HPI

Female pt. 46 ys old C/O weakness and diarrhea for 6 days Her usual BMs are EOD, that time she was

having 10 - 15 BMs/ day of fluid stool Denied nausea or vomiting Denied fever, skin rash, Bl or mucous or other constitutional symptoms

HPI
She had history of recent travel to New York,

one week prior to developing symptoms Pt had chicken salad lunch in a restaurant, on that very day she started developing her symptoms No body else dinning with her ever had such symptoms

PMH
Hypothyroidism ( following radio active I ) Hypercholesterolemia Abnormal MRI of brain ( DD stroke vs MS ) Abdominal hystrectomy ( fibroid uterus )

C section x 2

Meds
Paxil 20mg po QD ASA 81mg po QD Synthroid 0.125mg po QD Premarin 1.25mg po QD

Zocor 20mg po QD
No recent Abx

use NKDA (no known drug allergy)

Social Hx
Negative for alcohol or tobacco use Lives with family Works as an accountant

Family Hx
Negative for DM, CAD, HTN No history of cancer No history of colon polyps or ulcerative

colitis

Phys Exam
BP

T RR PR 84/60 98.2 16 84 HEENT: Unremarkable Neck: No lymphadenopathy or thyroid enlargement Heart: RRR, no murmurs or gallop detected Lungs: CTAs

Phys Exam
Abdomen: Soft, mild diffuse tenderness

without organomegally. No abdominal skin rash Extrem: No E,C,C. +ve PP Neuro: AAO, no focal deficits or CN palsies Rectal: No masses, normal tone of anal sphicter with Guiac - ve heme stools

Labs
Hgb

Hct RBCs WBCs Plat 14.2 43 4.99 6.0 211 Na K Cl Co2 BUN Cr Gluc 133 3.0 100 24 13 0.6 111 Urinalysis: Unremarkable T4 TSH 8.5 5.84

Course
Pt continued on IVFs with close monitoring

of I/Os and was given metamucil 2tsp TID Stool cultures grew Gm - ve pathogens Pt started on Ciprofloxacin 400mg IV Q 12hs Subcultures grew salmonella sero group D Flex sigmoidoscopy: Erythema and edema of colon compatible with salmonella colitis Abx D/Cd after one day, diarrhea resolved

Definitions
Increase in daily stool weight above 200gm Increase in frequency, fluidity or amount Differentiate from incontinence and IBS Acute lasts less than 7 - 14 days

Chronic lasts more than 2 - 3 weeks

Acute Diarrhea
INFLAMMATORY

Non-INFLAMMATORY

Fever & bloody with Leukocytes, volume <1L/ 24 hr secondary to colonic damage Shigella, Salmonella, Amebiasis, C.diff, E coli 0157:H7 toxin, Ischemia, UC, Crohns, Cytomegalovirus

Watery with N/V, volume >1L/ 24hr secondary to small intestine disease Norwalk & Rota virus, entrotoxins as Giardia, Staph aureus, Cholera, E coli, Bile acid, Laxatives, Malabsorpt

Evaluation
Most pt with acute diarrhea respond in 5-7

d for rehydration and antidiarrheal agents Isolation rate of pathogen from stool < 3% Stool leukocytes is inexpensive test to differentiate inflammatory vs noninflammatory types Sigmoidoscopy indicated for Proctitis, C diff, UC, Ischemic colitis

Management
Inflammatory Antidiarrheal agents are avoided Moderate to severe cases; start empiric Abx: Ciprofloxacin, TMP-SMA, Erythromycin Always treat: C diff, Amebiasis, Enteric fever, Shigella, STDs Non-inflammatory Rehydration is most important Loperamide offers relief, Anticholinergic contraindicated for megacolon Always treat: Cholera, Giardiasis, Travelers diarrhea

Salmonella food poisoning

Contaminated poultry especially egg yolk Incubation : 8- 48 Hrs Diarrhea, low temp. Bacteria grow on

surface with little invasion No Abx unless immune compromised Pt remains as carrier for up to 2 months

Enteric fever
Caused by Salmonella typhi, incubation 2 w Fever, bradycardia, altered behavior,

constipation followed by diarrhea 2nd week: Rose spots on abdomen & thorax, Spleenomegally and Lymphadenopathy Rx: Chloramphenicol, Ciprofloxacin, Ampicillin

Travelers diarrhea
E coli produces heat labile entrotoxin and

heat stable, causes 40 - 75% Diarrhea lasts 3- 5 days Other pathogens - Shigella, Salmonella, Rotavirus, Giardia Rx: Ciprofloxacin, TMP- SMA, Aztreonam

Chronic Diarrhea
Persists > 2 weeks Do stool cultures, ova and parasites Stool collection for 48 - 72 Hrs for weight ,

fat content, lytes and osmolality Sigmoidoscopy for visualization of mucosa and biopsy

Osmotic Diarrhea
Stool osmotic gap (Normally <50)

Measured - Estimated (Na + K) X 2

Stool volume decreases with fasting
Common causes

Lactose intolerance Sorbitol Laxatives Antacids

Secretory Diarrhea
Increased intestinal secretion or

decreased absorption with > 1 L diarrhea Little change with fasting Endocrine diseases
VIPoma carcinoid Bile salts medullary carcinoma Zollinger- Ellison syndrome Villous adenoma

Inflammatory Diarrhea
Fever , hematochezia and abdominal pain Causes

Ulcerative colitis Crohns disease Microscopic colitis Radiation enteritis Malignancy

Malabsorption
Wt loss, anemia, vitamin deficiency

with

fecal fat > 7 - 10 g/24 Hs Causes

Tropical sprue Whipples disease Pancreatitis Bacterial overgrowth ( vagotomy , diabetes )

Infections
Chronic infectious agents

Giardia Entamoeba histolytica Cyclospora

AIDS related infctions

Cytomegalovirus Cryptosporidium

Motility Disorders
Charachterised by systemic disease or

prior abdominal surgery

Diabetes Mellitus Hyperthyroidism Irritable bowel syndrome