Gastroenterology
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| Defn diarrhea | >3/day; 200 g or ml; loose/liquid consistency
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| Acute/ persistent/ chronic | Acute <14 days; Chronic >1 month
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| Chronic diarrhea: etiology | Malabsorption; motility disorders; inflammation
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| Assessing severity of illness | dehydration; duration of sx; inflammation (fever, blood, tenesmus)
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| Order stool studies if: | Diarrhea is persistent or recurring; h/o fever or tenesmus
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| E. histolytica | necrosis of lg intestine; tropical; abd pain, cramping, colitis; can be bloody/fevers; travelers, MSM
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| Vibrio | watery dia, abd cramping; V para: also wound infxn; heat to >75C to destroy; susceptible: liver dz & Fe overload states
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| V cholera MOA | activates adenylate cyclase (cAMP regulates Na & Cl absorpn/secretion)
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| V cholera S/S | rice-water stools; poss hypotensive shock within 2 hrs; dose fx; tx rehydrate & 1 dose Cipro; untx’d 50% mortality
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| Pre-formed toxins: organisms | S aureus; B Cereus; Clostridium Perfringens
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| Giardia: most susceptible | immunocompromised; immunocompetent w/Ig def
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| Dx giardiasis with: | giardia antigen stool assay
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| C perfringens sx | Abd cramps & watery diarrhea without fever or N/V; lasts <24 hr
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| Invasive pathogens (most common causes of infxs diarrhea) | Salmonella, shigella, campy, hemorrhagic E coli
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| E coli: most likely from: | undercooked beef; unpasteurized juice; spinach; in warm weather
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| E coli: hemorrhagic colitis: | severe abd pain, bloody diarrhea (no fever usually) caused by shiga or shiga-like toxin
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| HUS may be due to: | E coli; shigella
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| ETEC: tx | travelers diarrhea; Abx after sx onset may decrease duration; Cipro or rifaximin
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| Salmonella Sx | fevers, myalgias, abd cramping, HA;
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| Salmonella complications | Septicemia/Bacteremia; poss osteomyelitis, endocarditis, arthritis
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| Salmonella typhi Sx | 10-14d post-ingestion: fever, HA, myalgia, malaise, anorexia; followed by GI sx (GB colonization & intestine reinfxn); typhoid fever: pulse-temperature discordance; 1-5% chronic carriers
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| Shigella Sx | Lower abd cramps, diarrhea, fever, bloody, purulent stools & tenesmus; usu self-ltg (7 days)
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| Shigella Tx | Abx recommended (FQ or Bactrim)
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| Yersinia Sx: | Diarrhea, fever, abdominal pain for 1-2 wks (chronic: poss for mos); fx terminal ileum; lg lymph nodes (mimics appy); systemic dz: high mortality
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| Campy Sx: | dysentery; poss bacteremia; usu self ltg (may last 1 wk/longer); assoc w/GBS & Reiters
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| Most common cause of nosocomial diarrhea | C diff (Abx-induced diarrhea); tx w/Flagyl or oral vanco
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| Loperamide | opiate w/o systemic fx; inhibits peristalsis; can use w/Abx for traveler’s diarrhea
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| DO NOT use anti-motility agents in: | pts w/shigella, C diff, E coli O157 (inflammatory diarrhea)
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| Antimicrobial tx: used for: | shigellosis, traveler’s diarrhea, C.difficile, campylobacter; can prolong salmo/C diff shedding, or worsen shiga toxin course
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| Tx of choice for more severe infxs diarrhea: | FQ; TMP-SMX = 2nd-line tx; Add azithro for Campy
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| Common antibiotic causes of colitis: | Ampicillin, clindamycin, tetracycline, cephalosporins
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| C diff mgmt: | IV/PO Flagyl or PO vanco. 20% relapse in 1-2 wks after DC of therapy; relapses respond well to 2nd course of tx. Multiple relapses: consider taper & pulsed therapy
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| Diarrhea | >3/day or 200 mL; osmotic vs secretory; dx: fecal WBC, occult blood, flex sig/bx, upper GI
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| Diarrhea: inflam vs non-inflammatory agents | inflam: cMV, E histo, EHEC, C diff, SSC; non-inflam: noro, rota, giardia, crypto, SA, B cereus, vibrio cholera
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| Diarrhea: Abx for: | Shigella, cholera, ETEC, C diff; No Abx for salmo, campy, EHEC, Yersinia
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| Oral Rehydration Solution: | 3.5 g NaCl, 2.5 g Na HCO3, 1.5 g KCl, 20 g glucose, in 1L water
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| Traveler’s Diarrhea is caused by: | E. coli (ETEC); tx is hydration & Cipro
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| Greasy, foul smelling, floating stools. Pear-shaped flagellated protozoan w/ 2 “eyes”. Water, travel, camping history | Giardia
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| Afebrile, watery or loose stool. No blood or mucus | Viral Gastroenteritis
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| Abdominal pain, diarrhea after picnic/party. Eaten ham, cream, custards, mayonnaise | Staphylococcus aureus infectious diarrhea
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| Acute bacterial diarrhea w/ prodrome of HA, F, then crampy abd pain & diarrhea | Campylobacter jejuni (most common cause of acute bacterial diarrhea)
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| Most important agent of gastroenteritis in infants | Rotavirus A
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| Other agents of gastroenteritis in infants | Adenovirus (serotypes 40/41); Coxsackie Virus
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| Most important viral agent of gastroenteritis in children/adults | Calicivirus
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| Other viral agents of gastroenteritis in children/adults | Norwalk virus; Astrovirus; Reovirus
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| E. coli groups = small bowel processes | Enterotoxigenic; enteropathogenic; enteroaggregative
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| E. coli groups = colon processes (bloody diarrhea): | enterohemorrhagic; enteroinvasive
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| AIDS-associated diarrhea 2/2: | Mycobacterium avium-intracellulare (MAI)
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| E coli group = in developed countries | Enterohemorrhagic
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| E coli group = more common in pediatric populations (usu developing countries) | Enteropath & enteroaggregative
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| E coli group = most common in developing countries | Enteroinvasive
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| Severe cases of ETEC can be treated with: | SMZ/TMP or quinolone; prophylaxis not recommended
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| Most common cause of BACTERIAL gastroenteritis | C. jejuni
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| Parasitic GI Syndromes in AIDS patients/protracted diarrhea: | MAI, Giardia lamblia, Cryptosporidium parvum, Isospora belli
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| Toxin A = enterotoxin; Toxin B = cytotoxin | C. diff
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| Parasitic GI causes of diarrheal disease | G. lamblia, C. parvum, B. hominis
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| Intestinal amoebiasis | Entamoeba histolytica
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| Rice-water stools; poss hypotensive shock within 2 hrs; dose effects = | Vibrio cholera
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| HUS may be due to: | E coli; shigella ETEC: tx travelers diarrhea
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| Shigella Sx | Lower abd cramps, diarrhea, fever, bloody, purulent stools & tenesmus; usu self-ltg (7 days)
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| Gastroenteritis: Antimicrobial tx: used for: | shigellosis, traveler’s diarrhea, C.difficile, campylobacter; can prolong salmo/C diff shedding, or worsen shiga toxin course
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| Vibrio cholera MOA | stimulates adenyl cyclase in intestinal epithelial cells to overproduce cAMP => H2O & Cl- hypersecretion => diarrhea
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| salmonella: 3 patterns | Enteric (typhoid) fever; gastroenteritis; bacteremia
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| Salmonella: Enteric (typhoid) fever S/S | 5-14d incubation, insidious (kids abrupt); F, HA, ST, myalgia, malaise; abd pain, pea soup diarrhea; pulse-temperature discordance; freq relapse; 1-5% chronic carriers
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| Salmonella: gastroenteritis S/S | most common salmonella type; 8-48 hr incubation; F, N/V, crampy abd pain, bloody diarrhea 3-5d; +stool cx
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| Salmonella: bacteremia S/S | usually in immunocompromised pt; recurrent fever, local infxn (bone, joints, lungs)
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