Diarrhea and Constipation

Diarrhea and Diarrhea and ConstipationConstipation

Nadim J LalaniNadim J LalaniSeptember 9, 2004 September 9, 2004

Diarrhea: EpidemiologyDiarrhea: Epidemiology

4 million deaths worldwide /year…100,000 4 million deaths worldwide /year…100,000 child deaths (<5yrs) / day.child deaths (<5yrs) / day.US: 20 million diagnoses, 200,000 US: 20 million diagnoses, 200,000 hospitalisations and 400 deaths per year.hospitalisations and 400 deaths per year.

[Rosen’s Emergency Medicine. 5[Rosen’s Emergency Medicine. 5thth Ed. 2002. Mosby ] Ed. 2002. Mosby ]

DefinitionsDefinitionsDiarrhea:Diarrhea: stool weightstool weight greater than greater than 200 g in 24200 g in 24 hours. Clinically - a hours. Clinically - a change in stoolschange in stools, usually , usually defined as passage of defined as passage of three or more loose or three or more loose or watery stoolswatery stools in 24 hours. Acute diarrhea lasts in 24 hours. Acute diarrhea lasts less than 14 days. less than 14 days. Gastroenteritis:Gastroenteritis: Gut inflammation with Gut inflammation with diarrhea diarrhea and vomitingand vomitingDysentery:Dysentery: Diarrhea Diarrhea with bloodwith blood and/or and/or mucusmucus..Beware of vomiting kids! (need broad DDx)Beware of vomiting kids! (need broad DDx)

Case #1 “Turkish trots”Case #1 “Turkish trots”

Mr. Montezzuma is a 35-year-old who Mr. Montezzuma is a 35-year-old who presents with a 4-day history of abdominal presents with a 4-day history of abdominal cramps, headache, and 8-10 episodes/day cramps, headache, and 8-10 episodes/day of watery diarrhea. He has had a few of watery diarrhea. He has had a few episodes of vomiting but denies fever or episodes of vomiting but denies fever or bloody diarrhea. He was previously bloody diarrhea. He was previously healthy.healthy.What else?What else?

HISTORY:HISTORY:What do they mean by “diarrhea”.What do they mean by “diarrhea”.Features (onset, blood?)Features (onset, blood?)Other Symptoms (vomits, cramps, Other Symptoms (vomits, cramps, fever)fever)Travel / CampingTravel / CampingInfectious ContactsInfectious ContactsRecent Meds?Recent Meds?What food ? Potential toxins?What food ? Potential toxins?Medications, PmHX, FmHx Surg. &c.Medications, PmHX, FmHx Surg. &c.

Case 1 (cont’d)Case 1 (cont’d)

He just spent a week in New Delhi. He He just spent a week in New Delhi. He loves to immerse himself in other cultures loves to immerse himself in other cultures “when in Rome man!” and states that he “when in Rome man!” and states that he couldn’t keep himself from sampling couldn’t keep himself from sampling various roadside delicacies.various roadside delicacies.No one else sick, no meds, no surgeries.No one else sick, no meds, no surgeries.What now?What now?

P/E: afebrile, normal vitals,well dehydrated P/E: afebrile, normal vitals,well dehydrated but has a diffusely tender abdomen with but has a diffusely tender abdomen with hyperactive bowel sounds but no rebound hyperactive bowel sounds but no rebound or guarding. or guarding. DDx?DDx?Likely organisms?.Likely organisms?.What if no clear travel history/camping &c.What if no clear travel history/camping &c.

Differential – 5 I’sDifferential – 5 I’sInfectiousInfectious

1.1. Nausea and vomiting predominant Nausea and vomiting predominant - Bacillus cereus- Bacillus cereus- Staph. Areus- Staph. Areus- C. perfringens (gives more diarrhea though)- C. perfringens (gives more diarrhea though)pre-formed toxins cause sympts < 6 hrspre-formed toxins cause sympts < 6 hrsshort course which resolves within 24 h.short course which resolves within 24 h.

2. Diarrhea predominant 2. Diarrhea predominant Small bowel Small bowel Large bowel Large bowel

[S.Coderre/2003][S.Coderre/2003]

Small bowel (aka non-inflammatory):Small bowel (aka non-inflammatory):

watery, less pain (cramps), large volumewatery, less pain (cramps), large volume - due to mucosal hypersecretion and abN absorption. - due to mucosal hypersecretion and abN absorption. Fever and systemic symptoms usually absent. Fever and systemic symptoms usually absent.

VirusesVirusesBacteria Bacteria -- C. perfringens -- C. perfringens

– – Vibrio choleraVibrio cholera -- E. coli (ETEC)-- E. coli (ETEC) -- Salmonella*-- Salmonella* -- Yersinia*-- Yersinia*

Parasites – GiardiaParasites – Giardia

*can give “large bowel” sympts.*can give “large bowel” sympts.

Large bowel (aka inflammatory):Large bowel (aka inflammatory):

Bloody, painful, urgency, small volumeBloody, painful, urgency, small volume due to due to invasion of mucosa. More fever, malaise, and invasion of mucosa. More fever, malaise, and myalgia. myalgia.

Bacteria – CampylobacterBacteria – Campylobacter -- Shigella-- Shigella -- E. Coli 0157:h7-- E. Coli 0157:h7 -- C. Difficile *-- C. Difficile *

Parasites – E. histolyticaParasites – E. histolytica* Colonic invasion but with small bowel sympts.* Colonic invasion but with small bowel sympts.

The 5 I’s (cont’d)The 5 I’s (cont’d)

Inflammatory Inflammatory Non-bloody (Crohn’s Ileitis)Non-bloody (Crohn’s Ileitis) Bloody (Ulcerative Colitis and Bloody (Ulcerative Colitis and

Crohn’s Colitis) Crohn’s Colitis) IBSIBS IschemiaIschemia Impaction with overflowImpaction with overflow

Back to Case #1Back to Case #1

a 4-day history of abdominal cramps, a 4-day history of abdominal cramps, headache, and 8-10 episodes/day of headache, and 8-10 episodes/day of watery diarrhea. He has had a few watery diarrhea. He has had a few episodes of vomiting but denies fever or episodes of vomiting but denies fever or bloody diarrhea. bloody diarrhea. Is any work up indicated here?Is any work up indicated here?

Who gets worked up?Who gets worked up?Main two:Main two:1.1. Diarrhea >5 days Stool cultures +/- C.diff toxinDiarrhea >5 days Stool cultures +/- C.diff toxin2.2. Bloody diarrhea Bloody diarrhea

O & P with suggestive travel histories, O & P with suggestive travel histories, immunocompromised, diarrhea >14 days, immunocompromised, diarrhea >14 days, when the diarrheal illness is unresponsive to when the diarrheal illness is unresponsive to appropriate therapy.appropriate therapy.Blood cultures when bacteremia or systemic Blood cultures when bacteremia or systemic infection suspected.infection suspected.

““Delhi belly”: To treat or not to treat?Delhi belly”: To treat or not to treat?Mostly ETEC infections(40-50%).Generally do not require antibiotic Mostly ETEC infections(40-50%).Generally do not require antibiotic therapy. Treatment is mainly supportive (fluids). therapy. Treatment is mainly supportive (fluids). Sandford 2003:Sandford 2003:

Mild Diarrhea (Mild Diarrhea (≤3 unformed stools/d minimal sympts)≤3 unformed stools/d minimal sympts) Rehydration Rehydration Moderate Diarrhea (Moderate Diarrhea (≥4 stools/d +/- systemic sympts)≥4 stools/d +/- systemic sympts) add antimotility add antimotility

agentsagentsSevere Diarrhea: see belowSevere Diarrhea: see below

Antibiotics for:Antibiotics for:severe invasive (bloody) or >6 episodes/24 h or Fever > 38.5severe invasive (bloody) or >6 episodes/24 h or Fever > 38.5 high risk: elderly, diabetics, cirrhotics, and immunocompromised high risk: elderly, diabetics, cirrhotics, and immunocompromised

patients,patients, empirical treatment with a quinolone antibiotic for 3 to 5 days. empirical treatment with a quinolone antibiotic for 3 to 5 days. [[Oldfield III EC, Wallace MR. The role of antibiotics in the treatment of Oldfield III EC, Wallace MR. The role of antibiotics in the treatment of

infectious diarrhea. infectious diarrhea. Gastroenterol Clin North Am.Gastroenterol Clin North Am. 2001;30:817–836. 2001;30:817–836. ] ]

Antibiotics and Antimotiliy Agents:Antibiotics and Antimotiliy Agents:

Ciprofloxacin (Cipro) one 750-mg dose.Ciprofloxacin (Cipro) one 750-mg dose.In the absence of dysenteryIn the absence of dysentery, Loperamide (Imodium), , Loperamide (Imodium), 4mg at the start of diarrhea, followed by 2mg after each 4mg at the start of diarrhea, followed by 2mg after each loose stool (maximum daily dosage: 16 mg) . Can also loose stool (maximum daily dosage: 16 mg) . Can also give Pepto-Bismol 2 tabs (262 mg) PO QID.give Pepto-Bismol 2 tabs (262 mg) PO QID.Cipro vs placebo for severe diarrhea decreased duration Cipro vs placebo for severe diarrhea decreased duration of diarrhea and symptoms but did not change fecal of diarrhea and symptoms but did not change fecal carriage (NEJM 340: 1525, 1999)carriage (NEJM 340: 1525, 1999)

[[Note: Ddx for traveller’s includes: ETEC, Shigella, Salmonella, Campylobacter, Note: Ddx for traveller’s includes: ETEC, Shigella, Salmonella, Campylobacter, Giardia.] Giardia.]

Case #2: Disney’s Cruise RunsCase #2: Disney’s Cruise Runs

Marge is a 65 yo retired, just went on a Marge is a 65 yo retired, just went on a cruise to Alaska and came back with 3-4 cruise to Alaska and came back with 3-4 days of loose/watery stools and some abd days of loose/watery stools and some abd cramping. Her husband and friends also cramping. Her husband and friends also came down with “the runs”. Otherwise came down with “the runs”. Otherwise well. Nothing else on history. PE normal.well. Nothing else on history. PE normal.Likely org?Likely org?

Viruses in Alberta mostViruses in Alberta mostleast:least:

Rotavirus: Rotavirus: generally kids, in winter and hospitalised.generally kids, in winter and hospitalised.Adenovirus 40/41,Caliciviruses and Adenovirus 40/41,Caliciviruses and Astroviruses (kids/daycare)Astroviruses (kids/daycare)Norwalk/Norwalk-like:Norwalk/Norwalk-like:adults, eldercare facilities.adults, eldercare facilities.No Rx. Supportive care. No Rx. Supportive care. NOTE: NOTE: dehydration in kids and elderlydehydration in kids and elderly

Case #3: “I let the colonel do the Case #3: “I let the colonel do the cooking last night!”cooking last night!”

Rob got tired of cooking steaks and went Rob got tired of cooking steaks and went out for some finger-lickin’ goodness. out for some finger-lickin’ goodness. Developed intermittent fever, crampy Developed intermittent fever, crampy abdominal pain x 1 day. Now has had low abdominal pain x 1 day. Now has had low volume bloody diarrhea 8-10 times a day volume bloody diarrhea 8-10 times a day for three days. Well hydrated otherwise for three days. Well hydrated otherwise perfectly healthy. No other Hx. PE normal.perfectly healthy. No other Hx. PE normal.Likely organism?Likely organism?

Campylobacter factoids:Campylobacter factoids:The most common bacterial cause of food-borne illness.The most common bacterial cause of food-borne illness.Contaminated food mostly Contaminated food mostly chickenchickenCan mimic appendicitis.Can mimic appendicitis.““Campylobacter is the single most identifiable Campylobacter is the single most identifiable antecedent infection associated with the development of antecedent infection associated with the development of GBS …via molecular mimicry”.GBS …via molecular mimicry”.Incidence < 1/1000Incidence < 1/1000

[Nachamkin I; Allos BM; Ho T Campylobacter species and [Nachamkin I; Allos BM; Ho T Campylobacter species and Guillain-Barré syndrome.Guillain-Barré syndrome.Clin Microbiol RevClin Microbiol Rev - 01-JUL-1998; - 01-JUL-1998; 11(3): 555-6711(3): 555-67]]

Other factoids: Other factoids:

YersiniaYersinia can perfectly mimic can perfectly mimic appendicitisappendicitis because it causes terminal ileitis.because it causes terminal ileitis.If someone has been eating oysters/ If someone has been eating oysters/ shellfish think Vibrio parahaemolyticus.shellfish think Vibrio parahaemolyticus.Vibrio cholera causes a secretory diarrhea Vibrio cholera causes a secretory diarrhea that can result in profound hypovolemia. that can result in profound hypovolemia. The volume of fluid lost through the stools The volume of fluid lost through the stools in 24 hours can vary from 5 ml/kg (near in 24 hours can vary from 5 ml/kg (near normal) to normal) to 200 ml/kg200 ml/kg

Rehydration in the FieldRehydration in the Field Ceralyte, Pedialyte, or generic Ceralyte, Pedialyte, or generic solutions.solutions.Make your own:Make your own: 4 tsps sugar,3/4 tsps 4 tsps sugar,3/4 tsps of salt,1 tsp baking soda,one cup of salt,1 tsp baking soda,one cup orange juice, dilute with water to one orange juice, dilute with water to one litre. litre. [Dr Ukrainetz 2002][Dr Ukrainetz 2002]

Fluids given = fluid lossFluids given = fluid loss

Rehydration (con’td)Rehydration (con’td)WHO-recommended solutions can also be prepared by a WHO-recommended solutions can also be prepared by a pharmacy by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or 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 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 glucose polymer (e.g., 40 g of sucrose or 4 tablespoons of sugar or 50-60 g of cooked cereal flour such as rice, of sugar or 50-60 g of cooked cereal flour such as rice, maize, sorghum, millet, wheat, or potato) per liter of maize, sorghum, millet, wheat, or potato) per liter of clean water. This makes a solution of approximately Na clean water. This makes a solution of approximately Na 90 m90 mMM, K 20 m, K 20 mMM, Cl 80 m, Cl 80 mMM, HCO3 30 m, HCO3 30 mMM, and glucose , and glucose 111 m111 mMM..

[Guerrant RL [Guerrant RL Practice guidelines for the management Practice guidelines for the management of infectious diarrhea.of infectious diarrhea. Clin Infect DisClin Infect Dis - 1-FEB-2001; - 1-FEB-2001; 32(3): 331-51]32(3): 331-51]

Case #4: “Hey! Everyone needs a Case #4: “Hey! Everyone needs a colectomy!”colectomy!”

65 yr old male, major tooth pain and likely 65 yr old male, major tooth pain and likely abscess. The dentist gave him abscess. The dentist gave him clindamycin which helped. Four weeks clindamycin which helped. Four weeks later he begins to have profuse watery later he begins to have profuse watery stools 6-10 times a day. Now has a lot of stools 6-10 times a day. Now has a lot of abd pain. No remarkable Hx. PE: diffuse abd pain. No remarkable Hx. PE: diffuse abdominal tenderness +ve peritonitis abdominal tenderness +ve peritonitis warm, flushed, shocky appearing.warm, flushed, shocky appearing.Likely pathogen?Likely pathogen?

C Difficile:C Difficile:

2001-2004 1167 cases in Calgary.2001-2004 1167 cases in Calgary.Previous Hx Antibiotics: Clinda > Previous Hx Antibiotics: Clinda > Cephalosporins > Penicillins. (but any Abx Cephalosporins > Penicillins. (but any Abx can do it).can do it).Avoid use of clinda for dental abscesses Avoid use of clinda for dental abscesses use Penicillin instead.use Penicillin instead.Treated with flagyl or vanc. High risk may Treated with flagyl or vanc. High risk may need prophylaxis.need prophylaxis.

C. Diff (cont’d)C. Diff (cont’d)

The first reported case of The first reported case of pseudomembranous enterocolitis (PMC) pseudomembranous enterocolitis (PMC) was reported by J. M. Finney in was reported by J. M. Finney in association with William Osler in 1893.association with William Osler in 1893.The most common clinical setting in those The most common clinical setting in those cases not associated with antibiotic cases not associated with antibiotic therapy was colonic, pelvic, or gastric therapy was colonic, pelvic, or gastric surgery. surgery.

C diff cont’dC diff cont’dOther risk factors: spinal fracture, intestinal obstruction, Other risk factors: spinal fracture, intestinal obstruction, colon carcinoma, leukemia, severe burns, shock, uremia, colon carcinoma, leukemia, severe burns, shock, uremia, heavy metal poisoning, hemolytic-uremic syndrome, heavy metal poisoning, hemolytic-uremic syndrome, ischemic, cardiovascular disease, Crohn’s disease, ischemic, cardiovascular disease, Crohn’s disease, shigellosis, severe infection, ischemic colitis, and shigellosis, severe infection, ischemic colitis, and Hirschsprung disease. Hirschsprung disease.

There is no definitive explanation but it may be related There is no definitive explanation but it may be related to alterations in host defense mechanisms and enteric to alterations in host defense mechanisms and enteric flora. Several postoperative cases were related to flora. Several postoperative cases were related to hypotension and shock, suggesting an ischemic origin.hypotension and shock, suggesting an ischemic origin.

Case #5: “badabababa…I’m luvin Case #5: “badabababa…I’m luvin it”it”

Pierre is a 5 yo brought to the ED by his Pierre is a 5 yo brought to the ED by his mother with a 2-day hx of severe mother with a 2-day hx of severe abdominal cramps and diarrhea (5 to 7 abdominal cramps and diarrhea (5 to 7 watery stools daily). Today noticed blood watery stools daily). Today noticed blood in his diarrheal stools. No fever or vomiting in his diarrheal stools. No fever or vomiting He refuses to eat, but has been drinking He refuses to eat, but has been drinking well. Not sure of urine output. Previously well. Not sure of urine output. Previously healthy, no significant weight loss or other healthy, no significant weight loss or other symptoms. symptoms.

Case #5: HxCase #5: Hx

Traveled to USA a month ago, No Traveled to USA a month ago, No camping, no one else sick, baby sister camping, no one else sick, baby sister goes to daycare. He eats eggs, veggies, goes to daycare. He eats eggs, veggies, meats especially hot dogs and chicken meats especially hot dogs and chicken tenders. He likes apple juice, and his older tenders. He likes apple juice, and his older brother has a pet Iguana.brother has a pet Iguana.

Case #5 (cont’d)Case #5 (cont’d)

P/E: afebrile, normal blood pressure, P/E: afebrile, normal blood pressure, normal respirations and normal cap refill. normal respirations and normal cap refill. Dry mucosa, but skin turgor is normal. Dry mucosa, but skin turgor is normal. Abdomen: hyperactive bowel sounds, mild Abdomen: hyperactive bowel sounds, mild distension, and diffuse tenderness, but is distension, and diffuse tenderness, but is soft with no rebound or guarding. He has soft with no rebound or guarding. He has grossly bloody soiling of his underpants.grossly bloody soiling of his underpants.Ddx? Ddx? Work up?Work up?

Case# 5Case# 5

Pierre later admits having eaten a burger Pierre later admits having eaten a burger at his friend’s house…but he says it was at his friend’s house…but he says it was brown in the middle not pink.brown in the middle not pink.You do a Stool C & S.You do a Stool C & S.What treatment?What treatment?The lab calls you with the results of the The lab calls you with the results of the stool culture. Pierre's stool grew E. coli stool culture. Pierre's stool grew E. coli O157:H7. O157:H7.

E.Coli o157:H7 Abx or no?E.Coli o157:H7 Abx or no?Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic-uremic syndrome after antibiotic treatment of hemolytic-uremic syndrome after antibiotic treatment of Escherichia coliEscherichia coli O157:H7 infections. O157:H7 infections. N Engl J Med.N Engl J Med. 2000;342:1930–1936 2000;342:1930–1936..prospective cohort study of 71 children < 10 years old prospective cohort study of 71 children < 10 years old who had diarrhea caused by E. coli O157:H7.who had diarrhea caused by E. coli O157:H7.HUS developed 10 children (14%). Five of these 10 HUS developed 10 children (14%). Five of these 10 children had received antibiotics. children had received antibiotics. treatment with antibiotics (RR 14.3)(95% CI 2.9- 70.7) treatment with antibiotics (RR 14.3)(95% CI 2.9- 70.7) was significantly associated with HUS.was significantly associated with HUS.Conclusions: Antibiotic treatment of children with E. coli Conclusions: Antibiotic treatment of children with E. coli O157:H7 infection increases the risk of the hemolytic-O157:H7 infection increases the risk of the hemolytic-uremic syndrome. uremic syndrome.

Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic syndrome after antibiotic treatment of syndrome after antibiotic treatment of Escherichia.coliEscherichia.coli O157:H7 O157:H7

enteritis: a meta-analysis. enteritis: a meta-analysis. JAMA.JAMA. 2002;288:996–1001 2002;288:996–1001

meta-analysis of 9 studies published between 1990 and meta-analysis of 9 studies published between 1990 and 2000. 2000. Total of 1111 patients; 16% (range among studies, 8%-Total of 1111 patients; 16% (range among studies, 8%-35%) developed HUS.35%) developed HUS.The pooled odds ratio was 1.15 (95% confidence The pooled odds ratio was 1.15 (95% confidence interval, 0.79–168)interval, 0.79–168)Conclusion: “meta-analysis did not show a higher risk of Conclusion: “meta-analysis did not show a higher risk of HUS associated with antibiotic administration. A HUS associated with antibiotic administration. A randomized trial of adequate power, with multiple distinct randomized trial of adequate power, with multiple distinct strains of strains of E coliE coli O157:H7 represented, is needed to O157:H7 represented, is needed to conclusively determine whether antibiotic treatment of conclusively determine whether antibiotic treatment of E E colicoli O157:H7 enteritis increases the risk of HUS”. O157:H7 enteritis increases the risk of HUS”.

Commentary:Commentary:The authors note the major limitation of the meta-The authors note the major limitation of the meta-analysis: they were not able to analyze the risk of HUS analysis: they were not able to analyze the risk of HUS according to choice of antimicrobial agent or timing and according to choice of antimicrobial agent or timing and duration of therapy. duration of therapy. Some in vitro studies and animal models suggest the Some in vitro studies and animal models suggest the importance of drug choice, drug timing, and infecting importance of drug choice, drug timing, and infecting strain. strain. Some studies indicate that early treatment with an Some studies indicate that early treatment with an appropriate dose of an appropriate antimicrobial agent appropriate dose of an appropriate antimicrobial agent may reduce the risk of HUS. Other studies indicate that may reduce the risk of HUS. Other studies indicate that antimicrobial agents may be detrimental. antimicrobial agents may be detrimental. Perhaps the currently available data, including the meta-Perhaps the currently available data, including the meta-analysis, are insufficient to resolve this issue.analysis, are insufficient to resolve this issue.

What about adults?What about adults?

Adults can certainly get HUS 5-10% of Adults can certainly get HUS 5-10% of adults in nursing home outbreaks of which adults in nursing home outbreaks of which mortality is as high as 80% [Rosen’s 2002]mortality is as high as 80% [Rosen’s 2002]No data on whether treatment causes No data on whether treatment causes HUS in adults.HUS in adults.

Inflammatory Bowel Inflammatory Bowel ExcacerbationsExcacerbations

Crohn’s Disease:Crohn’s Disease: Mild diarrhea (not Mild diarrhea (not bloody), Abd pain and fever w/ spont bloody), Abd pain and fever w/ spont improvement.improvement.

45% Ileocolitis45% Ileocolitis35% Ileitis35% Ileitis20% Colitis – rectal bleeding20% Colitis – rectal bleeding

Can cause SBOCan cause SBOExtra intestinal manifestationsExtra intestinal manifestations


Treatment: Treatment: metronidazole (10 mg/kg/d in divided metronidazole (10 mg/kg/d in divided doses) or ciprofloxacin (500 mg twice a doses) or ciprofloxacin (500 mg twice a day) as adjunctive treatment with 5-day) as adjunctive treatment with 5-aminosalicylates (ASA), steroids, or aminosalicylates (ASA), steroids, or immunosuppressive agentsimmunosuppressive agents

[Isaacs KL; Sartor RB Treatment of inflammatory bowel [Isaacs KL; Sartor RB Treatment of inflammatory bowel disease with antibiotics. disease with antibiotics. Clin North AmClin North Am - 01-JUN-2004; - 01-JUN-2004; 33(2): 335-45]33(2): 335-45]


Ulcerative Colitis:Ulcerative Colitis: bloody diarrhea, rectal bloody diarrhea, rectal bleeding (v common) Abd pain, tenesmus, bleeding (v common) Abd pain, tenesmus, fever, wt loss, fatigue anorexia.fever, wt loss, fatigue anorexia.More extra abdominal symptsMore extra abdominal symptsLook out for toxic megacolon, perforation, Look out for toxic megacolon, perforation, LBO, GI haemorrhage LBO, GI haemorrhage


Treatment:Treatment:Sulfasalazine 2-6g/d divided dosesSulfasalazine 2-6g/d divided dosesHigh dose steroids for severe acute colitis High dose steroids for severe acute colitis

(fever, anemia, tachy, >6-8 stools/d)(fever, anemia, tachy, >6-8 stools/d)Hydrocortisone 100mg IV q 6-8hHydrocortisone 100mg IV q 6-8hMethylprednisone 20mg Iv q 6-8h Methylprednisone 20mg Iv q 6-8h


Disposition (Both): Admit the dehydrated Disposition (Both): Admit the dehydrated sickies.sickies.

Case #6: “post partum blues”Case #6: “post partum blues”

1 week old male, born at 36 weeks, normal 1 week old male, born at 36 weeks, normal delivery, babe is perfectly healthy. Parents delivery, babe is perfectly healthy. Parents noticed some blood in the babe’s loose poops a noticed some blood in the babe’s loose poops a couple of days. Now baby lethargic.couple of days. Now baby lethargic.Ddx?Ddx?Milk allergyMilk allergyAnal fissureAnal fissureInfectious diarrheaInfectious diarrheaNECNEC

Necrotizing enterocolitisNecrotizing enterocolitis

NEC typically seen in the NICU, occurring NEC typically seen in the NICU, occurring in in premature infantspremature infants in their first few weeks in their first few weeks of life. Occasionally, it is encountered in of life. Occasionally, it is encountered in the term infant, usually within the first 10 the term infant, usually within the first 10 days after birth.days after birth.Neonatal stress leading to hypovolemia, Neonatal stress leading to hypovolemia, bowel ischemia andbowel ischemia andNecrosis can lead to perforation, sepsis, Necrosis can lead to perforation, sepsis, and death. and death.

Necrotizing enterocolitisNecrotizing enterocolitis

typically present appearing quite ill, with typically present appearing quite ill, with lethargy, irritability, decreased oral intake, lethargy, irritability, decreased oral intake, distended abdomen, and bloody stools. distended abdomen, and bloody stools. Nb Symptoms might present fairly mildly, Nb Symptoms might present fairly mildly, with only occult blood-positive stools.with only occult blood-positive stools.High index of suspicion with birthing High index of suspicion with birthing stress/anoxia.stress/anoxia.

plain abdominal film shows pneumatosis intestinalis, plain abdominal film shows pneumatosis intestinalis, caused by gas in the intestinal wall.caused by gas in the intestinal wall.

Management Management

fluid resuscitation, bowel rest, and broad-fluid resuscitation, bowel rest, and broad-spectrum antibiotic coverage. spectrum antibiotic coverage. Early surgical consultationEarly surgical consultation>80% survival>80% survival

Case #7: “mmm… is that currant Case #7: “mmm… is that currant jelly?”jelly?”

Billy is an 8 month old brought in by Billy is an 8 month old brought in by parents because of intermittent abd pain, parents because of intermittent abd pain, vomiting and bloody/mucousy stools. vomiting and bloody/mucousy stools. History unremarkableHistory unremarkablePE shows distended and tender abdomen. PE shows distended and tender abdomen. Normal vitals.Normal vitals.Ddx?Ddx?Gastro, Meckels, Intussusception Gastro, Meckels, Intussusception

Intussusception Intussusception

80% occur before 24 months80% occur before 24 months4:1 boys to girls4:1 boys to girlsPalpable “sausage shaped mass” not Palpable “sausage shaped mass” not always found.always found.Current jelly stools are a late sign (20%)Current jelly stools are a late sign (20%)Rectal bleeding 50%Rectal bleeding 50%Lethargy increasingly recognized as Lethargy increasingly recognized as significantsignificant

IntussusceptionIntussusception

Diagnosis:Diagnosis:Films unreliable. May be normal Films unreliable. May be normal show show

signs of obstruction.signs of obstruction.The barium enema has been the gold The barium enema has been the gold standard for diagnosis and treatment of standard for diagnosis and treatment of intussusception.intussusception.air enemas being used increasingly (faster air enemas being used increasingly (faster and safer).and safer).

Clinical assessment of volume Clinical assessment of volume status:status:

Presence of > or = 2/4 high yield criteria is Presence of > or = 2/4 high yield criteria is 87% sensitive in detecting > 5% 87% sensitive in detecting > 5% dehydrationdehydrationDry mmDry mmIll appearanceIll appearanceNo tearsNo tearsCap refill > 2 secsCap refill > 2 secs

(Acad Em Med 1996)(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*&!Case # 8: Full of Sh*&!

Mr Farley 54 yo, convinced he is just Mr Farley 54 yo, convinced he is just bunged up. No exercise, drinks little H20, bunged up. No exercise, drinks little H20, eats only carbs and occasional meat. No eats only carbs and occasional meat. No Meds no other illnesses. Meds no other illnesses. PE: distended abd. Feels full of stoolPE: distended abd. Feels full of stoolYou need to de-bung this guy …what You need to de-bung this guy …what approach?approach?

De-bunging:De-bunging:

Get an AXRGet an AXRR sided stool-oral fleet(NaPO4)R sided stool-oral fleet(NaPO4)L sided stool-rectal fleet/glycerine L sided stool-rectal fleet/glycerine

suppository one prnsuppository one prnR and L--oral/rectalR and L--oral/rectal

Conservative treatments include Conservative treatments include increasing fibre (Psyllium), exercise, increasing fibre (Psyllium), exercise, adequate hydration, use of stool softeners adequate hydration, use of stool softeners and cathartics.and cathartics.

Rectal fecal Disimpaction:Rectal fecal Disimpaction:

Try warm water, can then go onto Try warm water, can then go onto phosphate soda enemas, saline enemas, phosphate soda enemas, saline enemas, or mineral oil enemas followed by a or mineral oil enemas followed by a phosphate enema. phosphate enema. May need pain control with manual May need pain control with manual disimpaction.disimpaction.

CONSTIPATIONCONSTIPATION:: Straining in >¼ defecationsStraining in >¼ defecations

Lumpy or hard stools in >¼ defecationsLumpy or hard stools in >¼ defecations Sensation of incomplete evacuation in >¼ Sensation of incomplete evacuation in >¼

defecationsdefecations Sensation of anorectal obstruction/blockade in >¼Sensation of anorectal obstruction/blockade in >¼

defecationsdefecations Manual maneuvers to facilitate >¼ defecations (e.g.,Manual maneuvers to facilitate >¼ defecations (e.g., digital evacuation, support of the pelvic floor) and/ordigital evacuation, support of the pelvic floor) and/or <2 defecations/week<2 defecations/week Loose stools are not present, and there are Loose stools are not present, and there are insufficient criteria for IBSinsufficient criteria for IBS

[Thompson WG, Longstreth GF, Drossman DA, Heaton KW, IrvineEJ, [Thompson WG, Longstreth GF, Drossman DA, Heaton KW, IrvineEJ, Muller-Lissner SA. Functional bowel disorders and Muller-Lissner SA. Functional bowel disorders and functionalabdominal pain. Gut 1999;45(suppl 2):II43-II47]functionalabdominal pain. Gut 1999;45(suppl 2):II43-II47]

CONSTIPATIONCONSTIPATION::

Depending on what you read as prevalent Depending on what you read as prevalent as 2% to 25 %. as 2% to 25 %. PrimaryPrimary

Slow transit/ Colonic inertia (problem with Slow transit/ Colonic inertia (problem with peristalsis +/- diet +/- culture)peristalsis +/- diet +/- culture)

Pelvic floor dysfunction (hypertonic vs Pelvic floor dysfunction (hypertonic vs hypotonic)hypotonic)SecondarySecondary (Meds, other conditions) (Meds, other conditions)

Secondary causes of Constipation:Secondary causes of Constipation:Drug effectsDrug effectsMechanical obstructionMechanical obstruction

Colon cancerColon cancer External compression from malignant lesionExternal compression from malignant lesion Strictures: diverticular or postischemicStrictures: diverticular or postischemic Rectocele (if large)Rectocele (if large) Postsurgical abnormalitiesPostsurgical abnormalities MegacolonMegacolon Anal fissureAnal fissure

Metabolic conditionsMetabolic conditions Diabetes mellitusDiabetes mellitus HypothyroidismHypothyroidism HypercalcemiaHypercalcemia HypokalemiaHypokalemia HypomagnesemiaHypomagnesemia UremiaUremia Heavy metal poisoningHeavy metal poisoning

Secondary causes of Constipation:Secondary causes of Constipation:MyopathiesMyopathies

AmyloidosisAmyloidosis SclerodermaScleroderma

NeuropathiesNeuropathies Parkinson's diseaseParkinson's disease Spinal cord injury or tumorSpinal cord injury or tumor Cerebrovascular diseaseCerebrovascular disease Multiple sclerosisMultiple sclerosis

Other conditionsOther conditions DepressionDepression Degenerative joint diseaseDegenerative joint disease Autonomic neuropathyAutonomic neuropathy Cognitive impairmentCognitive impairment ImmobilityImmobility Cardiac diseaseCardiac disease

Case # 8 (cont’d):Case # 8 (cont’d):

Maggie is 15 yo who presents with Maggie is 15 yo who presents with intermittent diarrhea for a month and is intermittent diarrhea for a month and is now constipated, She has some pain, gas, now constipated, She has some pain, gas, and bloating. No other illnesses. No meds. and bloating. No other illnesses. No meds. PE normal.PE normal.Ddx?Ddx?

Irritable bowel syndromeIrritable bowel syndrome

common condition in adolescentscommon condition in adolescentsThree factors: hypersensitivity of the gut, Three factors: hypersensitivity of the gut, altered motility, and psychosocial altered motility, and psychosocial dysfunction dysfunction Temporal fluctuation is characteristic.Temporal fluctuation is characteristic.have a high index of suspicion for the have a high index of suspicion for the presence of an eating disorder. presence of an eating disorder.

Newborn constipationNewborn constipation

Normal is seven a day to one in seven Normal is seven a day to one in seven days.days.Concern when baby not thriving, lethargic Concern when baby not thriving, lethargic &c. &c. Can give some prune juice/ brown sugar Can give some prune juice/ brown sugar with water.with water.

Hirschsprung’s diseaseHirschsprung’s disease

Failure of ganglionic migration into Failure of ganglionic migration into terminal colon.terminal colon.Usually distal 4 to 25 cm involved.Usually distal 4 to 25 cm involved.Often present as neonate, but can present Often present as neonate, but can present much later in mild casesmuch later in mild casesFunctional obstruction with need for Functional obstruction with need for enemas, suppositories, &cenemas, suppositories, &c

Hirschprung’s vs ConstipationHirschprung’s vs Constipation

InfancyInfancyMinimal abdo painMinimal abdo painEpisodic obstructionEpisodic obstructionNo encopresisNo encopresisEmpty rectumEmpty rectumNarrow section on Narrow section on bariumbariumAbnormal monometryAbnormal monometry

2 y.o. or greater2 y.o. or greaterColicky painColicky painEpisodic large stoolsEpisodic large stoolsEncopresisEncopresisFull rectumFull rectumDilated rectum on Dilated rectum on bariumbariumNormal monometry Normal monometry studiesstudies

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Diarrhea and Constipation