diarrhea and constipation phil ukrainetz, md, pgy5 october 31, 2002

Diarrhea and constipation

Phil Ukrainetz, MD, PGY5

October 31, 2002

Some people think its gross….

31 yr old male, intermittent fever, crampy abdominal pain and diarrhea x 1 week. Now has had low volume bloody diarrhea 8-10 times a day for three days. Well hydrated otherwise perfectly healthy. Patient had antibiotics 40 days ago for a strep throat, no travel, funny food or water.

Differential diagnosis:

Infectious colitisInflammatory bowel diseaseMeckl’sIntussusceptionIschemic bowel (volvulus etc)AppyCholy

Skill testing question:

Is this enteritis, gastroenteritis or dysentry?

Answers:

Enteritis: gut inflammation with diarrheaGastroenteritis: gut inflammation with

diarrhea and vomitingDysentery: diarrhea with passage of mucus or

blood

Work-up

Diarrhea > 5 daysBloodyOrder C&S and O&P and C. diff toxinC&S is positive for campylobacter

Treat or not treat

Sanford 2002 says….Greater than 6 unformed stools/day, or fever,

chills and bloody stoolTreat with ciprofloxacin 500 BID x 10 days or

azithromycin 250 mg QD x 3 daysNo caffeine or milk products

To prevent spread…. Osler would say - soap, water and common sense

Interestingly...

Campylobacter cases have exceeded Salmonella and Shigella

Number one agent of transmission is the “juices” of unprepared chicken

Eating raw-ish food is rarely the culprit50% of domestic dogs carry it and are thought

to be a major vector to humans

Not fun

Can get reactive arthritis and Guillain Barre syndrome (<1/1000) post enteroinvasive disease

I’m sh--ing thru the eye of a needle at 25 feet Doc!

25 yr o/w healthy recently returned from Mexico. In his colon he smuggled a friend called shigella back into Canada. Well hydrated, no blood in stool - just having to sprint for the washroom on a regular basis.

Treatment?

Antibiotics?Anti-motility?

> 5 days diarrhea, > 6 stools a day

Cipro vs placebo for severe diarrhea decreased duration of diarrhea and symptoms but did not change fecal carriage (NEJM 340: 1525, 1999)

Actual recommendation is loperamide and Cipro 750 mg PO x 1 dose

But you’ll increase the bacterial load if you use immodium!!!!

Do not use loperamide if patient is dysenteric - bloody stools, mucusa nd fevers

For run of the mill diarrhea - Antimotility agents are safe loperamide 4 mg PO then 2 mg after each stool to a max of 16 mg. Peptol bismol is another option

McGyver...

You are on a back packing in eastern Europe and your buddy is proving that your small bowel exchanges 50 litres/day of water and sodium. Since his large bowel can only absorb 4 litres - he has a little mismatch. How can you cheaply keep him hydrated?

Low end hydration hooch

One litre of “clean” waterOne teaspoon of saltFour heaping teaspoons of sugarMild dehydration give 5%, mod 7% of body

weight

High end diarrhea hooch

4 tsps sugar3/4 tsps of salt1 tsp baking sodaone cup orange juicedilute with water to one litre

What’s the problem with gatorade?

Heavy on the sugarLight on the sodiumAdd a pinch of saltMost diarrhea can be kept up with fruit juices,

pop or gatorade

I’ve been poisoned!!!

38 yr old female Stampede worker ate from salad bar two days ago and now is nauseated and has diarrhea x 4/day. Sytemically well, exam is normal. She swears she has “food poisoning”. Do you think she’ll have positive cultures and for what?

Likely viral

Toxin mediated is nasty V and DLittle feverAbdo exam not impressiveStaph and bacillus

My tooth!!!!!!!

27 yr old male, major tooth pain and likely abscess. The dentist gave him clindamycin and will see him tomorrow. The patient hasn’t taken any yet. He has no allergies and just wants some pain relief. What’s the issue with clindamycin?

Odontogenic infection

Avoid clinda - 600 c.diff cases in Calgary 2001

28 yr old had a colectomy!Use penicillinUse ancef IV, flagyl 500po bid

C.difficile colitis risks and Rxmt

All abx except flagyl and vancomycin in last month(John Gill 2002)

Hospital workers are likely colonizedFlagyl or vancomycin are used for RxmtHigh risk people could be put on prophylactic

oral flagyl 500 mg TID

FOS

54 yr old male, you are absolutely convinced he is just bunged up. He knows that he has got to exercise, drink H20, eat fruit and weggies and he promises to. How are you going to break the damn?

Bunged approachget an AXR

R sided stool-oral fleet(NaPO4)L sided stool-rectal fleet/glycerine suppository

one prnR and L--oral/rectalBeware in the young and elderly

Impaction

Rectal--fecal impactionMineral oil lubOral/rectal fleetFentanyl for pain-Grunt!

They are not just small adults you idiot!!!!!!

2 year old male, OM treated with antibiotics one week ago. Episodic abdominal pain and diarrhea with a little blood x 1day. Mom says her other boys had worse diarrhea over the last few weeks. She thinks he’s just “carrying on”.

Differential!!!!

IntussusceptionPseudo membranous colitisHemolytic-uremic syndromeAnal fissure with diarrheaBacterial enteritisViral enteritis

Intussusception

Diagnostic barium enema

Abrupt termination of barium column

Intussusception stats

80% occur before 24 months4:1 boys to girlsPalpable “sausage shaped mass” reported in up to

70% of casesCurrent jelly stools are a late sign (20%)Rectal bleeding 50%Lethargy increasingly recognized as significant

I fed my baby cow’s milk..

1 week old male, born at 36 weeks, normal delivery, babe is perfectly healthy. Mom is in hospital with endometritis. Dad is feeding baby and noticed some blood in the babe’s loose poops. After a grand jury inquisition Dad admits to feeding the baby cow’s milk.

Pneumatosis intestinalis

Necrotizing enterocolitis differential diagnosis

Milk allergyAnal fissure Infectious diarrheaNEC

NEC treatment

Neonatal stress leading to hypovolemia, bowel ischemia and potentially infarct

Rectal bleeding, vomiting, abdo distention, toxicXray: fixed, dilated loops of bowel, pneumatosis

intestinalis, portal vein air#1 cause for emergent neonatal laparotomy

NEC Treatment

3/4 managed conservatively

NPO, fluids, abx, drip and suck

Sx if perforation

>80% survival

He won’t stop crying….

8 wk old male, perfectly healthy, no problems until week 6. Breast fed, 3-4 BM’s/day and feeding well. Babe has episodes where his stomach appears to hurt him, he crunches up and howls relentlessly. Babe is sometimes soothed by a car ride. Mom insists that you do something like an enema or something - and give her a freakin!@#$%^&*( diagnosis!!!!!

Colic

Description of triad of symptoms; paroxysms of crying, apparent abdominal pain and irritability

May start with newborn but more likely once 4-6wks

Does not usually go beyond 3-4 months

Colic pathophys????

Bouts of crying lead to aerophagia, gut distress then flatulence and distention

May be hyperactive suckling response Impatient personality?Immature gut?

Rule out the nasties

Pyloric stenosisHirschsprungsIntussusception Volvulus Abuse

Once your happy - normal H/P & parents, child is gaining weight

Try bottle with small holes - give kid suckling time

Swaddle and lay on bellyChange formula to see if milk intolerance -

rare and no evidenceVibration puts them to sleep - car ride not a

drier (fall off).

Newborn constipation

Poop by 24hrs life?, thriving?Rare if breastfedPut 2 tsp brownsugar in 1 cup H201 ounce prunes and one ounce H20 qdKids can have 1bm/week then 9/day and it is

normal to change rapidly

Hirschsprung’s disease

Failure of ganglionic migration into terminal colon.Usually distal 4 to 25 cm involved.Often present as neonate, but can present much later

in mild casesFunctional obstruction with need for enemas,

suppositories, etc.

Hirschprung’s vs Constipation

InfancyMinimal abdo painEpisodic obstructionNo encopresisEmpty rectumNarrow section on

bariumAbnormal monometry

2 y.o. or greaterColicky painEpisodic large stoolsEncopresisFull rectumDilated rectum on

bariumNormal monometry

studies

The nagging senior

You are asked by your senior to figure out the pediatric patients fluid deficit to within one bzillionth of a nanolitre. Of course the child is desperately ill as he beats you about the ears while convincing you to give him a “horsey ride”. His parents tearfully await your calculations.

Dehydration

Presence of > or = 2/4 high yield criteria is 87% sensitive in detecting > 5% dehydration

Dry mmIll appearanceNo tearsCap refill > 2 secs

(Acad Em Med 1996)