26. diarrhea in all patients with diarrhea, a Determine hydration status

99 Priority Topics in Family Medicine PAGE

26. DIARRHEA

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:

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  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
    
  • 
    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
  
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  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).

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  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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      Improvement with defecation
      
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      Onset associated with a change in frequency of stool
      
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      Onset associated with a change in form (appearance of stool)
      
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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
      
  • 
    in the absence of structural or metabolic abnormalities to explain the sxs
    
  • 
    “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:
  
  • 
    Stool tend to be pale, greasy, voluminous, and foul-smelling
    
  • 
    Patients typically have weight loss despite adequate food intake
    
  • 
    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
    
  • 
    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
    
  • 
    Need to monitor for cancerous changes in colon
    
  • 
    Crohn’s:
    
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      present with abdo pain, diarrhea, weight loss and fever; hemoccult positive stools are common, macroscopic bleeding less common
      
    • 
      Can get inflammation anywhere along GI tract (“from gums to bum”) in discontinuous fashion
      
    • 
      Inflammation is transmural therefore commonly get fistula formation
      
  • 
    Ulcerative colitis:
    
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      Only involves colon, always starting distally and ascends in continuous manner
      
    • 
      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.