Diarrhea. Lecture Azad
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Transcript of Diarrhea. Lecture Azad
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8/3/2019 Diarrhea. Lecture Azad
1/11
Classification
of
diarrhea:I.Acutediarrhea
Threeormoreloose,waterystoolswithin24hours
II.BloodyDiarrhea/Dysentery
Bloody
diarrhea,
visible
blood
and
mucus
present
III.Chronic/Persistentdiarrhea
Episodesofdiarrhealastingmorethan14days
DIARRHEA
I.
Acutediarrhea
A.Usuallyaselflimitedinfectiousillness.
B.Particularfeaturesmaysuggestaspecificcause
1.Vomitingismorecommoninviralgastroenteritisoringestion of
apre
formed
bacterialtoxin(foodpoisoning)
2.Profusewaterydiarrheaissuggestiveofrotavirus(theNorwalk
agent),
cholera,
or
occasionally
Giardia.
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C.Deathfromacutediarrheaisduetodehydrationandelectrolyte
shifts.
1.Patients
at
risk
for
death
from
acute
diarrhea
are
those
at
extremes
ofage(especially
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F.Severityofacutediarrheaislargelydeterminedbyvolumestatus.
1.Assessmentofvolumestatusdiffersbetweenadultsandchildren
a)Adults
(1)Restingtachycardia,posturalhypotension,jugularvenous
distension,drymucousmembranes
b)
Children(1)Urineoutput,drymouth/eyes,sunkenfontanelle,skinturgor,
irritableorlethargic,drinkingpoorly
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G.TreatmentofAcuteDiarrheahas3phases
1.Rehydration
2.Replacementofongoinglosses
3.Nutritionalsupport
4.Additionalaspectsoftreatment
a)Hospitalize
if
severely
dehydrated,
malnourished,
age
viral
enteritis?)
g)Antibioticsusuallynotindicated
(1)Giveantibioticsfor:dysentery(seebelow),suspicionofcholera,
entericfever,giardiasis.
(2)Seeantimicrobialtablebelow
h)Antidiarrheal drugsandantiemetics aretypicallycontraindicated
inacute
diarrhea.
i)Protectyourselfandothersbywashingyourhandsbetween
patientsandtrimmingyour
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5.Howtouseoralreplacementsolution(ORS)
a)
Key
ingredients
are
sodium
and
glucose/rice,
in
an
iso
osmotic
orhypoosmotic solution.
b)TeachafamilymembertoprepareandgiveORS.
c)Givetoinfantsandyoungchildrenusingacleanspoonorcup,
notafeeding
bottle.
(1)Forbabiesaspoonorsyringewithoutaneedlecanbeusedto
putthesolutionintothemouth.
d)Children
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H.Preventionofacutediarrhea
1.Breastfeeding
2.Rotavirusvaccine
3.Accesstocleanwater
4.Handwashing
5.Use
of
latrines
II.BloodyDiarrhea
A.
Differential
diagnosis:1.Shigella,enterohemorrhagicEcoli(EHEC)
a)Oftenwithfever
2.Entericfever(Salmonellatyphi)
a)Systemic
illness
,ileal inflammation
(see
abdominal
pain
talk)
3.Amebiasis
a)Nofever(unlessinliver)
4.Noninfectiouscauses
a)Ischemic
colitis,
inflammatory
bowel
disease
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B.Infectiousdysenteryisusuallyaselflimiteddiseasethatdoesnot
requireantibiotictherapy.
1.Antibioticsarerecommendedfor
a)Entericfever(Salmonellatyphi)
b)Ameobiasis
c)Extremesofage
d)Immunocompromised ormalnourishedpatients
e)Toxicpatients,suspicionofsepsis
2.Antibioticscanprecipitatehemolyticuremic syndromeinchildren
withEcoliO157:H7infection,especiallyinindustrializedcountries.
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1. Persistentdiarrhea
in
children
A.Amonginfantsindevelopingcountries,upto20%ofacute
diarrheal illnessesbecomechronic.
B.Commonpathogensareenteropathic Ecoli(EPEC),giardia.
C.A
vicious
cycle
of
diarrhea
and
malabsorption can
lead
to
death.
D.Evaluation:checkstoolovaandparasiteexam;considerHIV
testing
E.Treatmentislargelynutritional
1.Isoosmolar carbohydrateporridgemadefromlocalingredients(yams,bananas,rice)anddeliveredthroughafeedingtubeif
needed
2.
Multivitamins
and
zinc3.Antibiotics
III.Chronic/Persistant Diarrhea
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2.Persistentdiarrheainadults
A.A
leading
presentation
of
HIV
infection
in
some
regions
B.Causesinclude:
1.Campylobacterileitis:chronicdiarrhea,rightlowerquadrant
tenderness
2.TB
enteritis:
doughy
abdomen,
high
ESR
3.Parasites:giardia,amoeba,cryptosporidium(detectedonacid
faststainofstool),isospora belli (detectedonroutineovaand
parasiteexam),cyclospora
4.Tropical
sprue:
fat
in
the
stool
5.Chronicpancreatitis:fatinthestool,pancreaticcalcificationson
abdominalXRayorUS
6.
Inflammatory
bowel
disease7.Malignancy
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Labtestsindiarrhealsyndromes
A.Stoolforovaandparasites:Especiallyinsevereorpersistent
diarrhea
B.Fecalleukocytes:Suggestscolitis,invasiveorganism
C.CBC:WontalteracuteRx,unlesstherearesignsofsevere
anemiaD.Stoolculture:Usuallynotavailableorrequired
E.StoolSudanstain(fecalfat):Inchronicdiarrheawithweightloss
F.XRay:ifconcernfortoxicmegacolon