Transcript Diarrhea and Constipation - Calgary Emergency Medicine

Diarrhea and
Constipation
Nadim J Lalani
September 9, 2004
Diarrhea: Epidemiology
4 million deaths worldwide /year…100,000
child deaths (<5yrs) / day.
US: 20 million diagnoses, 200,000
hospitalisations and 400 deaths per year.
[Rosen’s Emergency Medicine. 5th Ed. 2002. Mosby ]
Definitions
Diarrhea: stool weight greater than 200 g in 24
hours. Clinically - a change in stools, usually
defined as passage of three or more loose or
watery stools in 24 hours. Acute diarrhea lasts
less than 14 days.
Gastroenteritis: Gut inflammation with diarrhea
and vomiting
Dysentery: Diarrhea with blood and/or mucus.
Beware of vomiting kids! (need broad DDx)
Case #1 “Turkish trots”
Mr. Montezzuma is a 35-year-old who
presents with a 4-day history of abdominal
cramps, headache, and 8-10 episodes/day
of watery diarrhea. He has had a few
episodes of vomiting but denies fever or
bloody diarrhea. He was previously
healthy.
What else?
HISTORY:
What do they mean by “diarrhea”.
Features (onset, blood?)
Other Symptoms (vomits, cramps,
fever)
Travel / Camping
Infectious Contacts
Recent Meds?
What food ? Potential toxins?
Medications, PmHX, FmHx Surg. &c.
Case 1 (cont’d)
He just spent a week in New Delhi. He
loves to immerse himself in other cultures
“when in Rome man!” and states that he
couldn’t keep himself from sampling
various roadside delicacies.
No one else sick, no meds, no surgeries.
What now?
P/E: afebrile, normal vitals,well dehydrated
but has a diffusely tender abdomen with
hyperactive bowel sounds but no rebound
or guarding.
DDx?
Likely organisms?.
What if no clear travel history/camping &c.
Differential – 5 I’s
Infectious
1. Nausea and vomiting predominant
- Bacillus cereus
- Staph. Areus
- C. perfringens (gives more diarrhea though)
pre-formed toxins cause sympts < 6 hrs
short course which resolves within 24 h.
2. Diarrhea predominant
Small bowel
Large bowel
[S.Coderre/2003]
Small bowel (aka non-inflammatory):
watery, less pain (cramps), large volume
- due to mucosal hypersecretion and abN absorption.
Fever and systemic symptoms usually absent.
Viruses
Bacteria
-- C. perfringens
– Vibrio cholera
-- E. coli (ETEC)
-- Salmonella*
-- Yersinia*
 Parasites – Giardia
*can give “large bowel” sympts.
Large bowel (aka inflammatory):
Bloody, painful, urgency, small volume due to
invasion of mucosa. More fever, malaise, and
myalgia.
 Bacteria – Campylobacter
-- Shigella
-- E. Coli 0157:h7
-- C. Difficile *
Parasites – E. histolytica
* Colonic invasion but with small bowel sympts.
The 5 I’s (cont’d)
Inflammatory
 Non-bloody (Crohn’s Ileitis)
 Bloody
(Ulcerative Colitis and
Crohn’s Colitis)
IBS
Ischemia
Impaction with overflow
Back to Case #1
a 4-day history of abdominal cramps,
headache, and 8-10 episodes/day of
watery diarrhea. He has had a few
episodes of vomiting but denies fever or
bloody diarrhea.
Is any work up indicated here?
Who gets worked up?
Main two:
1. Diarrhea >5 days
2. Bloody diarrhea
Stool cultures +/- C.diff toxin
O & P with suggestive travel histories,
immunocompromised, diarrhea >14 days,
when the diarrheal illness is unresponsive to
appropriate therapy.
Blood cultures when bacteremia or systemic
infection suspected.
“Delhi belly”: To treat or not to treat?
Mostly ETEC infections(40-50%).Generally do not require antibiotic
therapy. Treatment is mainly supportive (fluids).
Sandford 2003:
Mild Diarrhea (≤3 unformed stools/d minimal sympts) Rehydration
Moderate Diarrhea (≥4 stools/d +/- systemic sympts) add antimotility
agents
Severe Diarrhea: see below
Antibiotics for:
severe invasive (bloody) or >6 episodes/24 h or Fever > 38.5
 high risk: elderly, diabetics, cirrhotics, and immunocompromised
patients,
 empirical treatment with a quinolone antibiotic for 3 to 5 days.
[Oldfield III EC, Wallace MR. The role of antibiotics in the treatment of
infectious diarrhea. Gastroenterol Clin North Am. 2001;30:817–836. ]
Antibiotics and Antimotiliy Agents:
Ciprofloxacin (Cipro) one 750-mg dose.
In the absence of dysentery, Loperamide (Imodium),
4mg at the start of diarrhea, followed by 2mg after each
loose stool (maximum daily dosage: 16 mg) . Can also
give Pepto-Bismol 2 tabs (262 mg) PO QID.
Cipro vs placebo for severe diarrhea decreased duration
of diarrhea and symptoms but did not change fecal
carriage (NEJM 340: 1525, 1999)
[Note: Ddx for traveller’s includes: ETEC, Shigella, Salmonella, Campylobacter,
Giardia.]
Case #2: Disney’s Cruise Runs
Marge is a 65 yo retired, just went on a
cruise to Alaska and came back with 3-4
days of loose/watery stools and some abd
cramping. Her husband and friends also
came down with “the runs”. Otherwise
well. Nothing else on history. PE normal.
Likely org?
Viruses in Alberta mostleast:
Rotavirus:
generally kids, in winter and hospitalised.
Adenovirus 40/41,Caliciviruses and
Astroviruses (kids/daycare)
Norwalk/Norwalk-like:
adults, eldercare facilities.
No Rx. Supportive care. NOTE:
dehydration in kids and elderly
Case #3: “I let the colonel do the
cooking last night!”
Rob got tired of cooking steaks and went
out for some finger-lickin’ goodness.
Developed intermittent fever, crampy
abdominal pain x 1 day. Now has had low
volume bloody diarrhea 8-10 times a day
for three days. Well hydrated otherwise
perfectly healthy. No other Hx. PE normal.
Likely organism?
Campylobacter factoids:
The most common bacterial cause of food-borne illness.
Contaminated food mostly chicken
Can mimic appendicitis.
“Campylobacter is the single most identifiable
antecedent infection associated with the development of
GBS …via molecular mimicry”.
Incidence < 1/1000
[Nachamkin I; Allos BM; Ho T Campylobacter species and GuillainBarré syndrome.Clin Microbiol Rev - 01-JUL-1998; 11(3): 55567]
Other factoids:
Yersinia can perfectly mimic appendicitis
because it causes terminal ileitis.
If someone has been eating oysters/
shellfish think Vibrio parahaemolyticus.
Vibrio cholera causes a secretory diarrhea
that can result in profound hypovolemia.
The volume of fluid lost through the stools
in 24 hours can vary from 5 ml/kg (near
normal) to 200 ml/kg
Rehydration in the Field
Ceralyte, Pedialyte, or generic
solutions.
Make your own: 4 tsps sugar,3/4 tsps
of salt,1 tsp baking soda,one cup
orange juice, dilute with water to one
litre. [Dr Ukrainetz 2002]
Fluids given = fluid loss
Rehydration (con’td)
WHO-recommended solutions can also be prepared by a
pharmacy by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or
2.9 g of Na citrate), 1.5 g of KCl, and 20 g of glucose or
glucose polymer (e.g., 40 g of sucrose or 4 tablespoons
of sugar or 50-60 g of cooked cereal flour such as rice,
maize, sorghum, millet, wheat, or potato) per liter of
clean water. This makes a solution of approximately Na
90 mM, K 20 mM, Cl 80 mM, HCO3 30 mM, and glucose
111 mM.
[Guerrant RL Practice guidelines for the management
of infectious diarrhea. Clin Infect Dis - 1-FEB-2001;
32(3): 331-51]
Case #4: “Hey! Everyone needs a
colectomy!”
65 yr old male, major tooth pain and likely
abscess. The dentist gave him
clindamycin which helped. Four weeks
later he begins to have profuse watery
stools 6-10 times a day. Now has a lot of
abd pain. No remarkable Hx. PE: diffuse
abdominal tenderness +ve peritonitis
warm, flushed, shocky appearing.
Likely pathogen?
C Difficile:
2001-2004 1167 cases in Calgary.
Previous Hx Antibiotics: Clinda >
Cephalosporins > Penicillins. (but any Abx
can do it).
Avoid use of clinda for dental abscesses
use Penicillin instead.
Treated with flagyl or vanc. High risk may
need prophylaxis.
C. Diff (cont’d)
The first reported case of
pseudomembranous enterocolitis (PMC)
was reported by J. M. Finney in
association with William Osler in 1893.
The most common clinical setting in those
cases not associated with antibiotic
therapy was colonic, pelvic, or gastric
surgery.
C diff cont’d
Other risk factors: spinal fracture, intestinal obstruction,
colon carcinoma, leukemia, severe burns, shock, uremia,
heavy metal poisoning, hemolytic-uremic syndrome,
ischemic, cardiovascular disease, Crohn’s disease,
shigellosis, severe infection, ischemic colitis, and
Hirschsprung disease.
There is no definitive explanation but it may be related
to alterations in host defense mechanisms and enteric
flora. Several postoperative cases were related to
hypotension and shock, suggesting an ischemic origin.
Case #5: “badabababa…I’m luvin
it”
Pierre is a 5 yo brought to the ED by his
mother with a 2-day hx of severe
abdominal cramps and diarrhea (5 to 7
watery stools daily). Today noticed blood
in his diarrheal stools. No fever or vomiting
He refuses to eat, but has been drinking
well. Not sure of urine output. Previously
healthy, no significant weight loss or other
symptoms.
Case #5: Hx
Traveled to USA a month ago, No
camping, no one else sick, baby sister
goes to daycare. He eats eggs, veggies,
meats especially hot dogs and chicken
tenders. He likes apple juice, and his older
brother has a pet Iguana.
Case #5 (cont’d)
P/E: afebrile, normal blood pressure,
normal respirations and normal cap refill.
Dry mucosa, but skin turgor is normal.
Abdomen: hyperactive bowel sounds, mild
distension, and diffuse tenderness, but is
soft with no rebound or guarding. He has
grossly bloody soiling of his underpants.
Ddx?
Work up?
Case# 5
Pierre later admits having eaten a burger
at his friend’s house…but he says it was
brown in the middle not pink.
You do a Stool C & S.
What treatment?
The lab calls you with the results of the
stool culture. Pierre's stool grew E. coli
O157:H7.
E.Coli o157:H7 Abx or no?
Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the
hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli
O157:H7 infections. N Engl J Med. 2000;342:1930–1936.
prospective cohort study of 71 children < 10 years old
who had diarrhea caused by E. coli O157:H7.
HUS developed 10 children (14%). Five of these 10
children had received antibiotics.
treatment with antibiotics (RR 14.3)(95% CI 2.9- 70.7)
was significantly associated with HUS.
Conclusions: Antibiotic treatment of children with E. coli
O157:H7 infection increases the risk of the hemolyticuremic syndrome.
Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic
syndrome after antibiotic treatment of Escherichia.coli O157:H7
enteritis: a meta-analysis. JAMA. 2002;288:996–1001
meta-analysis of 9 studies published between 1990 and
2000.
Total of 1111 patients; 16% (range among studies, 8%35%) developed HUS.
The pooled odds ratio was 1.15 (95% confidence
interval, 0.79–168)
Conclusion: “meta-analysis did not show a higher risk of
HUS associated with antibiotic administration. A
randomized trial of adequate power, with multiple distinct
strains of E coli O157:H7 represented, is needed to
conclusively determine whether antibiotic treatment of E
coli O157:H7 enteritis increases the risk of HUS”.
Commentary:
The authors note the major limitation of the metaanalysis: they were not able to analyze the risk of HUS
according to choice of antimicrobial agent or timing and
duration of therapy.
Some in vitro studies and animal models suggest the
importance of drug choice, drug timing, and infecting
strain.
Some studies indicate that early treatment with an
appropriate dose of an appropriate antimicrobial agent
may reduce the risk of HUS. Other studies indicate that
antimicrobial agents may be detrimental.
Perhaps the currently available data, including the metaanalysis, are insufficient to resolve this issue.
What about adults?
Adults can certainly get HUS 5-10% of
adults in nursing home outbreaks of which
mortality is as high as 80% [Rosen’s 2002]
No data on whether treatment causes
HUS in adults.
Inflammatory Bowel
Excacerbations
Crohn’s Disease: Mild diarrhea (not
bloody), Abd pain and fever w/ spont
improvement.
45% Ileocolitis
35% Ileitis
20% Colitis – rectal bleeding
Can cause SBO
Extra intestinal manifestations
Inflammatory Bowel
Excacerbations
Treatment:
metronidazole (10 mg/kg/d in divided
doses) or ciprofloxacin (500 mg twice a
day) as adjunctive treatment with 5aminosalicylates (ASA), steroids, or
immunosuppressive agents
[Isaacs KL; Sartor RB Treatment of inflammatory bowel
disease with antibiotics. Clin North Am - 01-JUN-2004;
33(2): 335-45]
Inflammatory Bowel
Excacerbations
Ulcerative Colitis: bloody diarrhea, rectal
bleeding (v common) Abd pain, tenesmus,
fever, wt loss, fatigue anorexia.
More extra abdominal sympts
Look out for toxic megacolon, perforation,
LBO, GI haemorrhage
Inflammatory Bowel
Excacerbations
Treatment:
Sulfasalazine 2-6g/d divided doses
High dose steroids for severe acute colitis
(fever, anemia, tachy, >6-8 stools/d)
Hydrocortisone 100mg IV q 6-8h
Methylprednisone 20mg Iv q 6-8h
Inflammatory Bowel
Excacerbations
Disposition (Both): Admit the dehydrated
sickies.
Case #6: “post partum blues”
1 week old male, born at 36 weeks, normal
delivery, babe is perfectly healthy. Parents
noticed some blood in the babe’s loose poops a
couple of days. Now baby lethargic.
Ddx?
Milk allergy
Anal fissure
Infectious diarrhea
NEC
Necrotizing enterocolitis
NEC typically seen in the NICU, occurring
in premature infants in their first few weeks
of life. Occasionally, it is encountered in
the term infant, usually within the first 10
days after birth.
Neonatal stress leading to hypovolemia,
bowel ischemia and
Necrosis can lead to perforation, sepsis,
and death.
Necrotizing enterocolitis
typically present appearing quite ill, with
lethargy, irritability, decreased oral intake,
distended abdomen, and bloody stools.
Nb Symptoms might present fairly mildly,
with only occult blood-positive stools.
High index of suspicion with birthing
stress/anoxia.
plain abdominal film shows pneumatosis intestinalis,
caused by gas in the intestinal wall.
Management
fluid resuscitation, bowel rest, and broadspectrum antibiotic coverage.
Early surgical consultation
>80% survival
Case #7: “mmm… is that currant
jelly?”
Billy is an 8 month old brought in by
parents because of intermittent abd pain,
vomiting and bloody/mucousy stools.
History unremarkable
PE shows distended and tender abdomen.
Normal vitals.
Ddx?
Gastro, Meckels, Intussusception
Intussusception
80% occur before 24 months
4:1 boys to girls
Palpable “sausage shaped mass” not
always found.
Current jelly stools are a late sign (20%)
Rectal bleeding 50%
Lethargy increasingly recognized as
significant
Intussusception
Diagnosis:
Films unreliable. May be normal  show
signs of obstruction.
The barium enema has been the gold
standard for diagnosis and treatment of
intussusception.
air enemas being used increasingly (faster
and safer).
Clinical assessment of volume
status:
Presence of > or = 2/4 high yield criteria is
87% sensitive in detecting > 5%
dehydration
Dry mm
Ill appearance
No tears
Cap refill > 2 secs
(Acad Em Med 1996)
Mild
Moderate
Severe
Infant 
5%
10%
15%
Child
3%
6%
9%
Heart Rate
Normal
Mild tacchy
Severe tacchy
BP
Normal
orthostatic
low
Cap Refill
< 2s
2-3s
>3s
Skin temp
Normal
Slightly cool
Cool
Skin Turgor
Normal
Slow retraction
Tenting
Fontanelle
Normal
Slight depress’d
Sunken
Eyes
Normal
Slight sunken
Severe sunken
Tears
Normal
decreased
Absent
Mucous Membs
Normal
dry
Parched
Mental Status
Alert
Irritable
Lethargic
Urine output
decreased
Very low
anuria
Case # 8: Full of Sh*&!
Mr Farley 54 yo, convinced he is just
bunged up. No exercise, drinks little H20,
eats only carbs and occasional meat. No
Meds no other illnesses.
PE: distended abd. Feels full of stool
You need to de-bung this guy …what
approach?
De-bunging:
Get an AXR
R sided stool-oral fleet(NaPO4)
L sided stool-rectal fleet/glycerine
suppository one prn
R and L--oral/rectal
Conservative treatments include
increasing fibre (Psyllium), exercise,
adequate hydration, use of stool softeners
and cathartics.
Rectal fecal Disimpaction:
Try warm water, can then go onto
phosphate soda enemas, saline enemas,
or mineral oil enemas followed by a
phosphate enema.
May need pain control with manual
disimpaction.
CONSTIPATION:
Straining in >¼ defecations
Lumpy or hard stools in >¼ defecations
Sensation of incomplete evacuation in >¼ defecations
Sensation of anorectal obstruction/blockade in >¼
defecations
Manual maneuvers to facilitate >¼ defecations (e.g.,
digital evacuation, support of the pelvic floor) and/or
<2 defecations/week
Loose stools are not present, and there are
insufficient criteria for IBS
[Thompson WG, Longstreth GF, Drossman DA, Heaton KW, IrvineEJ,
Muller-Lissner SA. Functional bowel disorders and
functionalabdominal pain. Gut 1999;45(suppl 2):II43-II47]
CONSTIPATION:
Depending on what you read as prevalent
as 2% to 25 %.
Primary
 Slow transit/ Colonic inertia (problem with
peristalsis +/- diet +/- culture)
Pelvic floor dysfunction (hypertonic vs
hypotonic)
Secondary (Meds, other conditions)
Secondary causes of Constipation:
Drug effects
Mechanical obstruction
Colon cancer
External compression from malignant lesion
Strictures: diverticular or postischemic
Rectocele (if large)
Postsurgical abnormalities
Megacolon
Anal fissure
Metabolic conditions
Diabetes mellitus
Hypothyroidism
Hypercalcemia
Hypokalemia
Hypomagnesemia
Uremia
Heavy metal poisoning
Secondary causes of Constipation:
Myopathies
Amyloidosis
Scleroderma
Neuropathies
Parkinson's disease
Spinal cord injury or tumor
Cerebrovascular disease
Multiple sclerosis
Other conditions
Depression
Degenerative joint disease
Autonomic neuropathy
Cognitive impairment
Immobility
Cardiac disease
Case # 8 (cont’d):
Maggie is 15 yo who presents with
intermittent diarrhea for a month and is
now constipated, She has some pain, gas,
and bloating. No other illnesses. No meds.
PE normal.
Ddx?
Irritable bowel syndrome
common condition in adolescents
Three factors: hypersensitivity of the gut,
altered motility, and psychosocial
dysfunction
Temporal fluctuation is characteristic.
have a high index of suspicion for the
presence of an eating disorder.
Newborn constipation
Normal is seven a day to one in seven
days.
Concern when baby not thriving, lethargic
&c.
Can give some prune juice/ brown sugar
with water.
Hirschsprung’s disease
Failure of ganglionic migration into
terminal colon.
Usually distal 4 to 25 cm involved.
Often present as neonate, but can present
much later in mild cases
Functional obstruction with need for
enemas, suppositories, &c
Hirschprung’s vs Constipation
Infancy
Minimal abdo pain
Episodic obstruction
No encopresis
Empty rectum
Narrow section on
barium
Abnormal monometry
2 y.o. or greater
Colicky pain
Episodic large stools
Encopresis
Full rectum
Dilated rectum on
barium
Normal monometry
studies