Download PDF 1MB - mucosalimmunology.ch

Management of diarrhoea
Dr. med. Henrik Csaba Horváth
Universitätsklinik für Viszerale Chirurgie und Medizin
Definition of diarrhea:
Passage of ≥3 unformed stools/day
Passage of ≥250 g of unformed stool/day
Types of diarrhea?
Etiology of diarrhea?
Acute: ≤ 14 days of duration
Infectious (bacterial, viral)
Persistent: 14 -30 days in duration
Noninfectious
Chronic: more than 30 days in duration
Management of diarrhea
No pathogen identified
Diarrhoe worsens
Diarrhoe becomes chronic
2
Universitätsklinik für Viszerale Chirurgie und Medizin
Pathogenes of acute diarrhea
Pathogene
Small bowel
Foodborne infections:
Salmonella*
E. coli
Norovirus
Cl. perfringens
Salmonella 16.1/100,000
aureus
CampylobacterS.13.4/100,000
B. cereus
Shigella 10.3/100,000
V. cholerae
Bacteria
E.coli 1.7/100,000
Cryptosporidium 1.4/100,000
Colon
Campylobacter*
Shigella
Cl. difficile
Yersinia
enteroinvasive E.coli
Plesiomonas shigelloides
V. parahemolyticus
Virus
Norovirus
Rotavirus
CMV, HSV
Adenovirus
Protozoa
Cryptosporidum
Microsporidum
Isospora
Cyclospora
Giardia lamblia
Entamoeba histolytica
*can involve both small bowel and colon, but most likely to occur as listed
Incubation period 8-72 hours
Watery diarrhoe
Incubation period 1-8 days
Inflammatory diarrhoe
Thielman et al NEJM 350;1 2004
Management of diarrhea
3
Universitätsklinik für Viszerale Chirurgie und Medizin
Evaluation of acute diarrhea
Initial assessment
Evaluate for: dehydration, duration, inflammation (fever, blood in stool), tenesmus
Symptomatic therapy
(hydration, alteration of diet)
Stratify management according to severity of illness
Epidemiologic clues:
Food, antibiotics, sexual activity,
travel, day-care attendance, outbreaks, season
Clinical clues:
Hypovolemia, blood/mucus in stool, fever (≥ 38.5C),
≥6 unformed stools/d, duration(≥7 days),
severe abdominal pain, elderly (≥65 yrs), hospitalized or
immunocompromised (HIV) pts, systemic illness, pregnancy
no
yes
Illness continues
Community acquired/
traveler`s diarrhea
Nosocomial diarrhea (onset ≥3
days after hospitalization)
Routine stool culture(Salmonella,
Shigella, Campylobacter)
+ E.coli O157:H17 and shiga-like
toxin (if hx of bloody diarrhea
+ C. diff. toxin test if recent
antibiotics, chemotx or
hospitalization
C. diff. toxin A and B test
+ routine stool culture (if outbreak,
>65 yrs, immunocompromised,
neutropenic, systemic infection
+ E.coli O157:H17 and shiga-like
toxin (if hx of bloody diarrhea)
Persistent diarrhea (≥7 days)
Illness resolves (<24 hours)
If patient immunocompromised
(esp. HIV+)
Consider protozoa
Management of diarrhea
Test for Microsporidia,
Mycobacterium, CMV
4
Universitätsklinik für Viszerale Chirurgie und Medizin
Endoscopic evaluation of acute diarrhea
Endoscopy has limited value in the diagnosis of acute diarrhea,
but may be helpful in the following settings:
Colonoscopy
In patients in whom pseudomembranous colitis is suspected
- while lab results are pending/not informative/negative
In patients in whom ischemic colitis is suspected
- but the diagnosis remains unclear after clinical and radiologic
assessment
In immuncompromised patients
- who are at risk for opportunistic infections (e.g. CMV)
Distinguishing IBD from infectious diarrhea
EGD
in patients with persistent diarrhea if standard stool and serologic studies are not diagnostic
(Giardia, early-onset celiac disease, small bowel pathology)
Management of diarrhea
5
Universitätsklinik für Viszerale Chirurgie und Medizin
Treatment of acute diarrhea
Oral rehydration solutions (WHO-ORS)
Per 1000 ml of water
3.5 g sodium chloride
2.9 g trisodium citrate or 2.5 g sodium bicarbonate
1.5 g potassium chloride
20 g glucose or 40 g sucrose
Empiric antibiotic therapy
Norfloxacin 2x400 mg/d for 1-5 days
Ciprofloxacin 2x500 mg/d
Levofloxacin 500 mg/d
If Campylobacter suspected
Azithromycin 500 mg/d for 3 days
Erythromycin 3x250-500 mg/d
In case of febrile dysentery
Suspected systemic infection
Severe cases of traveller`s diarrhea
Hospital/antibiotic-associated diarrhea
Severe nosocomial diarrhea (C. diff. toxin test pending)/suspected Giardia-infection
Metronidazol 3x500 mg/d for 10 days
Antimotility drug
Loperamide 4-8 mg/d for 48 hours
Bismutsubsalicylate (not available in Switzerland)
Management of diarrhea
Only if no fever,
no bloody/inflammatory stool
6
Universitätsklinik für Viszerale Chirurgie und Medizin
Treatment of acute diarrhea
Specific antibiotic therapy
Bacteriaemia occurs in 2-4% of patients
≥50 yrs of age
Lymphoproliferative disease
Cancer
Hemoglobinopathies
AIDS
Transplant recipients
Vascular grafts/valvular heart disease
Arteficial joints/degenerative joint diseases
Pt on corticosteroid therapy
Management of diarrhea
7
Universitätsklinik für Viszerale Chirurgie und Medizin
Chronic diarrhea
Etiology
Developed countries:
Less developed countries:
1.
2.
IBS
Idiopathic inflammatory bowel disease
1.
Chronic infections
3.
4.
5.
Malabsorption syndromes
Chronic infections
Idiopathic secretory diarrhea
2.
3.
4.
Functional disorders
Inflammatory bowel disease
Malabsorption
Management of diarrhea
8
Universitätsklinik für Viszerale Chirurgie und Medizin
Chronic diarrhea
Diagnosis
Minimal
laboratory
evaluation:
Physical
examination
Medical history
CBC, serum electrolytes
- Onset/duration of symptoms: congenital, sudden, gradual
Total protein
+ albumin
General:
fluid balance,
nutritional
status,
physical
signs of MEN
anemia
- Family history:
congential
absorptive
defects,
IBD,
celiac disease,
Thyroid function test
- Dietary history: «sugar-free» foods, raw milk
Iron/ferritin,
vitamin Bhepatomegaly,
cholesterol
12, calcium,
Abdomen:
- Travel history:
exposore
to impuremass,
waterascites,
source tenderness, pain
indicationg
prior abdominal
- Previousscars
therapeutic
interventions:
drugs,surgery
radiation, surgery, antibiotics
Spot stool analysis
- Current medication
- Rectal
occult digital
blood test
examination:
visible blood,diabetes,
anal fissure/fistula,
- Systemic
illness symptoms:
hyperthyeroidism,
vasculitis,
- abnormal
calprotectin
sphincter
pressure
Whipple`sanal
disease,
IBD, tuberculosis,
mastocytosis
- fecal cultures
- iv. drug abuse, promiscuity (risk factors for HIV infection)
• immunocompr.
patients/immigrants:
+ fungi,
protozoa, parasites
Skin: skin
rash, flushing, dermatographism,
mouth
ulcers
- Weight loss
- Lympadenopathy
Sudan stain for fat
- Abdominal
pain: mesenteric vascular insufficiency, obstruction, IBS
Thyroid gland:blood,
mass oil/food particles, white/tan colour, nocturnal diarrhea
- Stool characteristics:
Quantitative
48-hour
stool
collection
and analysis
Eyes:
episcleritis,
exophthalmus
volume
(small bowel
vs. colon)
- volume, weight, osmolality, pH, electrolyte conc. (Mg), elastase
- Leakage of stool/fecal incontinence
- Excessive flatus
Management of diarrhea
9
Universitätsklinik für Viszerale Chirurgie und Medizin
Chronic diarrhea
Diagnosis
Clinical relevance of osmolality in stool?
<290mOsm: contamination with water/dilute urine, gastrocolic fistula,
ingestion of hypotonic fluid
>290mOsm: not informative (bacterial metabolism of fecal carbohydrate)
Normal range of osmotic gap in stool?
Clinical relevance of osmotic gap in stool?
<50mOsm/kg
Secretory diarrhea
50-125 mOsm/kg
>125 mOsm/kg
Osmotic diarrhea
Osmotic gap: 290- 2([Na+]+ [K+])
Management of diarrhea
10
Universitätsklinik für Viszerale Chirurgie und Medizin
Chronic diarrhea
Diagnosis
Normal range of stool pH?
Clinical relevance of stool pH?
<5.3
Carbohydrate malabsorption
Management of diarrhea
5.3-5.6
>5.6
Generalized malabsorption
11
Universitätsklinik für Viszerale Chirurgie und Medizin
Chronic diarrhea
Diagnosis
Clinical relevance of urine analysis?
5-hydroxiindol acetic acid - carcinoid syndrome
Vanillylmandelic acid/metanephrine - pheochromocytoma
Histamin - mast cell disease
Output/ urinary Na, K concentration ↑
Management of diarrhea
Surreptitious diuretic use may
suggest coexisting laxative abuse
12
Universitätsklinik für Viszerale Chirurgie und Medizin
Chronic diarrhea
Diagnosis
Which serologic tests may be useful in patients with chronic diarrhea?
Test
Disorder
ANA
Vasculitis, scleroderma, autoimmune enteropathy
AGA, anti-EMA
Celiac sprue
pANCA
UC
Quantitative immunoglobulines
Selective IgA deficiency, common variable
immunodeficiency
HLA-DR, DQ typing
Celiac sprue, refractory/unclassified sprue,
possibly Crohn`s disease, UC
E. hystolitica antibody titers
Amoebiasis
HIV-antibodies
AIDS
Management of diarrhea
13
Universitätsklinik für Viszerale Chirurgie und Medizin
Evaluation of chronic diarrhea
History
Physical exam
Lab tests
Stool analysis
Categorize
Watery
Secretory
Exclude infection
Inflammatory
Low pH
Carbohydrate
malabsorption
Dietary review
Breath tests
Selective testing
Gastrin/Calcitonin/
VIP/Somatostatin
Management of diarrhea
Functional
Osmotic
Exclude
structural disease
C4 BAM test/
Cholestyramine
trial
Fatty
Exclude
structural disease
Exclude
structural disease
Exclude infection
Exclude
pancreatic
exocrine
insufficiency
<45 yrs of age
Normal basic
investigations
High Mg output
Inadvertent
ingestion
Laxative abuse
14
Universitätsklinik für Viszerale Chirurgie und Medizin
Evaluation of chronic diarrhea
Small bowel
History
Physical
exam
Lab
tests
Stool
analysis
C
a
t
e
g
o
r
i
z
e
Malabsorption
Pancreas
Colonic/
terminal
ileal disease
Rectal/anal
disease
«difficult»
diarrhea
Management of diarrhea
D2 biopsy/
MR enteroclysis
CT pancreas
Faecal elastase
Pancreolauryl test
Enteroscopy
Breath tests
Jejunal
aspirate&culture
Further structural test
ERCP/MRCP
Flexible colonoscopy
Ano-rectal manometry
Consider inpatient assessment
24-72 h stool weights, osmolality, osmotic gap
Gut hormones, serum gastrin, VIP, urinary 5-HIAA
15
Universitätsklinik für Viszerale Chirurgie und Medizin
Treatment of chronic diarrhea
Empiric therapy
1. Strongly suspected diagnoses:
-
Diarrhea after ileal resection: bile acid malabsorption
Association of symptoms with consumption of lactose
Patient with known recurrent bacterial overgrowth
Known outbreak of GI infections
2. Comorbidities limit diagnostic evaluation
3. After diagnostic testing with no definitive diagnosis or
with diagnosis has been made, but no specific treatment available/
specific treatment not effective
Symptomatic therapy
Loperamide 4-8 mg/d
Activated charcoal
Bismutsubsalicylate (not available in Switzerland)
Bile acid binding resins
Fibers
Opiates/octreotid (carcinoid tumors, dumping sy., chemotherapy-induced diarrhea)
Management of diarrhea
16