Transcript GI_2_-_Diarrhea_2015x

GI Disorders II
Nursing 870
Diarrhea
• Increase in stool frequency or greater
looseness
– Increase from normal frequency
– > 3/day
• Acute versus chronic
– Acute: up to < 2 weeks
– Chronic: usually > 2 weeks
• May be a symptom, result from a disorder, SE
of medication, others
Diarrhea
• Distinguish from
– Incontinence
– Rectal urgency
– Incomplete evacuation
Diarrhea
• Acute
– Viral
– Parasitic
– Bacterial
– New medication
Symptoms that Need Evaluation
•
•
•
•
•
•
•
•
•
•
Fever
Moderate to severe abdominal pain
Bloody diarrhea
Diarrhea with pre-existing co-morbidities; DM, heart
disease, AIDS
No improvement after 48 hrs.
Moderate or severe dehydration
Prolonged vomiting that prevents oral intake
Diarrhea after antibiotic use
After return from developing countries
In patients with chronic disease of intestines
Viral Gastroenteritis
• Most common cause of acute diarrhea
worldwide
• Incubation period 48-72 hrs
• Presents with abrupt onset nausea, vomiting,
cramps, diarrhea, headache, low grade fever
– Usually lasts 48-72 hrs; up to 1 week
– Usually mild or no fever
– No blood or pus in stool
Food Poisoning
• Defined as an illness caused by the consumption of food or
water contaminated with bacteria and/or their toxins, or
with parasites, viruses, or chemicals
• Symptoms within several hours after food or water
ingestion
• Most common causes include
– Staph aureus
• Food sources
• Symptoms 2-8 hrs after food ingested
• Symptoms last < 12 hrs
– Clostridium perfringens
• Food sources
• Incubation of 8-24 hrs.
• Diarrhea and cramping; limited vomiting
Food Poisoning
– Salmonella
– Camphylobacter
– Norovirus
• CDC (2013) reports
– Green leafy vegetables were the most common cause of (22%),
primarily due to Norovirus species and e coli
– Poultry was the most common cause of death from food
poisoning (19%), with Listeria and Salmonella species being the
main infectious organisms
– Dairy items were the second most frequent causes of foodborne
illnesses (14%) and deaths (10%), with the main factors being
contamination by Norovirus from food handlers and improper
pasteurization resulting in contamination with Campylobacter
species
Food Poisoning: S & S
• Abdominal pain: Most severe in inflammatory processes; painful
abdominal muscle cramps suggest underlying electrolyte loss
• Vomiting: Major presenting symptom of S aureus, B cereus, or
Norovirus
• Diarrhea: Usually lasts less than 2 weeks
• Headache
• Fever: May be an invasive disease or an infection outside the GI
tract
• Stool changes: Bloody or with mucus if invasion of intestinal or
colonic mucosa; profuse rice-watery if cholera or a similar process
• Reactive arthritis: Seen with Salmonella, Shigella, Campylobacter,
and Yersinia infections
• Bloating: May be due to giardiasis
Food Poisoning: History
• Food sources ingested
• Any travel
• Frequency and characteristic of stool may give
clues
• Vomiting
• Presence of fever or not
• Any other systemic symptoms
Food Poisoning: PE
• Major focus is to evaluate for dehydration
• Perform rectal exam on all patients
– Directly visualize the stool
– To palpate for any lesions
Diagnostics
• CBC
– Assess the inflammatory response and the degree of
dehydration
• Electrolytes, BUN, Creatinine
– Assess the inflammatory response and the degree of
dehydration.
• Stool for O & P
• Blood culture for fever
• C difficile
– To help rule out antibiotic-associated diarrhea in patients
receiving antibiotics or in those with a history of recent
antibiotic use.
Diagnostics
• Flat and upright abdominal x-ray (KUB)
– Obtained if the patient experiences bloating,
severe pain, or obstructive symptoms or if
perforation is suggested
• Colonoscopy/ Sigmoidoscopy
– Consider in patients with bloody diarrhea
– Can be useful in diagnosing inflammatory bowel
disease, antibiotic-associated diarrhea, shigellosis,
and amebic dysentery
Treatment
• Main objective is adequate rehydration and
electrolyte supplementation
• Oral rehydration
– Clear liquids and sodium-containing and glucosecontaining solutions. A simple ORS may be composed
of 1 level teaspoon of salt and 4 heaping teaspoons of
sugar added to 1 liter of water.
• The use of ORS has reduced the mortality rate associated
with cholera from higher than 50% to less than 1%.
• ORS also is indicated in other dehydrating diarrheal diseases.
• The World Health Organization (WHO) recommends a
solution containing 3.5 g of sodium chloride, 2.5 g of sodium
bicarbonate, 1.5 g of potassium chloride, and 20 g of glucose
per liter of water.
Treatment
• IV solutions are indicated in patients who are
severely dehydrated or who have intractable
vomiting
• Absorbents (eg, Kaopectate, aluminum
hydroxide) help patients have more control
over the timing of defecation
– They do not alter the course of the disease or
reduce fluid loss
Treatment
• Antisecretory agents, such as bismuth
subsalicylate (Pepto-Bismol), may be useful
– 30 mL every 30 minutes, not to exceed 8-10
doses.
• Antiperistaltics (opiate derivatives) should not
be used in patients with fever, systemic
toxicity, or bloody diarrhea or in patients
whose condition either shows no
improvement or deteriorates
Treatment
• Dietary Considerations
– Often develop an acquired disaccharidase
deficiency due to washout of enzymes
• Avoiding milk, dairy products, and other lactosecontaining foods is advisable
Complications
• Complications are very rare in healthy hosts,
except in cases of botulism or mushroom
poisoning.
• Infants, elderly people, and
immunocompromised hosts are more susceptible
• Other complications include
– Guillain-Barré syndrome (Campylobacter infection)
– Reactive arthritis
– Hemolytic uremic syndrome (E coli O157:H7)
Traveler’s Diarrhea
• Usual cause is e-coli (pathogenic)
• Visitors to foreign countries
– Warm climate
– Poor sanitation
•
•
•
•
Eat contaminated food
Symptoms start 3-7 days after arrival
Symptoms subside within 3 days
Other causes last > 3 days
– Shigella
– Giardia
– Campylobacter
Bacterial Entercolitis
•
•
•
•
Abdominal pain, cramps
Fever
Blood or pus in stool
Causes
– Campylobacter jejuni (Most common in US)
– Shigella
– Salmonella
– Clostridium difficile
– E. coli
Parasites
• Giardia lamblia
– Transmitted via drinking water
– Diarrhea with pus in stool
– No blood or pus in stool
– Mild or no fever
• Cryptosporidium
– Transmitted via contaminated water
Stray cat with Giardia
Tourists with Giardia?
Drug Induced
•
•
•
•
•
•
Drugs containing Mg
NSAID’s
Chemotherapy
Antibiotics
Antiarrhythmics
Antihypertensives
Diagnostics
• Highly individualized
– May be extensive testing
– May need no testing
– Stool for leukocytes
– Stool of ova and parasites
– Sigmoidoscopy
– Other GI tests may be needed
– https://www.youtube.com/watch?v=jsVgi8hoFFc
Management
• Hydration
• Some medication use
– Giardiasis: metronidazole (250 mg tid x 7-10d)
– Pseudomembranous colitis (Oral liquid
vancomycin or metronidazole), probiotic, some
use for cholestyramine
Clostridium Difficile (C. diff)
• C difficile colitis results from a disturbance of
the normal bacterial flora of the colon,
colonization by C difficile, and the release of
toxins that cause mucosal inflammation and
damage
• Antibiotic therapy is the key factor that alters
the colonic flora
• Occurs primarily in hospitalized patients
C. Difficile
• Should be suspected in
– Any patient with diarrhea who has received
antibiotics within the previous 3 months
– Been recently hospitalized
– And/or has an occurrence of diarrhea 48 hours or
more after hospitalization
• Can be a cause of diarrhea in community
dwellers without previous hospitalization or
antibiotic exposure
C. Difficile: Symptoms
• Mild to moderate watery diarrhea that is
rarely bloody
• Cramping abdominal pain
• Anorexia
• Malaise
C. Difficile: PE
•
•
•
•
Fever: Especially in more severe cases
Dehydration
Lower abdominal tenderness
Rebound tenderness
– Raises the possibility of colonic perforation and
peritonitis
C. Difficile: Diagnostics
• CBC: Leukocytosis may be present
• Electrolytes, including serum creatinine:
Dehydration, anasarca, and electrolyte imbalance
may accompany severe disease
• Albumin levels
– Hypoalbuminemia may accompany severe disease
• Serum lactate level
– Lactate levels are generally elevated (≥5 mmol/L) in severe
disease
• Stool examination: Stool may be positive for blood in
severe colitis, but grossly bloody stools are unusual;
fecal leukocytes are present in about 50%
C. Difficile: Diagnostics
• Stool assays for C difficile, from the most to the least
sensitive
– Stool culture: The most sensitive test (sensitivity, 90-100%;
specificity, 84-100%), but the results are slow and may lead
to a delay in the diagnosis if used alone (Gold Standard for
Dx)
– Glutamate dehydrogenase enzyme immunoassay (EIA):
This is a very sensitive test (sensitivity, 85-100%; specificity,
87-98%); it detects the presence of glutamate
dehydrogenase produced by C difficile
– Real-time polymerase chain reaction (PCR) assay: This test
is an alternative gold standard to stool culture (sensitivity,
86%; specificity, 97%[5] ); it may be used to detect the C
difficile gene toxin
C. Difficile: Diagnostics
– Stool cytotoxin test: A positive test result is the
demonstration of a cytopathic effect that is
neutralized by a specific antiserum (sensitivity, 70100%; specificity, 90-100%)
– EIA for detecting toxins A and B: This test is used
in most laboratories (moderate sensitivity, 7980%; excellent specificity, 98%)
– Latex agglutination technique: Another means of
detecting glutamate dehydrogenase; however, the
sensitivity of this test is poor (48-59%), although
the specificity is 95-96%
C. Difficile: Diagnostics
• Abdominal CT
– Imaging modality of choice when pseudomembranous
colitis, other complications of CDI, or other intraabdominal pathology is suspected
• If sepsis due to suspected megacolon, abdominal
radiography may be performed instead of CT to
establish the presence of megacolon in a timely
manner
• Endoscopy
– Less sensitive than stool assays
C. Difficile: Differential
•
•
•
•
•
•
•
•
•
•
Crohn’s Disease
Diverticulitis
Viral Gastroenteritis
Intra abdominal sepsis
IBS
Malabsorption
Salmanellosis
Shigellosis
Ulcerative Colitis
Other Infections
C. Difficile: Treatment
• European Society of Clinical Microbiology 2013 Guidelines
– For patients with nonepidemic, nonsevere CDI clearly induced
by antibiotic use, with no signs of severe colitis, it may be
acceptable to stop antibiotic treatment and observe the clinical
response for 48 hours
– Antibiotic treatment is recommended for all except very mild
cases actually triggered by antibiotic use; suitable treatments
include metronidazole, vancomycin, and fidaxomicin
– For mild/moderate disease, oral metronidazole (500 mg 3 times
daily for 10 days) is recommended as initial treatment
– In patients for whom oral treatment is inappropriate,
fidaxomicin may be used; specific indications include first-line
treatment in patients with recurrence or at risk for recurrence
C. Difficile: Treatment
– For patients with severe CDI
• Vancomycin (oral, 125 mg 4 times daily for 10 days; may be increased
to 500 mg 4 times daily) or fidaxomicin (200 mg twice daily for 10
days)
• Use of fidaxomicin is not supported in life-threatening CDI
• Use of oral metronidazole in severe or life-threatening CDI is
discouraged
• Fecal transplantation is recommended for multiple recurrent CDI
– For patients with colonic perforation and/or systemic
inflammation and deteriorating clinical condition despite
antibiotic treatment, total abdominal colectomy or diverting
loop ileostomy combined with colonic lavage is recommended
– Additional management measures include discontinuing
unnecessary antimicrobial therapy, adequate replacement of
fluids and electrolytes, avoiding antimotility medications, and
reviewing the use of proton pump inhibitors
C. Difficile: Treatment
• The Society for Healthcare Epidemiology of
America (SHEA) and the Infectious Diseases
Society of America (IDSA)
– Recommend a regimen of metronidazole (500 mg PO
TID for 10-14 days) as first-line therapy for mild to
moderate disease without complications (lower cost
and similar efficacy to PO vancomycin in these
patients)
– For patients who are unable to tolerate oral
medication, intravenous metronidazole is effective.
C. Difficile: Treatment
• For severe cases
– Vancomycin (125 mg PO QID for 10 days) is the
recommended first-line therapy.
C. Difficile: Other Considerations
• Relapse occurs in 20-27% of patients treated
with metronidazole or vancomycin
• Most recurrences occur 3 days to 3 weeks
after discontinuing antibiotic treatment
• Once a patient has 1 relapse, the risk for a
2nd relapse is 45%.
C. Difficile: Other Considerations
• Age greater than 65, severe underlying illnesses, and
ongoing antibiotic treatments during C difficile therapy
are all risk factors for recurrence
• For the first relapse, the choice of antibiotic should be
based on severity
– Mild symptoms of recurrence in patients who are
otherwise well may be managed without further antibiotic
therapy
– Initial recurrence that is not severe can be treated with
metronidazole
– For subsequent recurrences, patients may benefit from
vancomycin in a prolonged tapered and/or pulse regimen
or fidaxomicin with or without probiotics.
C. Difficile: Other Considerations
• Prevention
– Minimize antibiotic use
– Probiotics not recommended (ISDA)
References
•
Cohen, S. et al. (2010. Clinical practice guidelines for clostridium difficile infection
in adults: 2010 Update by the Society for Healthcare Epidemilogy of America and
the Infectious Disease Society of America. DOI 10.106/651706. Available at:
http://www.cdc.gov/HAI/pdfs/cdiff/Cohen-IDSA-SHEA-CDI-guidelines-2010.pdf