1. In all patients with diarrhea,
a) Determine hydration status:
-heart rate, BP, orthostatic vital signs, mucous membranes, skin turgor, urine output, capillary refill time, eyes, fontanelle (peds), production tears (peds)
b) Treat dehydration appropriately.
-mild-moderate dehydration: trial of PO rehydration
-Severe or failure of PO rehdration: IV fluid therapy – NS or RL bolus
2. In patients with acute diarrhea, use history to establish the possible etiology Note: acute diarrhea is <14days duration
Infectious etiology:
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Bacterial: shigella, salmonella, campylobacter, yersinia, ecoli, clostridium, vibrio, staph aureus, bacillus cereus
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Viral: norovirus, rotavirus, adenovirus, CMV, HSV
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Parasitic: cryptosporidium, microsporidia, entamoeba histolytica, giardia lamblia, cyclospora
Medications: Antibiotics, colchicine, laxatives, magnesium containing antacids
Food Intolerance: Lactose, fructose in soft drinks, sorbital, coffee
Intestinal Diseases (acute episodes): Celiac, inflammatory bowel dz
Clues from hx regarding specific cause:
-
presence of fever, bloody diarrhea and tenesmes suggest inflammatory diarrhea (eg. Shigella, salmonella, campylobacter, c diff colitis or IBD)
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Consider norovirus with classic history of nausea, vomiting, intense cramping, and watery diarrhea that usually lasts 48-72 hrs
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Travelers diarrhea is most commonly caused by enterotoxogenic E. Coli, but still consider other causes of diarrhea and specific organisms based on area of travel
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Exposure to contaminated water or camping think of parasites (giardia, cryptosporidium and entamoeba)
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Exposure to animals: Young cats/dogs campylobacter; Turtles Salmonella
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Organisms that cause food poisonings:
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Dairy food -Campylobacter and Salmonella species; Eggs -Salmonella species
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Ground beef - Enterohemorrhagic E coli
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Poultry -Campylobacter species
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Pork -C perfringens, Y enterocolitica
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Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibrio species
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Oysters - Calicivirus and Plesiomonas and Vibrio species
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Vegetables -Aeromonas species and C perfringens
3. In patients with acute diarrhea who have had recent hospitalization or recent antibiotic use, look for clostridium difficile.
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Suspect if antibiotic use within the last 2 months or discharge from hospital within last 72 hours; can happen with almost all antibiotics (although clinda is the classical example). Presents with watery diarrhea that is rarely bloody, crampy abdo pain, malaise, fever, anorexia.
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Can lead to fulminant colitis and toxic megacolon
4. In patients with acute diarrhea, counsel about the timing of return to work/school (re: the likelihood of infectivity).
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No return to work until no diarrhea for at least 48 hours
-
Food handlers/daycare workers/health care workers may require negative stool samples on 2 occasions at least 24 hrs apart prior to returning to work to prevent outbreaks
5. Pursue investigation, in a timely manner, of elderly with unexplained diarrhea, as they are more likely to have pathology.
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Any change in bowel habit should raise possibility of colorectal cancer
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Also consider other pathology such as diverticulitis, inflammatory bowel disease, etc.
6. In a young person with chronic or recurrent diarrhea, with no red flag symptoms or signs, use established clinical criteria to make a positive diagnosis of irritable bowel syndrome (do not over investigate).
-
Red flags: fevers/chills, weight loss, bloody stool, mucousy stool, nocturnal diarrhea, large volume stool, greasy stool, FHx of IBD or cancer, anemia, persistent daily diarrhea or constipation, severe pain
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Rome III criteria:
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Recurrent abdominal pain or discomfort for at least 3 days per month in the last 3 months associated with 2 or more of the following:
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criteria fulfilled for the last 3 mths with sx onset at least 6 mths prior to dx
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Supportive sxs that are not part of the diagnostic criteria include:
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a) <3 BM/week, b) >3BM/day or abnormal stool form c) lumpy/hard stool d) loose/watery stool e) defecation straining f) urgency or feeling of incomplete bowel movement, passing mucus or bloating
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in the absence of structural or metabolic abnormalities to explain the sxs
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“discomfort” means an uncomfortable sensation not described as pain
7. In patients with chronic or recurrent diarrhea, look for both gastro-intestinal and non-gastro-intestinal symptoms and signs suggestive of specific diseases
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Malabsorption Syndrome:
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Stool tend to be pale, greasy, voluminous, and foul-smelling
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Patients typically have weight loss despite adequate food intake
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Common disorders with malabsorption include: Lactose intolerance, chronic pancreatitis, Celiac disease, Bacterial overgrowth of the small intestine
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Cholecystecomy:
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Reported in 5-12% of patients following cholecystectomy, due to excessive bile salts entering the colon
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Usually resolves spontaneously over the course of weeks to months
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Can be treated with cholestryamine
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Inflammatory Bowel Disease: crohn’s and ulcerative colitis
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Age on onset typically between 15 and 40, but may have a second peak between 50 to 80
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Extraintestinal manifestions: iritis/uveitis, arthritis, skin changes, aphthous stomatitis, nail changes, pericholangitis, and sclerosing cholangitis
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Need to monitor for cancerous changes in colon
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Crohn’s:
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present with abdo pain, diarrhea, weight loss and fever; hemoccult positive stools are common, macroscopic bleeding less common
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Can get inflammation anywhere along GI tract (“from gums to bum”) in discontinuous fashion
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Inflammation is transmural therefore commonly get fistula formation
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Ulcerative colitis:
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Only involves colon, always starting distally and ascends in continuous manner
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Variable presentation depending on extent of disease, typically presents with bloody diarrhea, fever, weight loss,
References:
Wanke, CA. (2011). Approach to the adult with acute diarrhea in developed countries. In D.S. Basow (Ed.), UpToDate. Retrieved from http://www.uptodate.com/home/index.html
Bonis, PA and LaMont, JT. (2011). Approach to the adult with chronic diarrhea in developed countries. In D.S. Basow (Ed.), UpToDate. Retrieved from http://www.uptodate.com/home/index.html
http://emedicine.medscape.com/
Aberra, FN (2011). Clostridium difficile colitis. Retrieved from http://emedicine.medscape.com/
Guandalini, A. (2010). Diarrha. Retrieved from http://emedicine.medscape.com/
Rowe. WA (2011). Inflammatory bowel disease. Retrieved from http://emedicine.medscape.com/
Therapeutic Choices Sixth edition. Ottawa, Canadian Pharmacists Association. 2011.
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