Approach to the patient with diarrhea

วั�ตถุ�ประสงค์� 1. ทราบ Definition ของ Diarrhea

2. ทราบ กลไกการเก�ด Diarrhea 3. เร�ยนร��แนวัทางการวั�น�จฉั�ยและแยกโรค์ของ ภาวัะ Diarrhea 4. เร�ยนร��แนวัทางการวัางแผนการร�กษา

Definition of Diarrhea

Pathophysiology :- Stool weight > 200 g/day

(infant stool weight > 10 g/kg/day)

Clinical : Frequency , Liquidity,

Changing character

Form water

mucous - bloody

Frequency of bowel movement in general populationFrequency of bowel movement in general population

Mean number of bowel movement /dayMean number of bowel movement /day

Daily intake and Daily intake and endogenous secretion and endogenous secretion and

absorptionabsorptionNet balance 2000-200=1800Net balance 2000-200=1800

% absorbed 8800/9000=98%% absorbed 8800/9000=98%

Endogenous secretions 7000 mlEndogenous secretions 7000 ml

9000

Oral intake 2000

Salivary 1500Glands

Bile 500

Stomach 2500

Pancreas 1500

Intestine 1000

200

- 8800

Stool

Intake 2 liter

Stool <200 ml

Duodenum / jejunum~5.5 L

Ileum~ 2 L

Colon – Rectum~ 1.3 L

The amount of fluid absorbed differs throughout the intestine

Mechanism of Diarrhea

1. Osmotic diarrhea

2. Secretory diarrhea

3. Inflammatory diarrhea

4. Abnormal gastrointestinal motility

Osmotic Diarrhea

สาเหต�1. Unabsorbable osmotic

load 2. Malabsorption or

mmmmmmmmmmmmกลไก

1 . Unabsorbable solute load --- >more mmmmm

transport to l umen

Osmotic Diarrhea

Raised CI Secretion

Diarrhea Pseudodiarrhea

Acute Chronic

Clinical approach to diarrhea

Infectious Non infectious

Acute Diarrhea

Non infectious acute diarrhea

Drug induced

Diet

Poisoning

Acute Infective Diarrhea

Clinical Evaluation

• Severity of illness Special • Underlying disease Consideration

and management

Clinical setting

Diagnosis + treatment

Parasite Viruses Bacteria

Bacteria Enteroadherant E.coli Giardia

Parasites Cryptosporidia

Helminths

Etiology of infectious diarrhea

• Bacterial • Shigella Sp. • Aeromonas Shigelloides • Salmonella Sp. • Vibrio Sp. • Compylobactor Sp. • Clostridium difficile • E.coli (ETEC, EPEC, EIEC, EAEC and EHEC)

• Viral • Norwalk • Rotavirus • Enteric adenovirus • Cytomegalovirus• Herpes simple virus

• Fungal • Candida Sp. • Histoplasma Sp.

• Parasite • Entamoeba histolytica • Giardia lamblia • Strongyloides • Cryptosporidium • Cyclospora Cayetanensis

Severity of Diarrhea

• Sunken eyeballs

• Poor skin turgor

• Orthostatic hypotension

• Tachycardia

• Oliguria or Anuria

• Alteration of consciousness

Underlying diseases

• AIDS

• Hyperthyroidism

History of Diet

ชน�ดของอาหาร สาเหต�ของ diarrhea เห)ด Amanita phelloides

อาหารกระป*อง Botulismนม Lactose deficiency

Samonella Campylobacter

ขนมจ�น , แป,งหม�ก , ข�าวัผ�ด Bacillus cereus อาหารทะเล Vibrio cholerae

Vibiro pararhemolyticus Vibrio non-O-group I

Norwalk virus

History of Diet

ชน�ดของอาหาร สาเหต�ของ diarrhea

เน-.อไก/ และเค์ร-0องในส�ตวั� Samonella , Campylobacter

ไข/ด�บ Salmonella , S aureus

น2.าไม/สะอาด Giardia , Aeromonas ผ�กและผลไม�ไม/สะอาด Shigilla , Salmonella

E histolytica E coli (EHEC)

เน-.อ , หม� V. cholera , E coli น2.าแข)ง Norwalk Virus

ประวั�ต�การก�นยา

ยา• Antacid• Lactose containing

drugs• Cancer chemotherapy• Neomycin• Cadiovascular drugs :

digitalis , quinidine , gan - glionic blocking agent

• Antibiotics

สาเหต�ของ diarrhea • Magnesium induce

osmotic diarrhea• Osmotic diarrhea• Mucosal Injury• Malabsorption• Increase motility • Antibiotic associated

enterocolitis (Clostridium difficile)

Clinical Setting Food poisoning Water Diarrhea Dysentery

(entero/neuro (non-Invasive (Invasive organism)

toxin producing) Organism)

Fever Rare Non or Low Grade Common

Incubation < 6 hours 6 hours-3 days 1-3 days

Peroid

Mucous-bloody stool Non Non Common

Nausea vomiting ++ + +

Tenesmus - - +

Voluminous stool + ++ +

Etiology Staphylococcus EPEC, ETEC, EAEC Shigella

aureus, C.perfringens Aeromonas, P.shigelloides

B, ceceus Vibrio Cholerae EIEC EHEC

Salmonella Giardia, Salmonella

Cryptospodium Campylobactor

Salmonella C.difficile, virus E.Histolytica

V.Parahemolyticus

Stool Leukocyte

Present stool leukocyte Absent stool leukocyte

HSV Adenovirus

CMV Norwalk virus

Aeromonas Rotavirus

Campylobacter Bacillus cereus

EIEC, EHEC Staphylococcus aureus

Shigella ETEC, EPEC, EAEC

Salmonella Giardia lamblia

V.parahemolyticus Cryptosporidium

Plesiomenas Shigiloides V. cholerae

E.Histolytica Cyclospora sp.

Microsporidium

Strongyloides

Treatment

1. Supportive

2. Symptomatic

3. Specific

Antimicrobial treatment

• Fecal WBC

• Severe volume depletion

• Community out break

• Impaired host

การร�กษา เช-.อ Drug of choice

Alternative

Shigella sp. Norfloxacin , ofloxacin Ciprofloxacin, ceftriaxone

Areomonas sp. Amlnoglycoside TMP/SMX, loramphenical

Ceftriaxone

Campylobacter Erythromycin Ciprofloxacin

Norfloxacin

Clostridium difficile Metronidazole Bacitacin

Vancomycin

Vibrio cholerae Tetracycline Doxycycline , TMP/SMX

E. histolytica Metronidazole Emitine

Giardia lamblia Metronidazole Quinacrine hydrochloride

Strongyloides Thiabendazole Albendazole

Chronic Diarrhea

Functional Organic

HIV Non-HIV

Causes of chronic diarrhea in Thai-AIDS

29/45 Found causative organism %

Cryptosporidium 20TB 17.8

Salmomella spp. 15.5

CMV 11.1

MAC 6.6

Strongyloidiasis 4.4

Giardiasis 4.4

Cryptococcus 2.2

Histoplasma carsulatum 2.2

Campylobacter 2.2

Cyclospora 2.2

Manatsathit S. et al. J Gastroenterol.1996;31(4):533-7.

Chronic organic diarrhea (Non HIV)

Inflammatory Secretory

Malabsorption

Chronic Inflammatory Diarrhea

• Infection

• Inflammatory bowel

• Radiation

• Ischemic

Malabsorption syndrome

• Diarrhea

• Malnutrition

Intestinal epithelial cells are continually renewed

VillusRegion

CryptRegion

Cell death And sloughing

Turn over time ~ 48 – 72hr

Diving cells

Paneth cells

Normally : # Cells entering villus = # Cells dying

The intestine has a very large surface area

for absorption

The intestine has a very large surface area

for absorption

Type of surface Amplification

factor

Surface area

(cm2)

Mucosal cylinder

Fold of Kerkring

Villi

Microvilli

1

3

10

20

3,300

10,000

100,000

2,000,000

Malabsorption syndrome

• Strongyloidiasis

• Giardiasis

• Capillariasis

• Lymphoma

Chronic secretory diarrhea

• Vipoma

• Carcinoid syndrome

• ZE syndrome

Constipation

วั�ตถุ�ประสงค์�• ทราบ Definition• ร��กลไกการเก�ด Constipation•ทราบสาเหต�•เร�ยนร��แนวัทางการวั�น�จฉั�ยและแยกโรค์• เร�ยนร��แนวัทางการวัางแผนการร�กษา

Definition

Acute

Chronic

Patient review

Clinical review

Rome II Criteria for chronic constipation (At least 2 of following)

• Fever than 3 bowel movement/week

• Hard stool in more than 25% of BM

• A sense incomplete evaluation in more than 25% of BM

• Excessive staining in more than 25% of BM

• The necessity of digital manipulation to facilitate evalu

ation

• Any 12 week period in the least 12 months

Pathogenesis

Obstruction Pseudo-obstruction

Drugs (opiates, phenothiazines)

Cause of constipation

Extrinsic

Structural

Systemic

Neurological

Drugs

Extrinsic

• Inadequate dietary fiber, fluid

• Ignoring urge to defecate

Structural

• Colorectal : neoplasms, stricture,

ischemia , volvulus, diverticular dis

ease

• Anorectal : inflammations, prolapse,

rectocele,fissure, stricture

Systemic

• Hypokalemia

• Hypercalcemia

• Hyperparathyroidism

• Hypothyroidism

• Hyperthyroidism

• Diabetes mellitus

Neurological• CNS : Parkinson’s disease, multiple sclerosis, trauma, ischemia, tum

or

• Sacral nerves : trauma, tumor

• Autonomic neuropathy

• Aganglionosis (Hirschsprung’s disease)

Drugs

• Analgesics

• Opiates, non-steroidal anti-

inflammatory

• Anticholinergics

• Atropine agent,

antidepressants, neuroleptics

Drugs

• Metal ions

• Aluminum (antacids, sucralfate),

barium sulfate , bismuth, calcium, iro

n, heavy metals (arsenic, mercury)

• Resins

• Cholestyramine, polystyrene

Diagnosis and differential

• History taking

• Physical examination

• Diagnostic techniques

History taking

• How many stools per week?

• Chronic constipation or not?

• Is there concomitant abdominal pain?

• Dietary history

• Lifestyle

• Use of laxative

• Use of other drugs

Physical examination • Percussion (check for gas)

• Palpable feces (‘loaded colon’)

Rectal palpation

• Consistency / impaction

• Presence of non fecal masses pr abnormalities (tu

mor, hemorrhoid, fissures, fistulas, prolapse, neo

plasms)

• Presence of blood

• Sphincter tone

Diagnostic techniques

• Stool analysis (assess seriousness)• weighing 3 days ; < 100 g average means constipation

• Abdominal Xray (assess seriousness)

• Radiological or Endoscopic investigation (to assess/exclu

de obstructions) :

– megacolon

– redundant sigmoid colon

– pattern of haustral folds

» IBS patients ---> normal length haustral colon

» Colon inertia ---> longer length less haustral colon

Major Alarm symptoms especially in patients > 50 yr

• New onset constipation

• Anemia

• Weight loss

• Anal blood loss

• Positive occult blood test

• Sudden change in defecation pattern and appe

arance of stool

Stepped Treatment of Constipation

change lifestyle and diet

Stop medications which cause constipation

Bulk-forming agent

Contact laxatives

Pelvic floor physiotherapy

Enema Prokinetics

Osmotic laxatives

Laxatives

• Bulk laxative • Psyllium

• Polycarbophil

• Methylcellulose

• Lubricating agents • Mineral oil

Laxatives

• Osmotic agents

• Magnesium and phosphate salts

• Lactulose

• Sorbitol

• Polyethylene glycol

• Glycerin suppositories

Laxatives • Stimulant laxatives

• Surface acting agents– Ducusate

– Bile acids

• Diphenymethane derivates– Phenolphtalein

– Bisacodyl

– Sodium picosulfate

• Ricinoleic acid

• Anthraquinones– Senna

– Cascara sagrada

– Aloe

– Rhubarb