Acute Diarrhea (<14 days)
35 male presenting with diarrhea for the past 5 days. Please assess.
Ends up being [Link], toxic megacolon
Definitions:
Acute - < 14 days
Persistent - > 14 days
Chronic - > 30 days
Approach to Acute Diarrhea:
My approach to acute diarrhea is infectious vs inflammatory vs neoplastic vs
drugs, as well malabsorption vs. secretory vs motility, although the latter three
categories are usually more consistent with chronic diarrhea.
DDx of Non-Bloody Diarrhea DDx of Bloody Diarrhea
Infectious Bacteria: Bacterial:
E. coli E. coli (2 types):
Staph aureus Entero-invasive & 0157:H7
Bacillus cereus Salmonella
Clostridium perfringens Shigella
Vibrio Campylobacter
C. diff Yersinia enterocolitica
Mycobacterium avium C. difficile/Toxic Megacolon
(MAC, in immunosuppressed) MAC (in immunosuppressed)
Viruses: Viral:
Rotavirus/Norovirus/Adenovirus CMV colitis (in
CMV (in immunosuppressed) immunosuppressed)
Parasitic: Parasitic:
Giardia Entamoeba histolytica
Inflammatory Inflammatory bowel disease Inflammatory bowel disease
(Crohn’s > UC) Ischemic bowel
Ischemic bowel Radiation enteritis
Radiation enteritis Diverticulosis
Diverticulitis
Neoplastic Colon cancer Colon cancer
Drugs Any drug, but in particular:
Antibiotics, Lactulose, Antacids,
Colchicine, Chemo
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Initial:
ABC, Vitals, IV, O2, Monitor. If stable, proceed with hx
History:
Quantify diarrhea:
Symptoms – diarrhea (duration, frequency, volume, blood, floating in toilet bowl,
aggravating factors like diet and stress)
Nocturnal symptoms, urgency, tenesmus, fecal incontinence
Previous episodes of the same cause, diagnosis, treatment (including
procedures)
ROS:
Abdominal pain (characterize), fever, jaundice, nausea, vomiting, weight loss,
chills, sweats, mental status change, rashes
Extra-intestinal manifestations of IBD (uveitis, episcleritis, oral ulcers, arthritis,
erythema nodosum, pyoderma gangrenosum, PSC)
Travel before the onset of illness, exposure to potentially contaminated food or
water and illness in other family members, HIV risk factors/immunosuppression
Background:
Past Medical/Surgical history – DM, IBD, abdominal surgery, malignancy,
previous endoscopy, previous radiation, vascular risk factors
Medications – recent antibiotic use, new drugs, immunosuppressives
Allergies, Social history – EtOH, smoking, drugs, sexual history, occupation
Family history – malignancy, IBD, IBS
Physical Examination:
Would perform vitals and a full physical, however focus on the abdominal exam
including a rectal exam, as well as signs of hypovolemia.
Vitals – febrile, hypotension, tachycardia, febrile, orthostatic vitals
Abdominal Exam – distension, decreased BS, tenderness, guarding, rebound,
HSM, ascites, rectal exam for masses & BRBPR
Extraintestinal manifestations of IBD review
Investigations:
Bloodwork
CBC ( diff), electrolytes + Creatinine, INR/PTT, liver enzymes + LFTs
Iron studies (Fe deficiency in Celiac, Colon ca)
Stool C&S, Stool O&P, C. dificile toxin assay
Blood cultures
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AXR
Look for signs of perforation, obstruction, and colitis Criteria for toxic megacolon:
Radiographic evidence of
(thumbprinting, featureless colon/loss of haustra) colonic dilatation
Toxic megacolon signs are dilated >6cm (often to 15cm)
of transverse or right colon. Also, loss of normal colonic PLUS 3/following:
Fever >38
haustral pattern HR >120
Neutrophils > 10,500/mm3
CT Abdomen + Pelvis Anemia
To investigate for underlying causes, look for colitis (ie. PLUS 1/following:
wall thickening) and its complications (ie. perforation) Hypotension
Altered mental status
ECFV contraction
Colonoscopy/Flexible sigmoidoscopy +/biopsy Electrolyte abnormalities
To diagnose & assess severity of IBD, ischemic colitis
Stool C & S indications
o Patients with more severe, inflammatory diarrhea (including bloody
diarrhea)
o Patients with comorbidities that increase the risk for complications
o Immunocompromised patients, including those infected with the human
immunodeficiency virus (HIV)
o Patients with underlying inflammatory bowel disease in whom the
distinction between a flare and superimposed infection is critical
o Some employees, such as food handlers, occasionally require negative
stool cultures to return to work
Fecal Leukocytes (inflammatory sens 73% spec 84%) and elevated serum
WBCs supports the diagnosis of bacterial etiology in context with medical
history
Treatment:
ABC’s
Oxygen, IV access, Monitors
Hemodynamics
Supportive Rx
IV fluids + blood products as needed if bloody diarrhea (pRBC/platelets/FFP)
Anti-diarrheal if no evidence of infection (ie. Imodium)
Analgesia (avoid narcotics if possible)
Nutritional support
When to use antibiotics
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Consider antibiotics (ie. cipro) in patients with severe travelers' diarrhea with
> 4 unformed stools daily, fever, blood, pus, or mucus in the stool, and/or
immunocompromised. Azithro for Campylobacter
If give abx with [Link], can precipitate HUS
C. diff, Giardia and Entamoeba Metronodazole 500mg TID IV x14 days
C. Difficile tx:
Discontinue all non-essential antibiotics
Avoid antidiarrheal agents
IV fluids
Initial, mild disease - Metronidazole 250 mg QID PO, or IV if cannot tolerate
Severe disease – Metronidazole 500mg IV q8 or Metronidazole IV + Vanco
C. Diff recurrence – retreatment with 14 day course
Toxic Megacolon from [Link]:
Treatment similar to [Link] (see above)
Consult Gen Surg +/- GI
D/C non-essential antibiotics and avoid antidiarrheals & anticholinergics
IV fluid replacement
Metronidazole IV + Vanco PO
Info & Notes
Diarrhea and Associated syndromes
Salmonella – may cause septicemia in patients with sickle cell anemia or AIDS
Campylobacter – precedes 10 -30% of GBS
Yersinia – mesenteric adenitis, erythema nodosum
Diarrhea at Various settings
Traveler’s – ETEC
Nosocomial – C. Difficile
Persistent diarrhea – Giardia, Isospora belli, Cyclospora, Cryptosporidium
Immunocompormised – MAC,CMV,Microsporidia
Timing:
Symptoms that begin within 6 hours suggest ingestion of a preformed toxin
of Staphylococcus aureus or Bacillus cereus
Symptoms that begin at 8 to 16 hours suggest infection with Clostridium
perfringens
Symptoms that begin at more than 16 hours can result from viral or bacterial
infection (eg, contamination of food with enterotoxigenic or enterohemorrhagic
E. coli).
Syndromes that may begin with diarrhea but progress to fever and more
systemic complaints such as head ache, muscle aches, stiff neck may suggest
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infection with Listeria monocytogenes, particularly in pregnant woman.
