DIFFERENTIAL DIAGNOSIS OF

YSMU Department of Infectious Diseases

2016 Definition

 Increases the frequency of excretion ( 3 and more time per day) with fluid/loose consistency of stool  The excretion of stool usually 100-300g/day and frequency from 3 times/day to 3 time/week  The followings are not Diarrhea - fluid/loose consistency of stool, 1-2 times aday - 3-4 times a day with normal consistency Distribution  Registered cases of diarrhoeal diseases are 1.5 billiard/year  Second place as emergence death causes  6 million children under 5 year died of diarrhoeal diseases in Asia, Africa, Latin America  WHO have carried out special program since 1980 Ingestion and secretion Absorption Saliva (1litre)

Ingested fluids (2 liters) Gastric juice (2 liters)

Bile (1 litre)

Pancteatic juice (2 liters) Small bowel Intestinal (8 liters) juice (1 litre) Total 9 liters Large bowel (0.9 litre) Total 8.9 liters Exoreted in stool (0.1 litre) Pathogenesis

 Secretory (hypoosmolar)

 Hyperosmolar

 Hyperkinetic

 Hyper exudative 5. 4. adenylate cyclase  - s Protein kinases G c.AMP s G + - 6. Na Cl 1. 2. 3. - Cl Toxin Pathophysiology of secretor diarrhea Classification  By etiology  - infectious and non infectious

 By the duration  - acute and chronic

 By the affection of GI tract  -  -  -  - Infectious (1)

 Shigellosis  Salmonellosis  Echerichiosis   Yersiniosis  Food-borne  Food poisoning (St.aureus, botulism)  Cholera  Viral diarrhoea  HIV-infection Infectious (2)  Protozoal disease (Giardiasis, Amoebiasis, , etc.)  Helminthiasis (ascariasis,enterobiasis, trichu- riasis, strongyloidosis, ancylostomidosis, schisto- somiasis, taeniasis)   Microsporidiosis  Isosporosis   Cyclosporosis  Tuberculosis of intestine  Wipple diseases  syphilitic, gonorrheal, chlamydeous Noninfectious (1)   Inflammatory Bowel diseases: , Crohn’s disease  GI diseases: Hypoacid , Cancer, Chronic , Cancer of Pancreas & Major duodenal papilla, Cholelithiasis, Liver  Cancer of Small Bowel, mesenteric lymphatic nodes and retroperitoneal  Endocrinal diseases: Diabetes Mellitus, Hypofunction of the adrenal gland, Thyrotoxicosis, Parathyreosis Noninfectious (2)

 Exogenous Poisoning: mushrooms, Pb, Cu, As, Hg  Iatrogenic: NS enterocolitis, radiation  Endogenic intoxication – Uremia, avitaminosis  Surgical : acute , mesenterial vessels thrombosis, acute intestinal obstruction, adnexitis, pelveoperitonitis  Postsurgical: vagotomy, stomach resection, bowel resection, cholecystectomy  : gluten-sensitive & soybean , , lymphangiectasia  Systemic diseases - Amyloidosis, scleroderma  Drugs – antibiotics, NSAID, colchicine, antidiabetic drugs, etc. Acute diarrhea

 Mainly with dehydration

 Mainly bloody Acute diarrhoea

 2-3 weeks duration  In majority of cases has infectious origination  Evaluation: - stool culture - methylene blue to check WBC - test for ova and parasites Acute diarrhea with dehydration

 Cholera  Salmonellosis  Shigellosis (Sh. Sonnei and Grigoriev-Shig)  Echerichiosis (ЕТЕС)  Campylobacteriosis  Staph.aureus food poisoning  Viral diarrhea  Food-borne illnesses Shigella Salmonella V.cholerae 01

Penetration in intestine degreeof invasion Lamina propria Increasing Salmonellosis

 Gastrointestinal form in 75% of all cases  transmitted by poultry, eggs, water fowls  short incubation period (12 -24 h)  sudden onset with severe intoxication  start from gastritis (, recurrent , stomachache), than develop enteritis  large volume stool during whole diseases, stinking with mucus  abdomen palpation – painful in epigastria, right part up to ileoceacal; in 30% - hepatosplenomegaly Diagnosis  Bacteriological - stool, vomiting mass, food  Serological Shigellosis (Sh. sonnei)  transmitted by food  incubation period is up to 2 days  onset is acute with (up to 39º)  severe intoxication 1-2 days  vomiting 1-2 times per day  I-II degree of dehydration  stool is big volume, watery  in case of affection blood and mucous  no hepatosplenomegaly  CBC can be inflammatory

Diagnosis Stool culture Viral diarrhea

 Theses are anthroponose viral infections  Typical: - Gastroenteritis or enteritis - -Highly contagious - -winter-spring seasonality - -Runny nose, viral pharynx

 The following viruses can be etiological agents: Rotavirus Enterovirius Adenoviridus Parvoviridus Coronavirius Calicivirius Astrovirius Viral diarrhea  1/3 cases have rotaviral origin  acute onset  mild intoxication, subfebrile temperature  large volume stool without blood and mucous 5-10 times/day  bloating, borborymus (per distance)  in children possible severe dehydration with renal insufficiency and metabolic acidosis  Blood is normal, sometimes leucopoenia, lymphocytosis  can cause hospital infection Diagnosis  Immunofluorescence assay, ELISA, PCR Escherichiosis

 ЕС classification enterotoxigenic (ЕТЕС) enteropathogenic (ЕРЕС) enteroadhesive (ЕАЕС) enteroinvasive (ЕIЕС) enterohemmorrhagic (ЕНЕС)  ЕТЕС cause “cholera-like echerichiosis” in adults  ЕТЕС-main cause of “traveler’s diarrhea“(40-75%)  In many cases there is no fever - afebrile gastroenteritis  Onset is acute with gastroenteritis like cholera  Crucial for differential diagnosis from cholera epidemiological situation stool culture Campylobacteriosis  zoonosis infection cause by Campylobacter jejuni  transmitted by meat (pork, beef, chicken), milk  acute onset with gastroenteritis, enterocolitis, colitis  temperature up to 39°С  severe cramps in mesogastrium  large volume, watery, stinking stool, after 3 days with mucus and blood  1-2 weeks after diarrhea may develop terminal , mesadenitis, reactive arthritis, rash

Diagnosis  stool culture  serological tests 82%) (15-20%), up to ( Diagnosis

Yersiniosis (30-35%) transmitted by storage fruits andclinical vegetables, symptoms diary are products, polymorphic pork gastroenteritic variant is predominant acute onset with intoxication Pain in right ileac region stool is watery, stinking, big volumeaccompanied 3-10 with times catarrhal a symptoms day the face and sclera arepalms usually and hyperemic soles are hyperemic‘’strawberry-like and tongue’’ edematous peripheral lymph nodes are enlarged hepatosplenomegaly may develop arthritis, multiform ephemeral rash /4-5 days/ bacteriological /blood, urine, stool/ urine, bacteriological /blood, serological              Food-borne illnesses

 Transmitted by food, infected with facultative pathogenic microorganisms  The main etiological agents: Proteus, Bacillus cereus, Clostridium perfringens, Klebsiella, Citrobacter, Enterobacter, Campilobacter, Pseudomonas, St. aures etc.  Short incubation period /from 15 minutes/  Short duration of the disease  Massive character of the disease, outbreaks  Acute gastroenteritis with dehydration  Clinical symptoms depend on causative agent Diagnosis - double isolation of the same agent in 106 dilution in the first 3 days of the disease with later decrease of number - -detection of the same serotype from food, vomit mass or close contact area of the patient - -by autoaglutination reaction fourfold increase of antibody titres Staph.aureus food poisoning

 connect with milk, dairy products  St. aures enterotoxin can be destroied in boiling more than 30 min  very short incubation period (sometimes 30 min, mainly 2-6 hours)  sudden onset with gastritis  no fever, rare subfebrile  complains - nausea, vomiting, sharp pain in epigastria  diarrhea is short-term, not intensive  in severe cases – convulsions, collapse Botulism

 cause by bacterial exotoxin - botulotoxin  epidemiological anamnesis – homemade tinned goods  syndromes - gastrointestinal, hyposalivation, ophtalmoplegy, myoplegy, phonoplegy, phagoplegy, asphyxia, hemodynamic, intoxication  gastroenteritis 1-2 days, followed by , intestinal paresis Diagnosis - detection of toxin in blood before serotherapy - food, vomit mass, stool, gastric lavage mass are also examined Cholera  it is especially dangerous disease  no intoxication, no fever  clear conscious  starts from diarrhea, without abdominal pain, tenesmus and false impulses  then add vomiting without nausea  Stool loose, without fecal odour,  “rice water”  dehydration and demineralization /I-IV degree/ Diagnosis - stool culture - express tests (immunofluorescence after 1.5-2 hours, immobilization, microagglutination) Stool in Cholera Acute diarrhea with blood

 Causative agents - Shigella, Campylobacter, EIEC, EHEC, Clostridium, Entamoeba hystolitica, helminths  Rare – Yersinia and Salmonella  Ulcerative colitis  Crohn,s disease  Mesenteric thrombosis  Diverticulosis  Rectal cancer etc. Acute bloody diarrhoea

Shigella C. jejuni Salmonella EIEC Entamoabe histolytica Shigellosis (Sh. flexneri)

 Acute onset with severe intoxication  haemorrhagic proctosigmoiditis - very frequent, small volume stool streaked with blood & mucus - “rectal sputum“ - abdominal cramps in left ileocecal part - tenesmus & false impulse - incompletely closed anus - palpation of the sigmoid colon is painful Diagnosis  Anamnesis, clinical and epidemiological data  Stool culture  Stool microscopy  Rectoromanoscopy Amoebiasis

 gradual onset and undulating duration  mild intoxication  stool – up to 3-5 times/day, loose, which contain faeces with “glassy" sticky mucus and blood (“raspberry jelly")  abdominal pain (sometimes cramps) by projection of large bowel mainly in right ileac region  caecum infiltrated, painful, enlarged  hepatomegaly (rather often) Diagnosis - Microscopy of stool: detection of big vegetative forms and Charcot-Leyden crystals - - Slising pain in epigastrium Frequent, big volume, stinking Shigellosis Salmonellosis Cramps in left ileocecal region volume with blood and mucous

Differential diagnosis Differential (1) Differential symptoms Differential OnsetIntoxication(location, Pain in abdomen character) moderate 1-3 acute days severe 3-5 days sudden Tenesmus, false impulsesTenesmus, Stool YesHepatosplenomegaly No No Frequent small Yes Slising in right ileocecal region Frequent with glassy mucous and blood Shigellosis Amoebiasis Cramps in left ileocecal region volume with blood and mucous

Differential diagnosis(2) Differential Differential symptoms Differential OnsetIntoxication(location, Pain in abdomen character) Severe Acute Mild Gradual StoolExtraintestinal complications Rare Frequent small Chocolate abcsess Erythrocytes Leukocytes Charcot-Leyden crystals Colonoscopy Ulcers on cecum and ascending bowel Shigellosis Amoebiasis Leukocytes Erythrocytes proctosigmoiditis

Differential diagnosis(3) Differential Differential Differential symptoms Laboratory diagnosis Stool cultureCoprology Stool microscopy Instrumental diagnosis Rectoromanoscopy Treatment Furasolidon Echerichiosis caused by EIEC

 reminds bacterial  acute onset  mild intoxication  rare vomiting  stool – up to 3-5 times/day, loose with mucus, sometimes with blood  Sometimes tenesmus and false impulses Echerichiosis caused by ЕНЕС (ЕС О157:Н7)  acute onset with abdominal cramps in right ileac part, nausea, vomiting, watery diarrhea  normal temperature or subfebrile  severe hemocolitis from 2-3 day: , sometimes " only blood without stool"  intensity of abdominal pain increases  hemocolitis duration usually 8 days  Hemolytic-uraemic syndrome add 2-14 after diarrhoea stopped, especially in children  mortality 5% Diagnosis  Stool ELISA Pseudomembanous colitis

 caused by Clostridium difficile  serious sequelae of antibiotic therapy  pathogenesis – some antibiotics (, lincomycin, amoxicillin, etc.) press bowel normal flora and bring to C. difficile overgrowth  affects  symptoms - fever, profuse foul-smelling diarrhea, often with blood, abdominal cramps, nausea, vomiting, meteorism, leukocytosis, dehydration Diagnosis  C. difficile toxin in stool (latex-agglutination)  rectoscopy – squamuliform yellow pseudomembranes, cluster of fibrin, mucus and inflamed cells

Chronic diarrhoea (1)

 Persists for more than 3 weeks Causes:  Infectious or parasitic diseases  Chronic GI diseases endocrinopathy cardiovascular diseases tuberculosis, scleroderma, syphilis etc.  Possibly due to inflammatory bowel diseases (IBD) - ulcerative colitis, Crohn’s disease  Laxative abuse Chronic diarrhoea (2)

Causative agents  Shigella   Yersinia enterocolitica  Campylobacter jejuni  Helminths  Gardia lamblia   HIV-infection Giardiosis

 protozoal infection caused by Gardia lamblia

 watery outbreaks

 mild enteritis, without intoxication

 patients complain of borborymus, mild abdominal pain, diarrhoea (up to 4-5 times/day)

 semi-liquid, frothy stool pungent smell

Diagnosis

 Microscopy of stool or duodenal content

 ELISA Gardia lamblia HIV-infection

 diarrhea – one of earlier and frequent manifestations ( 70 % of patients)

 Causes - opportunistic infections - malabsorption - treatment (drug-related)

 Both small and large intestine are affected The most common etiological agents of diarrhea in HIV-infection: Bacteria: Protozoa:  Shigella  Cryptosporidia  Salmonella  Gardia lamblia  Camylobacter  Isospora  Mycobacteria  Microsporidia  Clostridia  Entamoeba histolytica Viruses: Worms:  Cytomegalovirus  Herpes simplex virus  Strongyloides sterсoralis

Fungi: Non infectious:  Candida  Kaposi's sarcoma  Lymfoma Chronic diarrhea /diagnosis/  Bacteriological examination of stool (detection of chronic infections)

 Detection of hidden blood in stool

 General examination of stool for detection of leukocytes (inflamatory or infectious process)

 Examination of stool for detection of calprotectine and lactopherine (inflamatory or infectious process)

 Detection of parazites (trophozoids of ameoba, , eggs of helminths)

 Examination of stool for: fat (malabsorbtion) electrolytes рН (absorbtion disorders)

 Instrumental diagnosis Conclusion  Pay attention to anamnesis morbi и anamnesis vitae  Figure out - duration of diarrhea – acute or chronic - clarify, which part of GI is affected – gastroenteritis, enteritis, colitis  Differentiate infection and non-infection origin

 Confirm diagnosis by - laboratory -instrumentalmethods Thank you for your kind attention