痢疾腹泻(diarrhea)

nullnullHPIHPIFemale pt. 46 ys old C/O weakness and diarrhea for 6 days Her usual BMs are EOD, that time she was having 10 - 15 BMs/ day of fluid stool Denied nausea or vomiting Denied fever, skin rash, Bl or mucous or other constitutional symptomsHPIHPIShe had history of recent travel to New York, one week prior to developing symptoms Pt had chicken salad lunch in a restaurant, on that very day she started developing her symptoms No body else dinning with her ever had such symptomsPMHPMHHypothyroidism ( following radio active I ) Hypercholesterolemia Abnormal MRI of brain ( DD stroke vs MS ) Abdominal hystrectomy ( fibroid uterus ) C section x 2MedsMedsPaxil 20mg po QD ASA 81mg po QD Synthroid 0.125mg po QD Premarin 1.25mg po QD Zocor 20mg po QD No recent Abx use NKDA (no known drug allergy)Social HxSocial HxNegative for alcohol or tobacco use Lives with family Works as an accountantFamily HxFamily HxNegative for DM, CAD, HTN No history of cancer No history of colon polyps or ulcerative colitisPhys ExamPhys ExamBP T RR PR 84/60 98.2 16 84 HEENT: Unremarkable Neck: No lymphadenopathy or thyroid enlargement Heart: RRR, no murmurs or gallop detected Lungs: CTAs Phys ExamPhys ExamAbdomen: Soft, mild diffuse tenderness without organomegally. No abdominal skin rash Extrem: No E,C,C. +ve PP Neuro: AAO, no focal deficits or CN palsies Rectal: No masses, normal tone of anal sphicter with Guiac - ve heme stools LabsLabsHgb Hct RBCs WBCs Plat 14.2 43 4.99 6.0 211 Na K Cl Co2 BUN Cr Gluc 133 3.0 100 24 13 0.6 111 Urinalysis: Unremarkable T4 TSH 8.5 5.84 Course Course Pt continued on IVFs with close monitoring of I/Os and was given metamucil 2tsp TID Stool cultures grew Gm - ve pathogens Pt started on Ciprofloxacin 400mg IV Q 12hs Subcultures grew salmonella sero group D Flex sigmoidoscopy: Erythema and edema of colon compatible with salmonella colitis Abx D/Cd after one day, diarrhea resolvednullDefinitionsDefinitionsIncrease in daily stool weight above 200gm Increase in frequency, fluidity or amount Differentiate from incontinence and IBS Acute lasts less than 7 - 14 days Chronic lasts more than 2 - 3 weeksAcute DiarrheaAcute DiarrheaINFLAMMATORY Fever & bloody with Leukocytes, volume <1L/ 24 hr secondary to colonic damage Shigella, Salmonella, Amebiasis, C.diff, E coli 0157:H7 toxin, Ischemia, UC, Crohn’s, CytomegalovirusNon-INFLAMMATORY Watery with N/V, volume >1L/ 24hr secondary to small intestine disease Norwalk & Rota virus, entrotoxins as Giardia, Staph aureus, Cholera, E coli, Bile acid, Laxatives, MalabsorptEvaluationEvaluationMost pt with acute diarrhea respond in 5-7 d for rehydration and antidiarrheal agents Isolation rate of pathogen from stool < 3% Stool leukocytes is inexpensive test to differentiate inflammatory vs non- inflammatory types Sigmoidoscopy indicated for Proctitis, C diff, UC, Ischemic colitisManagementManagementInflammatory Antidiarrheal agents are avoided Moderate to severe cases; start empiric Abx: Ciprofloxacin, TMP-SMA, Erythromycin Always treat: C diff, Amebiasis, Enteric fever, Shigella, STDsNon-inflammatory Rehydration is most important Loperamide offers relief, Anticholinergic contraindicated for megacolon Always treat: Cholera, Giardiasis, Traveler’s diarrheaSalmonella food poisoning Salmonella food poisoning Contaminated poultry especially egg yolk Incubation : 8- 48 Hrs Diarrhea, low temp. Bacteria grow on surface with little invasion No Abx unless immune compromised Pt remains as carrier for up to 2 monthsEnteric fever Enteric fever Caused by Salmonella typhi, incubation 2 w Fever, bradycardia, altered behavior, constipation followed by diarrhea 2nd week: Rose spots on abdomen & thorax, Spleenomegally and Lymphadenopathy Rx: Chloramphenicol, Ciprofloxacin, Ampicillin Traveler’s diarrheaTraveler’s diarrheaE coli produces heat labile entrotoxin and heat stable, causes 40 - 75% Diarrhea lasts 3- 5 days Other pathogens - Shigella, Salmonella, Rotavirus, Giardia Rx: Ciprofloxacin, TMP- SMA, AztreonamChronic DiarrheaChronic DiarrheaPersists > 2 weeks Do stool cultures, ova and parasites Stool collection for 48 - 72 Hrs for weight , fat content, lytes and osmolality Sigmoidoscopy for visualization of mucosa and biopsyOsmotic DiarrheaOsmotic DiarrheaStool osmotic gap (Normally <50) Measured - Estimated (Na + K) X 2 Stool volume decreases with fasting Common causes Lactose intolerance Sorbitol Laxatives Antacids Secretory DiarrheaSecretory DiarrheaIncreased intestinal secretion or decreased absorption with > 1 L diarrhea Little change with fasting Endocrine diseases VIPoma medullary carcinoma carcinoid Zollinger- Ellison syndrome Bile salts Villous adenoma Inflammatory DiarrheaInflammatory DiarrheaFever , hematochezia and abdominal pain Causes Ulcerative colitis Crohn’s disease Microscopic colitis Radiation enteritis MalignancyMalabsorptionMalabsorptionWt loss, anemia, vitamin deficiency with fecal fat > 7 - 10 g/24 Hs Causes Tropical sprue Whipple’s disease Pancreatitis Bacterial overgrowth ( vagotomy , diabetes )InfectionsInfectionsChronic infectious agents Giardia Entamoeba histolytica Cyclospora AIDS related infctions Cytomegalovirus CryptosporidiumMotility DisordersMotility DisordersCharachterised by systemic disease or prior abdominal surgery Diabetes Mellitus Hyperthyroidism Irritable bowel syndromenull