Eghan BA

Normal stool <200g/day 60-85% is water Normal bowel frequency 3X/week to 3X/day Stool wt depends on
Consistency Frequency Fibre content of diet Gender( wt of females< men)

Pseudodiarrhoea or hyperdefecation
Increase stool without weight increase.

Diarrhoea
Daily stool>200/day Abnormal increase in stool liquidity and frequency

Acute diarrhoea
Lasting<2weeks

Chronic diarrhoea
Lasting > 2weeks

Accounts for 4 million death in children Factors

Inadequate sewage disposal Good water supply

Most common cause of acute diarrhoea is infectious agents Ingestion of drugs and toxins May also be the onset of chronic diarrhoea

Faeco-oral transmission by way of water or food contaminated with human waste as a result ot poor sewage system or by domestic animal faeces in inadequately purified water. Beef, pork and poultry not properly cooked.

Food preparing surfaces may be contaminated by organism. Person-to- person through aerosolization rotavirus Contamination of hands and surfaces by (Clostridium difficile)

High rise of acute infective diarrhoea in travelers to or recently returning from developing nations. Persons ingesting shell fish

Typical presentation of acute diarrhoea:

Nausea Vomiting Crampy Abdominal pain Fever

Diarrhoea may be bloody, watery or malabsorptive depending on the cause.

Nausea Vomiting Abdominal pain Cramping

Ingestion of toxin or toxigenic infection

Nausea, vomiting prominent, cramping abdominal pain and rarely fever.

If parasitic and not invading mucosa eg Giadia lamblia and crytosporidium: mild abdominal pain. Steatorrhoea associated with giadia, gaseousness, bloating.

Invasive bacteria like Campylobacter, salmonella, shigella and those producing cytotoxins clostridium diffecile and enterohaemorrhagic E coli produce abdominal pain and fever. Some times peritoneal irritation suggesting surgical abdomen. Yesinia often affects terminal ileum and present right lower quadrant pain and tenderness suggestive of appendicitis.

Watery diarrhoea is typical of

organisms invading the intestinal epithelium with minimal inflammation. Eg enteric viruses. Those adhering but do not destroy epithelium. Eg enteropathic or enteroadherent E.coli, protozoa and helminths. Those producing enterotoxins which do not invade intestinal mucosa.

Both shegellosis and infection with enterohemorrhagic E. coli present with HUS especially in the very young or very old. Yesinia and other enteric bacteria infection may accompany Reiters syndrome (arthritis, urethritis and conjuctivitis), thyroiditis, pericarditis and glomerulonephritis

Medication GI drugs
Magnesium drugs Laxative Misoprostol

Cardiac drugs
Beta blockers ACEI Hydrallazine

Antibiotics
Clindamycin Ampicillin Cephalosporin Erythromycin

Lipid lowering agents

Clofibrates Gemfibrizol Lovastatin

Psychiatric drugs
Lithium Flouxetine Ethosuximide Valproic acid Theophilline Thyroid hormones Colchicine NSAIDS Organophosphates insecticide

Other drugs

Mushrooms Arsenic Caffeine

Acute diarrhoea with no fever, no blood, no dehydration is self limiting resolves by itself; no investigation Investigate if
Patient has fever Toxic bloody diarrhoea Dehydration

Outbreak Recent travel overseas, Immunocompromised Recent antibiotic use

Freshly collected stool should be examined for occult bloodand and WBC
Polymorphs: Salmonella, shigella, invasive E coli, Yesinia, E. histolytica.

Blood culture: Stool culture

Most labs examine stools for salmonella, Yesinia, shigella and campylobacter Special arrangement for c. difficile (culture and toxins), enterohaemorrhagic E. coli

Special cultivation or staining for diarrhoea caused by: Aeromonas Crytosporidium Vibrio species

Fluid replacement
Antibiotic in diarrhoea is controversial Consider antibiotic in the following:
Shigellosis Travellers diarrhoea Pseudomembranous enterocolitis Cholera Parasitic disease Oral Intravenous fluid

Regardless of the cause of the infectious diarrhoea patients should be treated if they:
Are immunocompromised Have a malignancy Abnormal heart valve Vascular or orthopaedic prosthesis Haemolytic anaemia Extremely young or old.

No anticholinergics or opiates if the diarrhoea is enteroinvasive because of the risk of prolongation of colonization or causing an ileus.

Chronic diarrhoea
Lasting > 2weeks

Categorized as Inflammatory Osmotive(malabsorption) Secretory Intestinal dysmotility Factitious

Characterised by fever, abdominal pain, tenderness, blood or leucocyte in stool. Inflammatory lesions on intestinal biopsy. Examples:
Ulcerative colitis, crohns disease, radiations enterocolitis, eosinophilic gastroenteritis, aids enteropathy

Occurs when an orally ingested food is not fully absorbed it exerts an osmotic load drawing fluid into the intestinal lumen. Examples
Clinical symptoms because of malabsorption of fat (steatorrhoea) or carbohydrate. Malabsoption of protein and amino-acid (azothorrhoea) not easy to recognise. Mostly recognised when patients become malnourished.

Pancreatic exocrine insufficiency when 90% of secretory capability is lost with chronic pancraetitis or pancreatic ductal obstruction. Cystic fibrosis in children Steatorrhoea from giadia, strongilodes Chronic ingestion of certain fruits, candies gums and foods Bacterial overgrowth of a blind loop or a segment of a stasis leading to steatorrhea Celiac sprue and gluten sensitive enteropathy

Characterized by large volume of faecal output caused by abnormal fluid and electrolytes not necessary related to ingestion of food. Diarrhoea persist with fasting. Examples are those mediated through hormones.
Metastatic Carcinoid tumours of the gut: diarrhoea flushing, skin lesion cynosis, pellagra-like skin lesions, cardiac murmur and brochospasm. Zolinger Ellison syndrome; recurent refractory and unusually located peptic ulcers due to gastrinoma.

Diarrhoea associated with disorders affecting intestinal motility.

IBS: Diarrhoea alternating with constipation and sometimes abdominal pain and passage of mucus and a sense in incomplete evacuation.

Self induced by the patient and may result from intestinal infection and addition of water and urine to the stool or self medication with laxative