DIFFERENTIAL DIAGNOSIS OF DIARRHEA
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 - gastroenteritis - enterocolitis - colitis - gastroenterocolitis Infectious (1)
Shigellosis Salmonellosis Echerichiosis Campylobacteriosis Yersiniosis Food-borne Food poisoning (St.aureus, botulism) Cholera Viral diarrhoea HIV-infection Infectious (2) Protozoal disease (Giardiasis, Amoebiasis, Balantidiasis, etc.) Helminthiasis (ascariasis,enterobiasis, trichu- riasis, strongyloidosis, ancylostomidosis, schisto- somiasis, taeniasis) Cryptosporidiosis Microsporidiosis Isosporosis Blastocystosis Cyclosporosis Tuberculosis of intestine Wipple diseases Proctitis syphilitic, gonorrheal, chlamydeous Noninfectious (1) Irritable Bowel Syndrome Diverticulosis Ischemic colitis Inflammatory Bowel diseases: Ulcerative colitis, Crohn’s disease GI diseases: Hypoacid Gastritis, Stomach Cancer, Chronic Pancreatitis, Cancer of Pancreas & Major duodenal papilla, Cholelithiasis, Liver Cirrhosis 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 enteritis Endogenic intoxication – Uremia, avitaminosis Surgical : acute appendicitis, mesenterial vessels thrombosis, acute intestinal obstruction, adnexitis, pelveoperitonitis Postsurgical: vagotomy, stomach resection, bowel resection, cholecystectomy Malabsorption: gluten-sensitive & soybean enteropathy, Tropical sprue, 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 Rotavirus
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 (nausea, recurrent vomiting, 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 fever (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 large intestine 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 ileitis, 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 constipation, 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 - -Colonoscopy 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 Metronidazole Echerichiosis caused by EIEC
reminds bacterial dysentery 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: blood in stool, 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 (clindamycin, lincomycin, amoxicillin, etc.) press bowel normal flora and bring to C. difficile overgrowth affects rectum 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 Entamoeba histolytica Yersinia enterocolitica Campylobacter jejuni Helminths Gardia lamblia Cryptosporidium HIV-infection Giardiosis
protozoal infection caused by Gardia lamblia
watery outbreaks
mild enteritis, duodenitis 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, giardia, 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