Acute diarrhea: Difference between revisions

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== Definitions ==
== Definitions ==
 
#Diarrhea: 3 or more stools per day; assumes shape of container
Diarrhea: 3 or more stools per day; assumes shape of container
#Hyperacute: 1-6 hours
 
#Acute: less than 2 weeks in duration
Hyperacute: 1-6 hours
#Gastroenteritis: diarrhea with nausea and or vomiting
 
#Dysentery: Diarrhea with blood/mucus/pus
Acute: less than 2 weeks in duration
#Invasive=Infectious
 
Gastroenteritis: diarrhea with nausea and or vomiting
 
Dysentery: Diarrhea with blood/mucus/pus
 
Invasive=Infectious


== Diagnosis ==
== Diagnosis ==
=== Emergent Causes ===
=== Emergent Causes ===
 
#Appendicitis
1) Appendicitis
#Mesenteric ischemia
 
#Ectopic
2) Mesenteric ischemia
#CO poisoning
 
#SAH
3) Ectopic
#Diverticultis
 
4) CO poisoning
 
5) SAH
 
6) Diverticultis


=== Questions ===
=== Questions ===
 
#Ingestions
Ingestions
#Abd pain
 
#Blood/Consistency
Abd pain
#Frequency/Quantity/Odor
 
#Tenesmus (infxs - shigella)
Blood/Consistency
#HIV/Immunocomp/Sexual hx
 
#Recent Abx (<30 dys), PPI
Frequency/Quantity/Odor
#Recent travel
 
#Timing: Chronic (>1mo) vs. acute (<2wk)
Tenesmus (infxs - shigella)
#Chemo
 
HIV/Immunocomp/Sexual hx
 
Recent Abx (<30 dys), PPI
 
Recent travel
 
Timing: Chronic (>1mo) vs. acute (<2wk)
 
Chemo


== Toxigenic v. Infectious ==
== Toxigenic v. Infectious ==
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== W/U ==
==Work Up==
 
#Toxigenic:Nothing
Toxigenic:Nothing
#Invasive:
 
##Stool Cx
Invasive:
###Additional Cx: E.Coli 0157:H7
 
#C. dif toxin
Stool Cx
#Sool O&P
 
###only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised
-Additional Cx: E.Coli 0157:H7
#Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)
 
C. dif toxin
 
Sool O&P
 
-only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised
 
Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)


== Treatment ==
== Treatment ==
=== Toxigenic ===
=== Toxigenic ===
 
#Rehydrate with fluids containing sugar, salt, fluids po, IV NS
Rehydrate with fluids containing sugar, salt, fluids po, IV NS
#Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)
 
#Eat! - BRAT diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery
Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)
#Analgesia as needed
 
#Anti-diarrheals
Eat! - BRAT diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery
#Kaolin-pectin agents
 
#Bismuth
Analgesia as needed
#Antimotility (avoid ''alone'' in invasive illness)
 
Anti-diarrheals
 
Kaolin-pectin agents
 
Bismuth
 
Antimotility (avoid ''alone'' in invasive illness)


=== Infectious ===
=== Infectious ===
'''Above plus:'''
'''Above plus:'''
 
#Antibiotics
Ciprofloxacin 500mg po bid or
##Ciprofloxacin 500mg po bid or
 
##Levofloxacin 500mg po qd or
Levofloxacin 500mg po qd or
##Bactrim DS 1tab po bid (+/-)
 
#3-7d treatment
Bactrim DS 1tab po bid (+/-)
 
3-7d treatment


==== Empiric Abx ====
==== Empiric Abx ====
 
#Toxic appearance
1) Toxic appearance
#Vital abnl
 
#Fever >39
2) Vital abnl
#Bloody diarrhea
 
#Severe dehydration
3) Fever >39
 
4) Bloody diarrhea
 
5) Severe dehydration


=== Loperimide Contraindications ===
=== Loperimide Contraindications ===
 
#Pediatric
1) Pediatric
#IBD
 
#C. Diff
2) IBD
#Dysentery
 
3) C. Diff
 
4) Dysentery


(always give with abx)
(always give with abx)


=== WHO Oral Rehydration ===
=== WHO Oral Rehydration ===
 
#1 cup orange juice
1 cup orange juice
#4 tsp sugar
 
#1 tsp baking powder
4 tsp sugar
#3/4 tsp salt
 
#in 1 liter of H2O
1tsp baking powder
 
3/4 tsp salt
 
in 1 liter of H2O


=== Other ===
=== Other ===
Octreotide can be used in AIDS-associated diarrhea unresponsive to loperimide


*Octreotide can be used in AIDS-associated diarrhea unresponsive to loperimide
Consider Pepto-Bismol for traveler's diarrhea (contraindicated in HIV-->encephalopathy)
 
*Consider Pepto-Bismol for traveler's diarrhea (contraindicated in HIV-->encephalopathy)


== Source ==
== Source ==
3/12/06 DONALDSON (adapted from Rosen); 09 Birnbaumer
3/12/06 DONALDSON (adapted from Rosen); 09 Birnbaumer


<br/>[[Category:GI]]
[[Category:GI]]
[[Category:ID]]

Revision as of 05:44, 14 March 2011

Definitions

  1. Diarrhea: 3 or more stools per day; assumes shape of container
  2. Hyperacute: 1-6 hours
  3. Acute: less than 2 weeks in duration
  4. Gastroenteritis: diarrhea with nausea and or vomiting
  5. Dysentery: Diarrhea with blood/mucus/pus
  6. Invasive=Infectious

Diagnosis

Emergent Causes

  1. Appendicitis
  2. Mesenteric ischemia
  3. Ectopic
  4. CO poisoning
  5. SAH
  6. Diverticultis

Questions

  1. Ingestions
  2. Abd pain
  3. Blood/Consistency
  4. Frequency/Quantity/Odor
  5. Tenesmus (infxs - shigella)
  6. HIV/Immunocomp/Sexual hx
  7. Recent Abx (<30 dys), PPI
  8. Recent travel
  9. Timing: Chronic (>1mo) vs. acute (<2wk)
  10. Chemo

Toxigenic v. Infectious

Characteristic Toxic Infectious/Invasive
Incubation 2-12h 1-3d
Onset abrupt gradual
Duration <10-24h 1-7days
Fever No Yes
Abdominal Pain Minimal Yes, tenesmus
Systemic No Yes, myalgias, N/V
Physical findings Nontoxic Toxic
Abdominal Tenderness No Yes
Stool Blood, WBCs No Yes

Work Up

  1. Toxigenic:Nothing
  2. Invasive:
    1. Stool Cx
      1. Additional Cx: E.Coli 0157:H7
  3. C. dif toxin
  4. Sool O&P
      1. only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised
  5. Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)

Treatment

Toxigenic

  1. Rehydrate with fluids containing sugar, salt, fluids po, IV NS
  2. Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)
  3. Eat! - BRAT diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery
  4. Analgesia as needed
  5. Anti-diarrheals
  6. Kaolin-pectin agents
  7. Bismuth
  8. Antimotility (avoid alone in invasive illness)

Infectious

Above plus:

  1. Antibiotics
    1. Ciprofloxacin 500mg po bid or
    2. Levofloxacin 500mg po qd or
    3. Bactrim DS 1tab po bid (+/-)
  2. 3-7d treatment

Empiric Abx

  1. Toxic appearance
  2. Vital abnl
  3. Fever >39
  4. Bloody diarrhea
  5. Severe dehydration

Loperimide Contraindications

  1. Pediatric
  2. IBD
  3. C. Diff
  4. Dysentery

(always give with abx)

WHO Oral Rehydration

  1. 1 cup orange juice
  2. 4 tsp sugar
  3. 1 tsp baking powder
  4. 3/4 tsp salt
  5. in 1 liter of H2O

Other

Octreotide can be used in AIDS-associated diarrhea unresponsive to loperimide

Consider Pepto-Bismol for traveler's diarrhea (contraindicated in HIV-->encephalopathy)

Source

3/12/06 DONALDSON (adapted from Rosen); 09 Birnbaumer

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