How to think about diarrhea Acute vs. Chronic The Paradigm Continued

Diarrhea: More Than You Want
to Know
David Carpenter, PAPA - C, MPAS
Arapahoe Gastroenterology
How to think about diarrhea
• Definition
• 200 g increase in stool per day
• 20 g in children
AAPA 2006
• Loose stool
• Infectious versus Other
• Travel vs Nosocomial vs Acute
Acute vs. Chronic
The Paradigm Continued
Acute
• Chronic
• Infectious
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• Bacterial
• Viral
• Parasite
• May become chronic
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> 4 weeks
Secretory
Osmotic
Functional
Medications
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Acute diarrhea
Is almost always infectious
May be acute presentation of a chronic disease
One approach
Travel history vs Nosocomial vs Other
• Infectious
• Early fever
• >6 stools per day
• Acute onset
• IBD
• Fever uncommon
• <6 stools per day
• Insidious onset
Characteristics of Infectious
Diarrhea
Colonic
• Small bowel
• Large Volume
• Small volume
• Diffuse abdominal pain
• Lower abdominal pain
• Malabsorption
and cramping
• Dehydration
• Tenesmus
• Dehydration
Infectious Diarrhea
Noninvasive Small Bowel
• Viral
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Rotavirus
Norwalk agent
Norwalk--like
Norwalk
Adenovirus
Astrovirus
• Bacterial
• Toxigenic E. coli
• Vibrio Cholera
• Parasites
• Giardia lablia
• Cryptosporidium
• Isospora belli
Infectious Diarrhea
Invasive Ileo
Ileo-- colonic
• Bacterial
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Campylobacter
Salmonella
Shigella
E. coli O157:H7
C. difficile
Yersinia
Aeromonas
Noncholera Vibrio
• Parasites
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Entamoeba histolytica
Strongyloides
Trichursis
Schistomiasis
• Viral
• CMV
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Question
In the US what are the four most common
pathogens causing bloody diarrhea?
Answer
Campylobacter
Salmonella
Shigella
E. coli 0157:H7
Campylobacter
Campylobacter jejuni
Campylobacter coli
• Progression is from
• N/V
• Watery diarrhea
• Bloody diarrhea
• Treatment
• Only valuable if early
Salmonella/Shigella
• Salmonella typhimurium
• Salmonella enteriditis
• Salmonella newport
• Causes acute ileo-colitis
• Treat only if severe
• Fever
• Toxicity
• Dysentery
• Immunosuppression
• Shigella dysenteriae
• Shigella Flexneri
• Shigella boydii sonneii
• Invasive & enterotoxin
• < 100 organism cause
disease
• Fever, watery diarrhea →
bloody
• Rx cipro - 5 days
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Types of E. coli infection
E coli 0157:H7
Enterotoxigenic Escherichia coli (ETEC)
Endemic
Traveler’s diarrhea
Brief illness (D, V, fever)
Enteropathogenic Escherichia coli (EPEC)
Small intestinal
Neonatal diarrhea (weanling)
Nosocomial
Escherichia coli O157:H7
Lessons from
Jack in the Box and Odwalla
• Inoculum is small (1(1-10 bugs)
Person to person transmission (10 – 15%)
Gastroenterologists will see patients first
- DDx
DDx:: ischemia, IBD
• Initial symptom
watery diarrhea
• Low grade fever
• Progresses to bloody
diarrhea and severe
cramping
• Incubation period 4
days (average)
• Treatment
• Avoid antidiarrheals
• Antibiotics
• Increase HUS in
children
• Does not change course
of disease
• Toxin binders being
studied
Other Entities
• Aeromonas hyrophilia • Yersinia enterocolitis
and Y
• Plesiomonas
pseudotuberculosis
shigelloides
• Usual sources
• Water/Shellfish
• Can mimic UC
• Treat if severe
• Ileitis and mesenteric
adenitis
• Chitterlings common
source
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Other Entities Continued
• Vibrio
• Listeria monocytogenes
• V. cholera
• Epidemic cholera
• V. Parhaemolyticus
• Shellfish borne
• Colonic invasion
• Self limited
• Treat if severe
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Gastroenteritis
Diarrhea and fever
Self limiting
US outbreak associated
with chocolate milk
• TB
• Usually seen in the ileo
ileo-cecal area
• Pain is the predominant
symptom
• 50% have pulmonary
symptoms also
When to get a stool culture
All bloody diarrhea
Toxic appearance
Fever
Severe abdominal pain
Possible epidemic diarrhea
Travelers Diarrhea
Immunosuppression
Any hospitalized patients
Infectious Diarrhea
Who to Treat?
• Definitely Treat
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Shigella
Cholera
Parasites
Travelers Diarrhea
Immunosuppressed
patients
• Pseudomembranous
colitis
• Probably treat
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Noncholera vibrio
Chronic yersinea
Campylobacter
Aeromonas
Plesiomonas
Enteropathic E. coli
Antibiotics in Bacterial
Diarrhea
Evidence is scant
3 RCT ’s with Cipro
When to treat
Mod – severe symptoms
Dysentery (bloody mucoid)
High fever (39° C)
↑ fecal WBC
≥ 6 stools/day
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Empiric Therapy
Which Drugs?
• Flouroquinolones (drug of choice)
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Clostridium difficile
C. difficile diagnosis and management
Enteropathogenic E. coli
Shigella
Cholera
Not for children(arthritis)
• 2nd Choice: TMP-SMX
• Caveats
• Resistant organisms
C. Dif Stool Tests
• Diagnostic endoscopy not needed
• Tissue culture - time consuming,
- expensive
• Commerical ELISAs toxin a
- good sensitivity
69 – 87%
- very good specificity 99 – 100%
• Quick – 2 hr
• No trained lab personnel needed
• Cost – relatively inexpensive
Effective Antibiotics for C.
difficile
Oral Metronidazole
205 mg qid x 10 d
Oral Vancomycin
125 mg or 250 mg qid x 10 d
Consider Rifaxamin or Bacitracin
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Parasites
Classification of Parasites
Protozoa
Helminths
Nematodes Cestodes
Trematodes
(Roundworms) (Tape worms) (Flukes)
Non-Bloody Diarrhea
Malabsorption
G. Lamblia
Crypto
I. Belli
Microsporidia sp.
Cyclospora sp.
Coccidiosis
Giardia
Strongyloides
Capillariasis
Cryptosporidia
Isospora belli
Bloody Diarrhea
Ameba
B. coli
Trichuris trichiura
Schistosome sp.
Cyclospora
(Cyanobacter
Cyanobacter/Blue
/Blue--Green Algae)
• Epidemic diarrhea
• Nepal
• Chicago
• Eastern US
• Sources
• Water borne
• Fruit (berries)
• Symptoms
• Watery diarrhea
• Fatigue
• Anorexia
• Prolonged course
• Incubation period 7
days
• 2 – 4 weeks illness
Occult Bleeding
Hookworm
Strongyloides
Giardia Diagnosis and Treatment
• Generally water borne illness
• Symptoms
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Diarrhea
Greasy stools
Crampy abdominal pain
Nausea
• Treatment Flagyl 500 mg TID x 77 - 10days
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Giardia
O&P vs ELISA
Stool O + P
50% → 75% → 95%
1
2
3
ELISA
80% → 94%
(1)
(2)
Chronic diarrhea
• Prevalence in US: 5%
• >4 wks duration
• Varying definitions:
• Abnormal frequency or consistency
• >3/day
• >200 gm/day
Acute Diarrhea Summary
• Look at history
• Hospital think C. dif
• Travel
• Other exposures
• Most self resolve
• Watch for warning signs
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Blood
Toxic appearance
Fever
Wasting
Differentiating Chronic Diarrhea
• Malabsorption
• Inflammatory
• Watery
• Secretory
• Osmotic
• IBS
• ? Fecal incontinence
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Chronic Diarrhea
• History is Key
• Associated symptoms:
• Onset: abrupt v s gradual
• Pattern: continuous vs
intermittent, ? nocturnal
• Duration
• Epidemiology: travel, food,
water
• Stool character: bloody,
watery, fatty
• wt loss, abdominal pain
• Aggravating / mitigating
factors: diet, stress, meds
• Systemic diseases: DM,
collagen-- vascular, AIDs
collagen
AIDs,,
prior surgery or radiation
Rx
Initial Evaluation
• Initial labs
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CBC
BMP
TSH
Anti--endomyosial
Anti
antibody or Tissue
Transglutaminase
• Stool giardia antigen
• Consider fecal fat
• Approaches
• Secretory
• Osmotic
• Drug induced
Stool Tests
• 72 (or 48) hr. quantitative stool: The gold
standard
• Stool wt: Normal <200 g/d
• >500 g/d
g/d:: not IBS
• >1000 g/d:
g/d: suspected endocrine neoplasm
• Stool fat: Normal 7 g/d
• Induced diarrhea: As high as 14 g/d
• Mod. fat: small bowel malabsorption
• High fat: >40 gm: pancreatic/biliary causes
• Who needs a
colonoscopy
• Age >40: Everyone
• Bloody diarrhea:
Everyone
• Age <40 / nonnon-bloody:
not needed unless
Crohn’s suspected
• Colonoscopy: Must
enter T.I. + biopsy nl
nl..
appearing colon
Malabsorption
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Celiac Disease
Pancreatic insufficiency
Short Bowel Syndrome
Whipple’s Disease
Superior Mesenteric
Artery Syndrome
• Bile Acid disorders – post
chole syndrome
• Symptoms
• Pale Bulky stools
• Frothy
• Foul odor
• Weight loss
• Resolves with two days
without eating
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Celiac Sprue
• Prevalence in US: 1:250
• Associated conditions:
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Osteoporosis, osteomalacia
Infertility, freq miscarriage
Dermatitis herpetiformis
Autoimmune: Sjogren’s, thyroid disease, type I
diabetes, Lupus
• Failure to grow in children
Celiac Sprue
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• Celia gene: neg not at risk, positive may not get
disease
• Rx: glutengluten-free diet
Pancreatic Testing
• Pancreatic Function Tests:
• Duodenal aspirate after secretin and/or CCK stim
stim..
• Technical difficulties limit accuracy
• Non
Non--invasive tests
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Fecal chymotrysin
Fecal elastase
Breath test: 14 C triolein
Bentiromide—
Bentiromide
—urinary metabolite
Anti-endomyosial
Antiendomyosial::
Sensitivity 95%
Specificity 95%
Tissue transglutamase
transglutamase::
Small bowel biopsy: Gold standard
Test 1st degree relatives: Risk 1010 - 20%
Inflammatory Diarrhea
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Inflammatory Bowel Disease
Ischemic Colitis
Radiation Colitis
Microscopic Colitis
Malignancy
• Imaging: CT, MRCP, EUS
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Inflammatory Bowel Disease
• Crohn’s
• Ulcerative Colitis
• Affects GI tract from
mouth to anus
• Bloody diarrhea
• Skip lesions on
colonoscopy
• RLQ pain
• Affects the colon only
• Continuous from
rectum
• Bloody Diarrhea
• Crampy abdominal
pain
Microscopic Colitis
• Non visible colitis of the collagen layer
• May present with blood, but frequently may
have only diarrhea as a presenting symptom
• Little known about variants
• Lymphocytic colitis
• Collagenous colitis
• Apoptotic colitis
• Occurs in some sprue pts
• Natural history:
Other Inflammatory Colitis
• Radiation Colitis
• May occur years after
initial radiation therapy
• Symptoms
• Diarrhea
• Mucus
• Tenesmus
• Ischemic Colitis
• Associated with PVD
• Associated with other
CAD
• Symptoms
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Blood in stool
Fever
Abdominal pain
Diarrhea
Vomiting
Microscopic Colitis
• Treatment options:
• Pepto Bismol tabs 8/day x2 months
• Mesalamine (Asacol
Asacol,, Pentasa
Pentasa))
• Budesonide (Entocort ) three 3 mg tabs qd
• Rarely requires prednisone or
immunosuppressants
• May be managed symptomatically
• may resolve spontaneously after 11-2 yrs
• May not recur
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Watery Diarrhea
• Osmotic
• Secretory
• Malabsorption
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Lactose
Glucose
Fructose
Sorbitol
• Celiac
• Drug Induced
• Lymphoma
• Endocrine
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Hyperthyroidsm
Pheochromocytoma
Gastrinoma
Vipoma
• IBD
Drug Induced Diarrhea
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Antibiotics
Chemotherapy
NSAID’s
Quinidine
ACE inhibitors and Beta Blockers
Antacids
• mg containing antacids
• H2 Blockers
• PPI’s
• Misoprostol
• Metformin
Fecal electrolytes increased in secretory diarrhea and
decreased in osmotic diarrhea
Irritable Bowel Syndrome
• Defined by a triad of
• Diarrhea, constipation, or both
• Crampy abdominal pain
• Pain is relieved with defecation
• Blood in the stool is never part of IBS
• Most common cause of chronic diarrhea
Refractory DiarrheaDiarrhea-Prone IBS
• Is bacterial O/G part of the picture?
• Controversial area
• RCT rifaximin for bloating: 40% vs 20%*
• Trial of antibiotics reasonable
• What other treatments?
• Tricyclics
• Alosetron
*Sharara AJG 2006
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Breath tests:
Are they helpful?
• Lactose: H2 breath
• Intolerance / deficiency is relative
• Trial of diet as effective
• Glucose: bacterial O/G
• Sensitivity 6262 -93%, specificity: 7878-90%
• Lactulose even lower specificity
• Not shown superior to antibiotic trial
Factitous Diarrhea
• Stool cathartic screen
• Fecal Mg >45 mmol
mmol/L
/L suggests MgMg induced
• Sodium phosphate / sulfate cause secretory
diarrhea
• Osmality <290: added water or urine
• ? Room search
Rarely needed tests
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Urine for 5HIAA: carcinoid
Urine for VMA, metanephrine (pheo
pheo))
Urine for histamine (mast cell disease)
Peptide hormones: VIP, calcitonin
calcitonin,, gastrin
gastrin,,
glucagon
• HIV antibody
• ANA
ANA—
—connective tissue disease
• Quantitative immunoglobulins
Small Bowel Imaging
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Small bowel biopsy
Dedicated SBFT
CT enterography
Capsule Endoscopy
Double balloon enteroscopy
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Chronic Diarrhea Summary
• Let history and physical guide you
• Remember who needs a colonoscopy
• Try to differentiate based on history and
testing
Sources
•
AGA Technical Review on the Evaluation and Management of Chronic Diarrhea GASTROENTEROLOGY
1999;116:1464-1486
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http://www.fpnotebook.com/index.htm
•
Sleisenger & Fortran's Gastrointestinal and Liver Disease, 7th Edition
•
Grace Elta MD, Common Sense Approach to Chronic Diarrhea, AGI Pow -Wow, 2006
• Inflammatory vs non inflammatory
• Secretory vs osmotic
Questions?
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