Diarrhea is loosely defined as passage

of abnormally liquid or unformedStool at an increased frequency.

For adults on a typically westernDiet, stool weight exceeding 200g/dCan generally be considered diarrheal.

Secretory Secretory diarrheadiarrheaOsmoticOsmotic diarrheadiarrheaInflammatoryInflammatory (( exudative ) exudative ) diarrhea diarrhea

Motility Motility ( dismotile ) diarrhea( dismotile ) diarrheaAnatomic Anatomic ( decreased absorptive surface)( decreased absorptive surface)

Pathophysiologic classification of diarrhea

Secretory diarrheaSecretory diarrheaIncreased secretion and / or Increased secretion and / or

decreased absorption of electrolytes.decreased absorption of electrolytes.Large volume watrey stool,no blood, Large volume watrey stool,no blood,

no FSG, no pus, no response to no FSG, no pus, no response to fasting.fasting.

Small intestine type diarrhea.Small intestine type diarrhea.

Some causes of Some causes of Secretory diarrheaSecretory diarrhea

Cholera ,Ecoli, and Salmonella toxins.Cholera ,Ecoli, and Salmonella toxins.Serotonine,VIP,Calcitonine,Bile acids.Serotonine,VIP,Calcitonine,Bile acids.Castrol oil, Biscodyl, Senna, Castrol oil, Biscodyl, Senna, Villus atrophy Villus atrophy ((Celiac sprue , Int. lymphoma).Celiac sprue , Int. lymphoma).Collagen vascular dis.Collagen vascular dis.) ) ( ( SLE , MCTD SLE , MCTD

OSMOTIC DIARRHEAOSMOTIC DIARRHEA Non absorbable,osmoticlly active Non absorbable,osmoticlly active

molecules in gut lumen.molecules in gut lumen. Watrey stool, no blood, no pus in the Watrey stool, no blood, no pus in the

stool.stool. Improves with fasting.Improves with fasting. May have high FSG.May have high FSG. FSG = 280 – (fecal Na + fecal K ) * 2FSG = 280 – (fecal Na + fecal K ) * 2

Some causes of osmotic diarrheaSome causes of osmotic diarrheaDisacaridase deficiencies.Disacaridase deficiencies.Lactulose, Manitol, Sorbitol, Mg ++Lactulose, Manitol, Sorbitol, Mg ++Sulfate, phosphate (Laxatives).Sulfate, phosphate (Laxatives).Sodium citrate ingestion.Sodium citrate ingestion.Steatorrhea, generalized malabsoption.Steatorrhea, generalized malabsoption.Rotavius induced diarrhea.Rotavius induced diarrhea.

EXUDATIVE DIARRHEAEXUDATIVE DIARRHEA

Destruction of intestinal mucosa.Destruction of intestinal mucosa.Small frequent bloody stools with Small frequent bloody stools with

pus, and tenesmus.pus, and tenesmus.FeverFeverLarge intestine type diarrheaLarge intestine type diarrhea..

Some causes of exudative diarrheaSome causes of exudative diarrhea

Entero-invasive E.coliEntero-invasive E.coliShigellaShigellaE. histoliticaE. histoliticaUlcerative colitisUlcerative colitisIschemic colitisIschemic colitis

Acute Acute if < 2 weeks if < 2 weeks

PersistentPersistent if 2 to 4 weeks if 2 to 4 weeks

Chronic Chronic if > 4 weeks if > 4 weeks

Epidemiology of Epidemiology of Acute DiarrheaAcute Diarrhea

Worldwide, >1000,000,000 Worldwide, >1000,000,000 people/yearpeople/year5 -8 million deaths / year in 5 -8 million deaths / year in developing countries.developing countries.3000/year mortality in US.3000/year mortality in US.

High risk groups for diarrheaHigh risk groups for diarrhea Travelers.Travelers. 40 % of tourists develop diarrhea40 % of tourists develop diarrhea Most commonly duo to ETEColiMost commonly duo to ETEColi

Consumers of certain foods.Consumers of certain foods. Picnic, restaurant, undercooked Picnic, restaurant, undercooked

hamberger, seafoods(raw)hamberger, seafoods(raw) Immunodeficient personsImmunodeficient persons Daycare participants and their Daycare participants and their

familyfamily members.members. Institutionalized persons.Institutionalized persons.

Gastrointestinal VirusesGastrointestinal VirusesVirus type Major risk group Seasonality Dx test RxVirus type Major risk group Seasonality Dx test Rx

Rotavirus Rotavirus Children< 3 y Winter ELISA ORS Children< 3 y Winter ELISA ORS (groupA)(groupA)

Adenovirus Adenovirus children< 3y year-round ELISA ORS children< 3y year-round ELISA ORS (types 40,41) (types 40,41)

Calicivirus Calicivirus young unknown EM(?) ORS young unknown EM(?) ORS children children Astrovirus Astrovirus young winter EM(?) ORS young winter EM(?) ORS childrenchildrenNorwalk like Norwalk like children , winter EM (?) ORS children , winter EM (?) ORS virusesviruses adultsadults

Factors that influence virulance of Factors that influence virulance of entric pathogensentric pathogens

Inoculum size Inoculum size (Shigella,EPEC,giardia 10-100)(Shigella,EPEC,giardia 10-100)

AdherenceAdherence Toxin production Toxin production ((enterotoxin, cytotoxin, neurotoxinenterotoxin, cytotoxin, neurotoxin)) InvasionInvasion Normal flora of the hostNormal flora of the host Gastric acidGastric acid Intestinal motilityIntestinal motility ImmunityImmunity

Major Causes of Acute DiarrheaMajor Causes of Acute Diarrhea INFECTIONSINFECTIONS ((Including Travelers Diarrhea)Including Travelers Diarrhea)BacteriaBacterial l : : Campylobactre Species, C.difficile, E.coli, Salmonella eneritides Campylobactre Species, C.difficile, E.coli, Salmonella eneritides

, Shigella Species , Shigella SpeciesParasitic/protozoalParasitic/protozoal : : E. histolytica, Giardia lambilia,Cryptosporidium ,CyclospoaE. histolytica, Giardia lambilia,Cryptosporidium ,CyclospoaViral Viral :: Adenovirus , Norwalk virus , Rotavirus ,AIDS, OthersAdenovirus , Norwalk virus , Rotavirus ,AIDS, OthersFungalFungal FOOD POISONINGFOOD POISONING : : B.Cereus , C . Perfringens , Salmonella species , B.Cereus , C . Perfringens , Salmonella species ,

S .aureus, Vibrio species, Shigella species , Camppylobacter.jejuni, S .aureus, Vibrio species, Shigella species , Camppylobacter.jejuni, E.coliE.coli

MEDICATIONSMEDICATIONS RECENT INGESTION OF LARGE AMOUNT OF RECENT INGESTION OF LARGE AMOUNT OF

POORLY ABSORBABLE SUGARSPOORLY ABSORBABLE SUGARS INTESTINAL ISCHEMIAINTESTINAL ISCHEMIA FECAL IMPACTIONFECAL IMPACTION PELVIC INFLAMMATIONPELVIC INFLAMMATION GRAFT VS HOST DISEASEGRAFT VS HOST DISEASE

MAJOR CAUSES OF CHRONIC DIARRHEAMAJOR CAUSES OF CHRONIC DIARRHEA IBSIBS IBDIBD Ischemic bowel diseaseIschemic bowel disease Chronic bacterial / mycobacterial infectionChronic bacterial / mycobacterial infection Parasitic & fungal infectionsParasitic & fungal infections Radiation enteritisRadiation enteritis Malabsorption SyndromesMalabsorption Syndromes Medications, AlcoholMedications, Alcohol Colon cancer , Villous Adenoma ,intestinal LymphomaColon cancer , Villous Adenoma ,intestinal Lymphoma DiverticulitisDiverticulitis Previous Surgery ( Previous Surgery ( gastrectomy, vagatomy, intestinal resection )gastrectomy, vagatomy, intestinal resection ) Endocrine causesEndocrine causes Fecal impactionFecal impaction Heavy metal poisoningHeavy metal poisoning Epidemic idiopathic chronic diarrheaEpidemic idiopathic chronic diarrhea

Indications for evaluation a patient Indications for evaluation a patient with acute diarrheawith acute diarrhea

1.1. Profuse diarrhea with dehydration.Profuse diarrhea with dehydration.2.2. Grossly bloody diarrhea.Grossly bloody diarrhea.3.3. Fever > or = 38.5 CFever > or = 38.5 C4.4. New community outbreaks.New community outbreaks.5.5. Associated sever abdominal pain in Associated sever abdominal pain in

patients older than 50 years.patients older than 50 years.6.6. Elderly (> or = 70).Elderly (> or = 70).7.7. Immunocompromised patients.Immunocompromised patients.

TESTS THAT MAY BE USEFUL IN EVALUATION OF TESTS THAT MAY BE USEFUL IN EVALUATION OF PATIENTS WITH ACUTE DIARRHEAPATIENTS WITH ACUTE DIARRHEA

Stool Exam for:Stool Exam for: WBCs , Ova of parasites , Culture for WBCs , Ova of parasites , Culture for

bacteria & virus , Clostridium difficile toxin , bacteria & virus , Clostridium difficile toxin , Giardia , Entameba , Viral antigens ( Rotavirus )Giardia , Entameba , Viral antigens ( Rotavirus )

Blood test forBlood test for:: CBC , Na , K , BUN , Creatinine ,CBC , Na , K , BUN , Creatinine , CultureCulture Flexible SigmoidoscopyFlexible Sigmoidoscopy Abdominal RadiographAbdominal Radiograph

Acute diarrhea

Hx & P.ExLikely

noninfecutiosLikely

infectious

Mild ModerateActivities altered

Severe(Incapacitated)

Institue fluid & electrolyte replacement

Observe

Resolves

Fever >38 .bloody stool, fecal WBCsImmunocompromised or elderly host

Stool microbiology study

Evaluate & Rx

No Yes

PersistAntidiarrheal agents Pathogen

found

YesSpecific Rx

No

Empiric Rx +further evaluation

Empiric treatment in acute diarrheaEmpiric treatment in acute diarrhea

Moderately to severly ill patients with Moderately to severly ill patients with febrile desentry.febrile desentry.

Give Ciprofluxacin 500 mg bid for 3-5 Give Ciprofluxacin 500 mg bid for 3-5 days.days.

Suspected Giardiasis Rx with Suspected Giardiasis Rx with Metronidazole 250 mg qid for 7 days.Metronidazole 250 mg qid for 7 days.

Indications ofIndications of antibiotic coverageantibiotic coverage wether or not a causative organism is wether or not a causative organism is

discovered in acute diarrheadiscovered in acute diarrhea

1.1. Immunecompromised patient.Immunecompromised patient.2.2. Mechanical heart valves or Mechanical heart valves or

recent vascular graft.recent vascular graft.3.3. Elderly.Elderly.

Antibiotic prophylaxisAntibiotic prophylaxis is indicated foris indicated for travelers (to high risk countries), withtravelers (to high risk countries), with

1.1. Gastric achlorhydriaGastric achlorhydria2.2. IBDIBD3.3. ImmunocompromiseImmunocompromise GiveGive Co-trimoxazole Co-trimoxazole or or

CiprofluxacineCiprofluxacine

Thank youThank you

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