summarized presentation about acute diarrhea.

1. SOEPEL Session 3
Internal Medicine Clinical Rotation
(Hepato-gastroenterology)
1

2. S
 Subjective:
 Patient:
A 77 year-old male presented to the Emergency Department with complaints
of two days of copious watery diarrhea. He denied abdominal pain or
cramping, nausea, fever, and blood or mucus in the stool.
The patient had a recent travel history including one week of boating in the
Chesapeake Bay During the boat trip the patient and other travelers
consumed raw oysters. Approximately 24 hours after returning from the
trip, the patient developed symptoms.
2

3. OEP
 Objective:
 Temp: 36.7.
 Pulse:112 b/min
 RR: 16 /minute.
 BP: 132/80 mmHg.
 Mucous membranes were tacky.
 His abdomen was soft and non- tender, and without rebound, guarding, or
flank pain
 Evaluation:
 DDx: traveler diarrhea, food poisoning, infectious diarrhea (bacterial).
 Plan:
 CBC:
 WBC: 9.1x 10^9 / L with a slight left shift of 83% neutrophils.
 Stool analysis:
 +ive for occult blood
 - ive for Clostridium difficile toxin and ova and parasites
 Moderate white blood cells were present
3

4. EL
 Elaboration:
 Relieve the symptoms.
 Causes of this presentation.
 Proper treatment strategy for this situation.
 Learning Goals:
Acute diarrhea.
4

5.  Increase in the stool weight to >250g/d, accompanied by increase
frequency and liquidity of stool.
1.
Sudden onset of frequency with cramp pains, and a fever =
infective cause.
2.
bowel frequency with loose blood-stained stools =
inflammatory basis.
3.
passage of pale offensive stools that float, often accompanied
by loss of appetite and weight loss, to steatorrhoea. Nocturnal
bowel frequency and urgency usually = organic cause.
4.
Passage of frequent small-volume stools (often formed) =
functional cause.
5

6. Diarrhea
A- Acute infectious Diarrhea
(gastroenteritis)
- <2 weeks.
- It may result from:
Emotional stress.
Food intolerance
Organic substance (mushrooms, shellfish).
Drugs and infectious agents.
1- Inflammatory or
bloody diarrhea
B- Chronic Diarrhea
- >2 weeks
- Divided into 6categories
Osmotic
Secretory
Inflammatory
Malabsorptive
Chronic infections
Motility disorders diarrhea
2-Non-inflammatory
diarrhea
Food poisoning
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7.  Suggest involvement of large intestine by
invasive:
o Bacteria.
o Parasites.
o Toxins.
 Clinical pt. present presentation:
o Frequent bloody, small volume stools.
o often +fever, +abdominal cramps, + tenesmus and fecal
urgency.
7

8.  Infectious agent invades the intestinal
mucosa
intestine.
acute inflammation of the
 Organisms produced Invasive intestinal
infections:
Viruses:
Adenovirus.
Cytomegalovirus.
Bacteria:
Salmonella.
Shigella.
Campylobacter.
Parasites:
Entameba histolytica.
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9. 
Milder disease caused by:
o
o

Viruses.
Toxins.
Affect small intestine and interfere salt and
water balance resulting in:
o
o
Large volume watery diarrhea.
Often +nausea, +vomiting and cramps.
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10.  A- enterotoxin- mediated diarrhea:
o
o
Does not invade the intestinal mucosa and its effect
mediated by its enterotoxins (exotoxin).
No inflammation of intestinal mucosa.
vibrio cholerae
E.Coli- toxigenic
Staphylococcus aureus
Clostridium perfringens
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11.  B- Non-Invasive organisms:
o
The organism exists in the intestinal lumen but does not
invade the tissue.
Giardia
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12. 12

13.  Disease caused by toxins present in consumed food.
Food
poisoning
-Incubation period (1-6hr)
-Toxins preformed in food.
-Vomiting.
-Fever usually absent.
*S.aureus.
*Bacillus cereus.
-Incubation period (8-16hr).
-organism produced toxins after
ingestion.
-Vomiting less prominent.
- Abdominal crambs ±,
Fever often –
*Clostridium perfringens.
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14. 14

15. 15

16. 1. Severity of diarrhea can divided as:
Mild:
≤3 stools/day.
Moderate:
≥4 stools/day.
Local symptoms:
-Abdominal cramps.
-Nausea.
-Tanesmus.
Severe:
≥4stools/day.
Systemic symptoms:
-fever.
-chills.
-dehydration.
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17. 2. Features suggest infectious diarrhea:
 Similar recent illness in family members.
 Recent ingestion of improperly stored or prepared food.
 Exposure to unpurified water in camping.
 Recent travel aboard causing( traveler diarrhea).
 Antibiotics adm. Within the preceding several weeks increase
likelihood of clostridium difficile colitis.
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18. 3. symptoms:
 Nausea.
 Vomiting.
 Abd. Pain.
 Fever.
 Diarrhea:
 Watery.
 Bloody.
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19. 4. Signs:
 General appearance.
 Mental status.
 Dehydration manifestation:






Dry mouth.
Inelastic skin.
Oliguria.
Weakness.
Lethargy.
Sunken eyes.
Depend of the degree of dehydration.
 Abdominal examination:
 Tenderness.
 Peritonitis.
 Features of metabolic acidosis.
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20. 20

21.  CBC:
 Look for leukocytosis.
 Hb level (may be falsely high due to hemoconcentration due to
dehydration).
 Urea, creat. & electrolytes:
 Pre-renal acute renal failure.
 Electrolytes imbalance: hyponatremia, hypokalemia and low bicarbonate
may present.
 Stool analysis:
 leukocytes, blood, ova and parasites.
 Stool culture:
 In case of bloody diarrhea.
 Sigmoidoscopy:
 If ulcerative colitis suspected.
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22. Circulatory shock.
Acute renal failure.
Electrolytes depletion leading to lethargy and
paralytic ileus.
Metabolic acidosis.
22

23. 1.
Diet:
 Soft easily digested diet (soups).
 Frequent feeding of fruits drinks, tea, cold drinks are encouraged.
 Rest bowel by avoiding high fiber diet, fats, milks products, caffeine.
2.
Rehydration:
 ORS: inexpensive, highly effective (awake pt.), fluids should be
giving 50-200ml/kg/d depend on hydration state.
 IV fluids: severe dehydration, normal saline or ringolactate to
restore water and electrolytes.
 Dextrose water should be avoided.
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24.  Assessment of dehydration using the “Dhaka method”
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25. 3.
Antidiarrheal agents:
 Mild to moderate diarrhea (improve pt. comfort).
 Contraindicated in :
 Bloody diarrhea.
 High fever.
 Systemic toxicity.
 Loperamide (cap. Imodium 2mg) :initially 4mg followed by 2mg
after each loose stool. (max. 16mg/24hr)
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26. 3. Antibiotic therapy (empirical treatment):
 Not recommended for all pts. With acute diarrhea.
 Only Invasive bacterial infection suggested by clinical
manifestation:
 Moderate- sever fever.
 Tanesmus.
 Bloody stool.
 Present of fecal leukocytes while stool culture in process.
 Drug of choice is quinolone such as:
 Ciprofloxacin (ciproxin)500mg TPD/5-7days.
 If suspect Giardia give metronidazole (flagyl) 250-500mg four times
/day. (Giardia appear –ive in 50% of pts.
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27.  (World Gastroenterology Organization Global Guidelines 2012)
 http://www.worldgastroenterology.org/assets/export/userfiles/Acute%2
0Diarrhea_long_FINAL_120604.pdf
 Medical diagnosis and management (INAM DANISH).
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