TRANSCRANIAL MAGNETIC STIMULATION Faten Alzaben PGY5 RESIDENT.
Diarrhea and constipation Phil Ukrainetz, MD, PGY5 October 31, 2002.
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Transcript of 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)