Transcript Simposium nr. 2

Acute Diarrhea
Session 20.2
Internal Medicine
– Infectious diseases
– Gastroenterology
Pediatrics
Family Medicine
Pharmacology
O&G
Radiology
Introduction
Spectrum of acute infective diarrhea
Mild annoyances to Devastating dehydration
Attack rates in children < 5y
Developed countries: 2-3 illnesses per child
per year
Developing countries: 10-18 illnesses per
child per year
Acute Diarrhea
Case 1
Case -1
•
A 26 year old man complains of severe
abdominal cramps, nausea, vomiting and
diarrhoea for the last 12 hours. He attended
a party the night before he became ill.
•
Benadering
–
–
–
–
Geskiedenis
Ondersoek
Samevatting (Problem list)
Hantering
What do you want to know
from the history?
• Suspected food?
• Time of ingestion
• Duration and
frequency of diarrhoea
• Presence of blood in
stools
• Abdominal pain
• Tenesmus
• Fever
• Current problem list
– Acute food
poisoning with
predominant
vomiting
• Differential diagnosis
– Staph. Aureus
– Bacillus cereus
– Clostridium
perfringens
Definition
Acute diarrhea
• Abnormally increased
– frequency or
– decreased consistency of stools
• < 2 weeks
(< 3 weeks)
Causes of acute diarrhea
(Table 1.25; p 37 - Davidson’s)
• Infectious agents
– Non inflammatory (Toxin
mediated)
– Inflammatory
•
•
•
•
•
Enteroviruses (Rota)
Campylobacter
Salmonellae
Shigella
E Coli
– EIEC, EHEC etc.
• Cl difficile
– Parasites
• Giardiasis
• Amebiasis
• Non- Infectious
– GIT
• Diverticulitis
• IBD
– Metabolic
•
•
•
•
Ketosis
VIP
Carcinoid syndrome
Uremia
– Generalised illness
• Sepsis (meninigococ)
• Pneumonia (atypical)
• Malaria
– Drugs
Drugs that commonly course
diarrhea
• GIT
– Mg++ containing antacids
– Laxatives
– Misoprostol
• CVS
–
–
–
–
–
Digoxin
Quinidine / Procainamid
B-blockers
ACE
Hypolipidemic agents
• Antibiotics
– Erythromycin
– Amox-clav
• CNS
– Lithium
– Valproic acid
– Fluoxitine
• Other
–
–
–
–
Theophylline
Thyroid hormone
Colchicine
NSAIDS
History
• Toxin
• Infectious
– Incubation period
– Incubation period
• < 12 hours
– Fever - NO
– Blood or mucus - NO
– fecal leukocytes - NO
• 24 - 72 hours
– Fever - YES
– Blood or mucus- YES
– Fecal leucocytes - YES
Examination
• General
– Dehydration
• Mild: Thirst, dry mouth, dry axilla, decrease urine output
• Moderate: Orthostatic hypotension, skin tenting, sunken eyes
• Severe: Hypotension, tachycardia, confusion, shock
– Weight and BMI
– Jaundice, anemia, cyanosis, clubbing, lymph nodes,
edema
– Nutritional status
– Other signs of underlying disease
• HIV / AIDS, DM etc.
Management and explanation
•
•
•
•
•
•
•
What is food poisoning?
How did I contract the disease?
Is it contagious?
Diagnostic investigations
Treatment
Prognosis
- Davidson – Table 1.25
General advise
Toxin mediated food poisoning
• It is NOT an infection
• DO NOT GIVE ANTIBIOTICS
• It is a toxemia associated with the ingestion of
preformed microbial toxins
• symptomology occurs rapidly
– usually within 2-12 hours
• toxins either affect
– the intestine (enterotoxin of C. perfringens)
– or the central nervous system (neurotoxin of C.
botulinum)
– or both (S. aureus and B. cereus)
S.aureus toxin
• exotoxins produced by chromosomal genes
– 5 distinct antigenic types (A, B, C, D, E)
– water-soluble, low molecular weight proteins
• heat stable (resist boiling for 30 minutes)
• mode of action is unknown
– enteric effect (diarrhea) +
– neurologic effect (vomiting)
Clinical symptoms
S. aureus
• Incubation period
– 1-4 hours after ingestion of contaminated food
(generally mayonnaise or dairy products)
• Vomiting (often projectile)
• Diarrhea (little or sometimes no )
• no fever
B. cereus toxin
• In meat the enterotoxin is formed
– stimulate cAMP and cause fluid accumulation in the
intestine
– profuse diarrhea with a little vomiting
– 10-14 hours after ingestion
• In rice or pasta the neurotoxin is formed
– vomiting
– 2-3 hours after ingestion (?mechanism)
– little diarrhea
– no fever
C. perfringens toxin
• heat-labile protein (34000 mw)
– inhibits glucose transport in intestinal epithelial cells
– damages the intestinal epithelium and causes protein
loss into GI lumen
– activity is maximal in the ileum and minimal in the
duodenum
• profuse diarrhea
– +/- 12 hours after ingestion of meat
• little or no vomiting
• no fever
C. botulinum toxin
• 8 antigenic types (A, B, C1, C2, D, E, F, G)
– Types A, B, E, F and G are coded by chromosomal
genes.
– C1 and D are coded by phage genes that are lysogenic
in C. botulinum.
– Types A, B and E cause almost all human botulism.
– All toxins are proteins of 150,000 molecular weight
– prevent release of acetylcholine at the neuro-muscular
junction causing a flaccid paralysis
C. botulinum
• Incubation period
– 6 hours to 8 days after ingestion of green beans,
peppers, chili or sausage.
– a function of the amount and antigenic type of toxin
ingested
• symmetric impairment of cranial nerves
• followed in a descending pattern by weakness or
paralysis of the muscles of the extremities and
trunk
physical examination
C. botulinum
• No fever
• ophthalmoplegia and ptosis of the eyelids are
usually prominent
• decreased gag reflex
• facial weakness
• Mental status and deep tendon reflexes are normal
• Characteristic EMG findings
• Nerve conduction studies, blood cell counts,
urinalysis, serum electrolytes, cerebrospinal fluid
and blood enzymes are normal.
Diagnosis
C. botulinum
• Other toxemias
– are not severe and symptoms generally disappear within
24 hours
• Presumptive diagnosis
– by the presence of a rapidly descending paralysis
• A history
– ingestion of home canned food or honey
• Confirmative diagnosis
– botulinal toxin in the patients serum or feces or
– in incriminated food using a mouse toxin-neutralization
test
Differential diagnosis
C. botulinum
• Guillain-Barré syndrome
– ascending paralysis, paresthesias or other sensory
abnormalities, elevated CSF protein, a history of an
antecedent viral infection
• Myasthenia gravis
– descending paralysis, muscle fatigability, response to
endrophomium
• Other food poisonings and gastroenteritis
– no cranial nerve involvement
• Chemical (non-microbial) food poisonings
– symptoms occur within minutes of ingestion
Treatment
C. botulinum
• replenishment of fluids and electrolytes
• ? botulism
– admit to ICU
– monitoring of respiratory and cardiac function
– Airway patency should be guaranteed
• ET tube or tracheostomy
• before bulbar or respiratory impairment becomes
severe.
Treatment
C. botulinum
• Induction of vomiting or gastric lavage
– if exposure has occurred within several hours
• purgation
– unless there is paralytic ileus
– even after several days, to facilitate possible
elimination of unabsorbed toxin from the
gastrointestinal tract
– alternately, high enemas may be used
Treatment
C. botulinum
• Injectable therapeutics sometimes used include:
– Trivalent (ABE) equine-origin botulinal antitoxin to
neutralize unabsorbed toxin.
– Guanidine hydrochloride to increase release of
acetylcholine from nerve terminals.
– 4-aminopyridine to increase release of acetylcholine.
ANTIEMETICS
• Domperidone
– is a dopamine blocker selective for the CETZ
• Less selective dopamine blockers
– Metoclopramide
– Promethazine (Aterax®
– Neuroleptics
25 mg 4-6 hourly)
• such as prochlorperazine (Stemetil®)
• initially 20 mg, followed by 10 mg 2 hours later if necessary
• Avoid in children under 2 years, or weighing less than 10
kg
• Phosphorated carbohydrate
Emetrol® Also: Emex®
• solution, sucrose 3.77 g, phosphoric acid 0.025
g/5 mL
Adult dose: Undiluted, 10-20 mL as required.
Paediatric dose: 5-10 mL as required (10-15
minutes before feeds for vomiting and
regurgitation in infants).
• Vomifene® tablets
– buclizine HCl 25 mg, pyridoxine 50 mg
Adult dose: 1-2 tablets 3 times daily
Cyclizine
Valoid®
– piperazine-type antihistamine used to prevent
and treat motion sickness, vertigo, nausea and
vomiting caused by labyrinthine disorders
(including Meniere's disease), and by other
conditions.
– less sedative than promethazine, although
individual variation in its sedative and
anticholinergic effects is common.
Serotonin (5HT3) antagonists
• ondansetron, granisetron and tropisetron
• control of nausea and vomiting induced by
chemotherapeutic agents
– Chemotherapeutic agents and radiotherapy may
cause release of 5HT in the small intestine
– thus activating vagal afferents, which in turn
may cause release of 5HT in the area prostrema
of the fourth ventricle resulting in vomiting
Acute Diarrhea
continue
Case 2
Case– 2
• ‘n 40 jarige MIV positiewe dame
– Koors
– Bloederige diaree
– Dehidrasie
• Benadering
–
–
–
–
Geskiedenis
Ondersoek
Samevatting (Problem list)
Hantering
History
• Problem list
– Dehydration
• Assess
severity
– Infectious diarrhea
• Fever
• Bloody stools
– Immune-compromised
• ?CD4
• Differential diagnosis
– Enteric viruses
– Bacteria
• Campylobacter
• Shigella
• Non-typhoid
salmonellae
• Entero-invasive E. coli
• Enterohaemorrhagic
E.coli (EHEC / VTEC)
• Cl. Difficile
– Parasites
• E. Histolytica
• Cryptosporidium
Treating infective
diarrhea
1.) Maintaining or correcting hydration and
electrolyte loss:
 Home made oral hydration fluid
 1 litre of clean or boiled water
 5 teaspoons of sugar
 ½ teaspoon of salt
 Take 1 – 2 cups of this fluid or more, after every
diarrhoeal stool
Diarrhoeal disease
2.) First line treatment for
uncomplicated diarrhoea:
 TMP-SMX (BactrimR, SeptranR etc.)
2 tablets 2 X per day for 5 to 7 days
+
 Flagyll
200 - 400mg 3 x per day for 5 to 7 days
Diarrhoeal disease
3.) Symptomatic treatment:
 Codeine phosphate
 10mg q 6 – 8 hourly or
 Loperamide (ImodiumR)
 2 tabs stat, then 1 tab after each loose stool to a
maximum of 4 tabs per 24 hours
 only if the patient does not have:
 fever of > 380C
 severe abdominal pain or
 bloody stools
Diphenoxylate (2,5mg) +
Atropine (0,025mg) Lomotil®
• Opiate like constipating effects
• Drowsiness, Anticholinergic symptoms
• Avoid
–
–
–
–
Severe liver disease
Pseudomembraneous EC
Infectious diarrhea (<2y)
IBD _ Toxic megacolon
Loperamide - Imodium®
• 2 mg tablets
– 4mg stat then 2mg after each loose stool
• Structurally related to pethidine
– Binding to opiate receptors
• CI – same as for lomotil
• Well tolerated
– Dry mouth, blurred vision
When to refer a patient with
diarrhoea to hospital?
• Severe dehydration or unable to take oral
rehydration fluid
– (e.g. due to persistent vomiting or unable to swallow
because of weakness or to painful to swallow)
•
•
•
•
Fever > 380C
Severe abdominal cramps or pain
Bloody diarrhoea
Diarrhoea not responding to first line therapy
within 5 days
• Persistent diarrhoea or
diarrhoea lasting for > 3 weeks
Acute Infectious diarrhea in
AIDS
1. Enteric viruses
•
•
•
•
•
•
•
Adenovirus, astrovirus, picornavirus, calcivirus
15 – 30%
Most labs cannot detect these virusses
Watery diarrhea, acute
1/3 become chronic
Any CD4
Supportive treatment
Acute Infectious diarrhea in
AIDS
2. Non Typhi- Salmonella
–
–
–
–
–
5-15%
Watery diarrhea, fever, variable fecal WBCs
Any CD4 count
Stool + Blood cultures
TMP-SMX (1 DS b.d x 14 days)
•
–
or Ciprofloxacin or 3rd gen Cephalopsporin
May need to be extended for > 4 weeks
Salmonellae
• gram- bacilli, facultative
anaerobic
• members of the
enterobacteriaceae
• may persist within the
RES
• motile with flagellae
• non-encapsulated
– except for S typhi and S
paratyphi C both of which
express the Vi Ag
flagellae
O Ag
Vi Ag
Salmonellae
• H Ag – serotype
H Ag
• O Ag = LPS / endotoxin
– Lipid A = biologically
active component
– Toxic to cells
– Group (A-E)
– hypersensitivity reactions
– fever, leucopenia,
hypotension, DIC, death
O Ag
Vi Ag
• Vi Ag – virulence or
invasiveness
Serotype (O + H Ag)
• Gastroenteritis
– > 2200 different
organisms
– S. enteritidis + S.
typhimurium
• Distributed throughout the
animal kingdom
• Contaminated food or
water
– poultry, eggs, fast foods
– may persist for months in
cheese, frozen meat, or
ice cream
• Enteric fever
– S typhi
– S paratyphi
• A
• B - scottmuleri
• C - hitchfeldi
• Purely human
pathogens
symptomatic infection is
influenced by
• number of organisms
– >104 to 106 : higher
rates of illness +
shorter IP
– even 5 to 100
organisms may
cause disease in
susceptible hosts
• Asymptomatic
excretion may occur
• Water supplies are
contaminated at lower
levels than food
• serotype
• intrinsic virulence
factors
• host immune
response
– antibiotic use
– achlorhydric states,
gastric surgery and
antacids or H2
blockers or PPI’s
Other host factors
• Cell-mediated immunity
– glucocorticoids , AIDS , and malignancy
• polymorphonuclear leukocytes
– sickle cell anemia, malaria ,
schistosomiasis, and histoplasmosis
• humoral immunity
Acute Infectious diarrhea in
AIDS
3. Shigella
–
–
–
–
–
–
1-3%
Watery diarrhea or bloody
Fever, fecal WBCs is common
Any CD4 count
Stool culture
TMP-SMX (1 DS x 3 days)
•
ciprofloxacin
Acute Infectious diarrhea in
AIDS
4. Campylobacter jejuni
•
•
•
•
•
•
4-8%
Watery diarrhea or bloody
Fever, +/- fecal WBCs
Any CD4
Stool culture
Erythromycin 500 mg qid x 5 days
Acute Infectious diarrhea in
AIDS
5. Idiopathic
–
Variable non infectious causes
•
•
•
–
–
Any CD4
Negative studies
•
–
Rule out medication
Dietary
IBS
Stool + blood culture, O+P, neg C difficili toxin
If severe
•
Ciprofoxacin +/- metronidazole
Acute Infectious diarrhea in
AIDS
6. Clostridium difficile
•
•
•
•
•
•
•
10-15%
Watery diarrhea, +/- WBCs, Fever, leucocytosis,
Previous AB: Clindamycin, Ampi, cephalosp
Any CD4
Stool toxin
Endoscopy
CT scan
•
•
Metronidazole: 400mg tds x 10 –14 days
•
•
Colitis with thickened mucosa
or Vancomycin po
Antiperistaltic agents are contraindicated
Pseudomembraneous enterocolitis
normal
mucosa is
replaced by
pseudomemb
ranous
plaques of
fibrin,
cellular
debris, and
neutrophils
If normal intestinal flora is altered, colonization by toxigenic C.
difficile can occur
Novel treatment for
toxigenic C. difficile
• Immunoglobulins
• "probiotics"
– nontoxigenic C. difficile
– Lactobacillus GG
• "bacteriotherapy"
– with enemas using normal stool flora or other bacteria
• Saccharomyces boulardii
– a nonpathogenic yeast
• partial to total colectomy
– sepsis and toxic megacolon or ileus
Diagnostic approach
Fecal WBCs or
lactoferin
Invasive colitis
• Shigella
• Campylobacter
• C difficile
• EHEC
Chronic Infectious diarrhea in
AIDS
•
•
•
•
Cryptosporidium
Entamoeba Hystolitica
Giardia Lamblia
CMV
Mycobacterium avium complex
• Microporidia
• Isopora belli
• Idiopathic
Acute Diarrhea
continue
Case 3
Case 3
• 50 jarige man
– Vorige gastrektomie
– Terug van ‘n reis na Indië
•
•
•
•
(Suid Afrika)
Malaise, anoreksie, delirium
Hoe koors, hoofpyn
Buikpyn
Geringe diaree (hardlywigheid)
p57 Davidson
Typhoid fever
Enteric fever
or paratyphoid fever
= SEPTICAEMIA
SYSTEMIC INVASIVE INFECTION