Diarrhea & Constipation

Dr.Walaa Gholam ER resident NGH - AKMC

Diarrhea Perspective
Most cases of diarrhea are self-limited, require only supportive care. patients with more serious infection + associated comorbidity may present with life-threatening dehydration + shock. associated sepsis + septic shock component.

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Diarrhea Perspective

Definitions: Acute diarrhea (< 14 days) usually infectious. majority self-limited, viral & bacterial pathogens Persistent diarrhea (>14 days) enteric pathogen other than viral, such as bacterial or protozoan.

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Diarrhea Perspective
Diarrhea results from 4 different pathologic processes

1) Secretory diarrhea
- pathogens produce cytotoxins cellular permeability oversecretion of water & electrolytes. - Most cases of diarrhea in ED are secretory. - Noninfectious causes of secretory diarrhea Box 23-2

2) Abnormal motility
- generally chronic diarrhea - but is always a component of acute diarrhea. - Hypermotility contact time between luminal contents + absorbing mucosa limiting water & electrolyte absorption.

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Diarrhea Perspective
3) Inflammatory diarrhea - invasive, severe diarrhea, dysentery - cellular damage to the intestinal mucosa hypersecretion of water, electrolytes, blood, mucus, plasma proteins. - most commonly invasive bacterial & parasite (that produce dysenteric illnesses)
- Some noninfectious causes (chemotherapy, radiation therapy, hypersensitivity reactions, autoimmune disorders, ischemic colitis, IBD) - fecal leukocytes & erythrocytes typically are present
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Definition & Categorization

Infectious 85% , noninfectious 15%. Infectious diarrhea : 70% viral, 24% bacterial, 6% parasitic
BOX 23-1 infectious diarrhea Viral (60%)
Helminths Angiostrongylus costaricense Anisakiasis Ascaris lumbricoides Diphyllobothrium latum Enterobius vermicularis Hookworms Schistosoma spp. Strongyloides stercoralis Taenia spp. Trichinella spiralis Trichuris trichiura Toxigenic food poisoning with preformed toxins Bacillus cereus Clostridium botulinum Staphylococcus aureus toxin formation after colonization Aeromonas hydrophila Clostridium perfringens Enterohemorrhagic E. coli* O157:H7 Enterotoxigenic E. coli Klebsiella pneumoniae Shigella spp. Vibrio cholerae

Bacterial (20%) Invasive* Aeromonas spp. Campylobacter spp. Clostridium difficile Enteroinvasive E. coli Mycobacterium spp. Plesiomonas shigelloides Salmonella spp. Shigella spp. Vibrio fluvialis Vibrio parahaemolyticus Vibrio vulnificus Yersinia enterocolitica Yersinia pseudotuberculosis

Emergency Assessment & Stabilization

pt's stability, airway, adequacy of oxygenation & ventilation, circulation, attention to volume status. Tachycardia, orthostatic hypotension, poor skin turgor & color, diaphoresis, mental status hypovolemia & hypoperfusion. if septic shock hypotension, general organ hypoperfusion, diarrhea may be a manifestation of toxic shock Dr.Walaa Gholam ER resident www.medkaau.com/vb syndrome.

Secondary Survey
overall health, toxicity, fever, volume status, signs of surgical abdomen, presence of blood in the stool. Young healthy adults maintain normal BP & HR even with significant dehydration. antiarrhythmic or beta-blocker, conduction disease, fixed-pace rhythms HR not reliable indicator of volume status. Signs of volume depletion & impending shock dry mucosa, poor skin turgor, urine output, mental status changes.

Characterization of the Diarrheal Syndrome

1) Acute Infectious Diarrhea - viral, bacterial - self-limited - secretory diarrhea - lasts < 14 days - mild dehydration & minimal systemic symptoms - do not require extensive testing - treated symptomatically - 90% of the infections are caused by norovirus species - Bacterial & protozoan, less commonly
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clinical evaluation should screen for all factors that change the probability of

23-1 Factors Increasing Probability of Nonbenign Diarrhea Red Flags

23-1 Factors Increasing Probability of Nonbenign Diarrhea

Characterization of the Diarrheal Syndrome

2) Chronic Infectious Diarrhea * Persistent diarrhea > 14 days * chronic diarrhea > 30 days Infectious agents: bacteria, parasites, rarely viruses Bacterial pathogens
Aeromonas, Plesiomonas, Campylobacter, Clostridium difficile, Salmonella, Mycobacterium tuberculosis.

Parasites colonic: Amoeba, Trichuris, Yersinia, or small

Schistosoma species

intestinal: Giardia, Cryptosporidium, Cyclospora, Isospora, Strongyloides.

Characterization of the Diarrheal Syndrome

3) Noninfectious Diarrhea see Box 23-2 15% of all diarrhea cases distinction may not be clinically apparent A complete evaluation should consider: - surgical pathology of the abdomen - toxic exposures or ingestions - Endocrine pathology
Dr.Walaa Gholam ER resident

- hormone-secreting tumors

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23-2 Noninfectious Diarrhea

noninfectio us diarrhea, Toxins Drugs ACE inhibitors Alprazolam (Xanax)

Dietetic Foods Mannitol Sorbitol Xylitol Fish-Associated Toxins Amnestic shellfish poisoning Ciguatera Echinoderms Neurotoxic shellfish poisoning Paralytic shellfish poisoning Scombroid Tetroton Plant-Associated Toxins Herbal preparations Horse chestnut MushroomsAmanita spp. Nicotine Other plant toxins Pesticidesorganophosphates Pokeweed Rhubarb Miscellaneous Allergic reactions Carbon monoxide poisoning Ethanol Heavy metals Monosodium glutamate (MSG) Opiate withdrawal

Noninfectious Diarrhea

Gastrointestinal Pathology Appendicitis Autonomic dysfunction Bile acid malabsorption Blind loop

Endocrine-Related Carcinoid syndrome (serotonin) Hormonal hypersecretion Hyperthyroidism (thyroid hormone) Medullary carcinoma of the thyroid (calcitonin) Pancreatic cholera (VIP) Somatostatinoma (somatostatin) Systemic mastocytosis (histamine) Zollinger-Ellison syndrome (gastrin) Endocrine Pathology Adrenal insufficiency Diabetes enteropathy Hypoparathyroidism Pancreatic insufficiency Systemic Illness/Other Alcoholism Amyloidosis Connective tissue disease Cystic fibrosis Ectopic pregnancy Hemolytic-uremic syndrome Henoch-Schnlein purpura Lymphoma Otitis mediainfants Pelvic inflammatory disease Pneumonia/sepsis Pyelonephritis Scleroderma/SLE Severe malnutrition Stevens-Johnson syndrome Toxic shock syndrome Wilson's disease Miscellaneous Factitious diarrhea Runner's diarrhea

Ancillary Testing

Most cases are self-limited laboratory & diagnostic tests minimum. Testing is indicated in pts who have a high probability of non-norovirus clinical picture & worrisome historical data, signs, symptoms.
Dr.Walaa Gholam ER resident

Fever with a toxic appearance & volume depletion, blood- or mucus-containing

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Ancillary Testing
Hemoccult & fecal cell count: presence of fecal leukocytes is not specific or sensitive inflammatory diarrhea red & white blood cells in stool examination. presence of blood does not correlate with presence of fecal leukocytes, so reliance on positive stool guaiac test alone for antibiotic therapy is not recommended. presence of blood without fecal leukocytes amebiasis, malignancies, heavy metal poisoning, fissures, hemorrhoids, bowel ischemia, primary GIT

Ancillary Testing
E. coli O157:H7 toxin assay: in endemic areas, in pts suspected hemolytic-uremic syndrome. Stool culture for bacteria: febrile, toxic-appearing, immunocompromised, extremes of age, prolonged course, not responding to conventional treatment. Stool examination for ova and parasites: not routinely recommended. in pts with chronic diarrhea (E. histolytica, Cryptosporidium); history of travel to

Empirical Management
Oral rehydration is the ttt of choice for mild to moderate fluid losses sports beverages, commercial rehydration solutions, balanced clear liquid diet in the home (consisting of water, salt-containing liquids such as canned soups, potassium from oranges or bananas)

The WHO has defined an oral rehydration solution (WHO-ORS) dissolving the following in 1 liter of clean water: 3.5 g of sodium chloride 2.9 g of trisodium citrate or 2.5 g of sodium bicarbonate 1.5 g of potassium chloride 20 g of glucose or 40 g of sucrose
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Empirical Management
Replacement of micronutrients, particularly copper and zinc, has been recommended bowel rest has been abandoned because it may worsen diarrhea In healthy patients with mild to moderate dehydration sports drinks, diluted fruit juices, soft drinks supplemented with soups, broths, or crackers. may contain excess sugars & insufficient sodium content osmotic diarrhea. caffeine should be avoided, caffeine increases cyclic

Empirical Management
any antimicrobial treatment must be empirical Viral & noninvasive bacterial gastroenteritis selflimiting and require only supportive therapy. Empirical antibiotic ttt against invasive bacterial & parasitic organisms. Antibiotic ttt suspected invasive process, severe diarrhea, systemic symptoms, fever, abdominal pain, appear toxic. ciprofloxacin, 500 mg orally BID, or levofloxacin, 500 mg orally every 24 hours for 3 to 5 days.

Empirical Management
If amebic dysentery is of concern ttt metronidazole after stool analysis for ova & parasites recent antibiotic use suspected of C. difficile colitis C. difficiletoxin assay followed by vancomycin or metronidazole use of antimotility agents in ttt of acute enteritis has been controversial. simple, acute viral gastroenteritis benefit from antimotility agents, obtain significant relief of symptoms, with less fluid loss, without significant

Disposition
uncomplicated, acute diarrhea can be discharged home after assessment & symptomatic relief. Hospitalization rarely is required. exact etiologic agent of diarrhea is not identified in the ED. Admission:
Dr.Walaa Gholam ER resident

severe dehydration

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Constipation

Dr.Walaa Gholam ER resident

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Perspective
symptom, not a disease Patients broad set of complaints: straining, hard or infrequent stools, feeling of incomplete evacuation, abdominal discomfort. Constipation may be acute (new for the patient) or chronic. Chronic constipation presence of symptoms for at least 3 months. The Rome III criteria constitute a definition of functional chronic constipation When constipation becomes severe with constant pain

Pathophysiology
GIT 9-10 L/day of secretions + ingested fluids. small intestine absorbs all except 500 mL. colon mixes the ileal effluent, ferments & salvages the unabsorbed carbohydrate residues, desiccates the contents to form stool. process of stool transport & evacuation is complex, regulated by neurotransmitters, intrinsic colonic reflexes.
Dr.Walaa Gholam ER resident www.medkaau.com/vb Constipation may result from structural, metabolic,

Differential Considerations
In ED acute constipation due to side effects of medications or avoidance of defecation secondary to presence of painful perianal lesions (fissures, hemorrhoids, perirectal abscesses) Obstructive
Anal stenosis Crohn's disease Colon cancer Stricture Rectal prolapse Gynecologic Table 24-2 - Causes of Constipation Large rectocele Pelvic relaxation Secondary Causes

Primary Causes
Dr.Walaa Gholam ER resident

Functional Disorders

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Differential Considerations
Secondary causes Lifestyle/General Condition Dehydration Inadequate dietary fiber Sedentary Voluntary suppression of defecation Medications Antacids Anticholinergics Anticonvulsants Antidepressants Antihistamines Antiparkinsonian drugs Antipsychotics Calcium channel blockers Calcium supplements Diuretics Iron supplements Laxatives (chronic abuse) Nonsteroidal anti-inflammatory drugs Opiates Metabolic/Endocrine Diabetes mellitus Hypercalcemia Hypokalemia Hypothyroidism Hypomagnesemia Porphyria Uremia

Myopathic Scleroderma Amyloidosis Neurologic Cerebrovascular accident Autonomic neuropathy Mutiple sclerosis Paraneoplastic neuropathy Parkinson's disease Amyotrophic lateral sclerosis Psychological Anxiety Depression Eating disorders Situational stress Sexual abuse

Pivotal Findings history

Defining what the patient means by constipation presence / absence of alarming signs / symptoms: fevers, anorexia, nausea, vomiting, new onset or worsening of constipation, blood in the stool, weight loss, family history of IBD, colon cancer. character of the stools: in caliber of the stool mass lesion

constipation IBS.
Dr.Walaa Gholam ER resident

diarrhea alternating with

Frequency of stools, what normal for the pt review of systems

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Pivotal Findings physical examination

The abdominal examination usually normal findings may reveal tenderness, a mass, distention, evidence of obstruction. Bowel sounds should be auscultated. anorectal examination + evaluation of the stool (most important) Anorectal inspection fissures, skin excoriations, hemorrhoids, rectal prolapse. DRE palpation for masses, presence or absence of pain, strictures, high sphincter tone, presence of blood.

Ancillary Testing
majority do not need any testing. Plain radiographs may provide stool retention, megacolon, volvulus. plain radiographs documenting stool load in constipated patient cannot be used to rule out more serious underlying disorders, especially if significant amount of abdominal pain or tenderness on examination.

laboratory studies not routinely indicated.

Diagnostic algorithm
additional symptom of abdominal pain. workup toward this symptom Constipation cause abdominal pain diagnosis of exclusion physical examination structural/mechanical cause, (pain from hemorrhoids, fissures, mass lesion) ttt If no obvious cause is found then determination of presence or absence of stool in the rectal vault
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Empirical Management
eradicating the underlying cause providing symptom relief Prevention of further episodes of constipation ( fluid intake, dietary fiber, and, synthetic bulk agents)

withholding a causal medication management of an anal fissure draining of perirectal abscess Table 24-3 -- General Approach to ttt of Constipation

Empirical Management
Specific agents for symptomatic ttt Table 24-4. Most are category B or C polyethylene glycol (category C) was the optimal laxative for pregnant women (effective & minimally absorbed, has few side effects, is low risk) Pts who are on chronic, medically necessary medications that cause constipation (opioids with chronic pain / cancer) bowel regimens preventive measures (high levels of dietary fiber), stimulant laxatives. Dr.Walaa Gholam ER resident www.medkaau.com/vb

Dr.Walaa Gholam ER resident

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Empirical Management
Enemas if laxatives have failed to provide relief large volume of stool in lower colon or rectum that cannot be expelled Warm tapwater enemas (safest)

For immediate relief manual disimpaction elderly with large amounts of stool present in rectal vault. rare case disimpaction with procedural sedation.

recalcitrant constipation interventions such as acupuncture, biofeedback, bowel training.

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Disposition
Constipation is appropriately treated at home severe cases disimpaction / enema ttt in ED.

Admission? complications presence of a serious disorder as a cause for the constipation, such as fecal impaction beyond that able to be resolved by digital disimpaction, megacolon, volvulus, or bowel obstruction

Dr.Walaa Gholam ER resident

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Diarrhea & Constipation

Dr.Walaa Gholam ER resident NGH - AKMC

Dr.Walaa Gholam ER resident

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