perfringens
Toxin production: enterotoxigenic Toxin production: enterotoxigenic E. coliE. coli, , Vibrio Vibrio
choleraecholerae, , Vibrio parahaemolyticusVibrio parahaemolyticus
Protozoa: Protozoa: Giardia lambliaGiardia lamblia, , CryptosporidiumCryptosporidium, ,
CyclosporaCyclospora, , IsosporaIsospora

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Infectious: invasive or inflammatoryInfectious: invasive or inflammatory
ShigellaShigella, , SalmonellaSalmonella, , CampylobacterCampylobacter, enteroinvasive , enteroinvasive
E. coliE. coli, , E. coli E. coli O157:H7, O157:H7, Yersinia enterocoliticaYersinia enterocolitica, ,
Clostridium difficile Clostridium difficile (e.g., pseudomembranous (e.g., pseudomembranous
colitis), colitis), Entamoeba histolyticaEntamoeba histolytica, , Neisseria gonorrhoeaeNeisseria gonorrhoeae, ,
Listeria monocytogenesListeria monocytogenes

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Bloody Diarrhea DDxBloody Diarrhea DDx
ShigellaShigella, ,
SalmonellaSalmonella, ,
CampylobacterCampylobacter, ,
enteroinvasive enteroinvasive E. coliE. coli, (, (E. coli E. coli O157:H7), O157:H7),
Yersinia enterocoliticaYersinia enterocolitica, ,