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