DiarrheaDiarrhea

A messy subjectA messy subject

CaseCase

A 1 year oldA 1 year old girl is brought to clinic with 3 days of girl is brought to clinic with 3 days of watery brown diarrhea, vomiting, and irritability. On watery brown diarrhea, vomiting, and irritability. On exam the child is lethargic, afebrile, with sunken exam the child is lethargic, afebrile, with sunken eyes and a weak pulse of 140/minute. Which of the eyes and a weak pulse of 140/minute. Which of the following is the best management plan?following is the best management plan?A) Check CBC and stool tests for pathogensA) Check CBC and stool tests for pathogensB) Prescribe oral rehydration solution B) Prescribe oral rehydration solution C) Prescribe oral antibioticsC) Prescribe oral antibioticsD) Begin IV fluids and hospitalizeD) Begin IV fluids and hospitalize

“More than 70 per cent of almost 11 million child deaths every year are attributable to six causes: diarrhoea, malaria, neonatal infection, pneumonia, preterm delivery, or lack of oxygen at birth.””

-- UNICEFUNICEF

Deaths per year from diarrheal illnessDeaths per year from diarrheal illness

•• United States: 6,000United States: 6,000•• Developing world: 1.5 to 2 million Developing world: 1.5 to 2 million

(children < 5 years old)(children < 5 years old)

World Gastroenterology Organization (WGO) Practice GuidelineWorld Gastroenterology Organization (WGO) Practice GuidelineAcute Diarrhea (March 2008)Acute Diarrhea (March 2008)

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008

Classification of diarrheaClassification of diarrhea

Acute diarrheaAcute diarrhea

•• Acute diarrhea is usually a selfAcute diarrhea is usually a self--limited infectious illnesslimited infectious illness

•• Usually viral (Norwalk) or bacterialUsually viral (Norwalk) or bacterial•• Vomiting:Vomiting:

-- ViralViral-- Ingestion of a preIngestion of a pre--formed toxinformed toxin

•• Profuse watery diarrhea:Profuse watery diarrhea:-- ViralViral-- CholeraCholera-- GiardiaGiardia-- Ingestion of a preIngestion of a pre--formed toxinformed toxin

•• Risk factors for death: Risk factors for death: -- Extremes of age, malnutrition, Extremes of age, malnutrition,

immunocompromiseimmunocompromise

http://bepast.org/docs/photos/cholera/rice-water%2520stool.jpg

Acute diarrhea: clinical prioritiesAcute diarrhea: clinical priorities

•• Look at the stoolLook at the stool-- rice water stool: cholerarice water stool: cholera-- bloody stool: dysenterybloody stool: dysentery

•• Assess severity Assess severity -- signs of dehydration, signs of dehydration,

malnutritionmalnutrition-- abdominal examabdominal exam-- body temperaturebody temperature

•• O + P exam for O + P exam for moderate/severe illnessmoderate/severe illness

•• Hgb if pt looks anemicHgb if pt looks anemic

http://spirochetesunwound.blogspot.com

http://biology.unm.edu/ccouncil/Biology_203/Images

Exam: nutritional and volume statusExam: nutritional and volume status

Kwashiorkor: Kwashiorkor: lack of proteinlack of protein

www.cs.stedwards.eduwww.cs.stedwards.edu

Marasmus: Marasmus: protein + calorie malnutritionprotein + calorie malnutrition

www.glahaiti.orgwww.glahaiti.org

Malnutrition is a major risk factor for diarrhea mortalityMalnutrition is a major risk factor for diarrhea mortality

Exam: volume statusExam: volume status

•• Adults and ChildrenAdults and Children•• Tachycardia, postural hypotensionTachycardia, postural hypotension•• Jugular venous distensionJugular venous distension•• Mucous membranesMucous membranes

•• ChildrenChildren•• Urine output, dry mouth/eyesUrine output, dry mouth/eyes•• Sunken fontanelleSunken fontanelle•• Skin turgorSkin turgor•• Irritable or lethargic, drinking poorlyIrritable or lethargic, drinking poorly

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008

If the gut works, use itIf the gut works, use it

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008

Oral rehydration saves livesOral rehydration saves lives

Oral rehydration solution (ORS)Oral rehydration solution (ORS)

RiceRice--based ORS is superior based ORS is superior to glucoseto glucose--based ORS in patients with cholera based ORS in patients with cholera

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008

RxRx of mild/moderate dehydrationof mild/moderate dehydration

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008

RxRx of severe dehydrationof severe dehydration

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008

Acute diarrhea Acute diarrhea RxRx -- childrenchildren

•• Admit to hospital if malnourished, severely Admit to hospital if malnourished, severely dehydrated, age < 1 year, recent measlesdehydrated, age < 1 year, recent measles

•• ORS if dehydrated; IV fluids (RL, NS) if severely ORS if dehydrated; IV fluids (RL, NS) if severely dehydrated; rehydrate over 3 to 6 hoursdehydrated; rehydrate over 3 to 6 hours

•• ReRe--feed as soon as rehydration is accomplishedfeed as soon as rehydration is accomplished•• Zinc 20 mg daily x 14 daysZinc 20 mg daily x 14 days•• Antibiotics not usually indicatedAntibiotics not usually indicated•• Give Give antibxantibx for: for:

•• DysenteryDysentery•• Suspicion of cholera or enteric feverSuspicion of cholera or enteric fever•• Giardiasis or amebiasisGiardiasis or amebiasis

Acute diarrhea Acute diarrhea RxRx -- adultsadults

•• ORS or IV fluids (RL, NS) if severely ORS or IV fluids (RL, NS) if severely dehydrateddehydrated

•• Bismuth or loperamide (contraindicated if Bismuth or loperamide (contraindicated if there is fever or bloody stool)there is fever or bloody stool)

•• Antibiotics not usually indicatedAntibiotics not usually indicated•• Give Give antibxantibx for: for:

•• Dysentery (some cases) Dysentery (some cases) •• Suspicion of cholera or enteric feverSuspicion of cholera or enteric fever•• Giardiasis or amebiasisGiardiasis or amebiasis

DysenteryDysentery•• Bloody stools Bloody stools •• Shigella, enterohemorrhagic Shigella, enterohemorrhagic

E coli (EHEC), other bacteria E coli (EHEC), other bacteria –– often with feveroften with fever

•• Enteric fever (salmonella Enteric fever (salmonella typhi)typhi)

•• Amebiasis Amebiasis –– no fever (unless no fever (unless in liver)in liver)

•• Less likely causes: ischemic Less likely causes: ischemic colitis or inflammatory bowel colitis or inflammatory bowel diseasedisease

•• Infectious dysentery is Infectious dysentery is usually a selfusually a self--limited disease limited disease that does not require that does not require antibiotic therapyantibiotic therapy

Dysentery: AntibioticsDysentery: Antibiotics

•• Antibiotics recommended for:Antibiotics recommended for:•• Salmonella typhi, Salmonella typhi, ameobaameoba•• Extremes of ageExtremes of age•• Immunocompromised or Immunocompromised or

malnourished patientsmalnourished patients•• Toxic patients, suspicion Toxic patients, suspicion

of sepsis of sepsis

•• Antibiotic Antibiotic RxRx may precipitate may precipitate hemolytichemolytic--uremic syndrome uremic syndrome in children, especially in in children, especially in industrialized countriesindustrialized countries library.thinkquest.org/26260/pg1.html

AntimicrobialsAntimicrobials•• CholeraCholera

•• Adults: doxycycline 300 mg once, or tetracycline 500 mg Adults: doxycycline 300 mg once, or tetracycline 500 mg daily x 3 days daily x 3 days

•• Children: azithromycin, TMP/SMX, furazolidone, Children: azithromycin, TMP/SMX, furazolidone, norfloxacinnorfloxacin

•• ShigellosisShigellosis•• Adults: ciprofloxacin 500 BID x 2 days, or azithromycin or Adults: ciprofloxacin 500 BID x 2 days, or azithromycin or

ceftriaxoneceftriaxone•• Children: ciprofloxacin 15 mg/kg BID x 2 days, or Children: ciprofloxacin 15 mg/kg BID x 2 days, or

azithromycin, or ceftriaxone 50azithromycin, or ceftriaxone 50--100 mg/kg daily 100 mg/kg daily i.mi.m. x 2. x 2--5 5 daysdays

•• Resistance is commonResistance is common

•• GiardiaGiardia•• Metronidazole, tinidazole, nitazoxanide, or paromomycinMetronidazole, tinidazole, nitazoxanide, or paromomycin

•• AmeobaAmeoba•• Metronidazole followed by iodoquinol or paromomycinMetronidazole followed by iodoquinol or paromomycin

Persistent diarrhea Persistent diarrhea -- childrenchildren

•• Among infants in developing Among infants in developing countries, 20% of acute countries, 20% of acute diarrheal illnesses become diarrheal illnesses become chronic chronic

•• Enteropathogenic E coli (EPEC), Enteropathogenic E coli (EPEC), GiardiaGiardia

•• Vicious cycle of diarrhea and Vicious cycle of diarrhea and malabsorption leading to deathmalabsorption leading to death

•• Consider HIVConsider HIV•• RxRx is largely nutritional: is largely nutritional:

•• IsoIso--osmolar carbohydrate osmolar carbohydrate porridge, via feeding tube if porridge, via feeding tube if neededneeded

•• MVI and zincMVI and zinc•• AntibioticsAntibiotics

Persistent diarrhea Persistent diarrhea -- adultsadults

•• Consider HIVConsider HIV•• Campylobacter ileitis: chronic Campylobacter ileitis: chronic

diarrhea, RLQ tenderness, diarrhea, RLQ tenderness, signs of inflammationsigns of inflammation

•• TB enteritis: doughy abdomenTB enteritis: doughy abdomen•• Parasites: Giardia, Parasites: Giardia, ameobaameoba, ,

cryptosporidium, cryptosporidium, isosporaisosporabelli, belli, cyclosporacyclospora

•• Wasting, or fat in stool? Wasting, or fat in stool? Consider sprue, chronic Consider sprue, chronic pancreatitispancreatitis

•• Inflammatory bowel disease or Inflammatory bowel disease or malignancymalignancy http://scanned.files.wordpress.com/

2007/10/aidspatient2.jpg

Lab testsLab tests

•• Stool for ova and parasitesStool for ova and parasites•• Especially in severe or persistent diarrheaEspecially in severe or persistent diarrhea

•• Fecal leukocytesFecal leukocytes•• Suggests colitis, invasive organismSuggests colitis, invasive organism

•• CBCCBC•• WonWon’’t alter acute t alter acute RxRx, unless there are signs of , unless there are signs of

severe anemiasevere anemia•• Stool cultureStool culture

•• Usually not available or requiredUsually not available or required•• Stool Sudan stain (fecal fat)Stool Sudan stain (fecal fat)

•• In chronic diarrhea with weight lossIn chronic diarrhea with weight loss•• XX--Ray: if concern for toxic megacolonRay: if concern for toxic megacolon

CaseCase

A 1 year oldA 1 year old girl is brought to clinic with 3 days of girl is brought to clinic with 3 days of watery brown diarrhea, vomiting, and irritability. On watery brown diarrhea, vomiting, and irritability. On exam the child is lethargic, afebrile, with sunken exam the child is lethargic, afebrile, with sunken eyes and a weak pulse of 140/minute. Which of the eyes and a weak pulse of 140/minute. Which of the following is the best management plan?following is the best management plan?A) Check CBC and stool tests for pathogensA) Check CBC and stool tests for pathogensB) Prescribe oral rehydration solution B) Prescribe oral rehydration solution C) Prescribe oral antibioticsC) Prescribe oral antibioticsD) Begin IV fluids and hospitalizeD) Begin IV fluids and hospitalize

ResourcesResources

WGO Practice Guideline WGO Practice Guideline –– Acute Diarrhea March 2008Acute Diarrhea March 2008