Normal Bowel Frequency Acute Diarrhea Akeek S . Bhatt , MD 3 times/day 3 times/week Assistant Professor of Clinical Medicine Division of Gastroenterology, Hepatology, & Nutrition Director of Endoscopy University Hospital East The Ohio State University’s Wexner Medical Center Diarrhea Definition Acute Diarrhea • Formal definition: Stool weight >200g/day INFECTIOUS Non-Infectious (5%) • Practical definition: (GASTROENTERITIS) -Persistent/chronic – ≥ 3 loose/watery stools/day -Self-limited 1. Drugs – Decrease in consistency AND increase in 1. Viruses 2. Food allergy/intolerance frequency from the patient’s norm 2. Bacteria 3. Other disease states 4. Primary GI disease • Acute: 2 weeks or less 3. Protozoa • Persistent: 2-4 weeks • Chronic: > 4 weeks 1 Initial Evaluation Social History • Quit smoking (UC flare, OTC nicotine) • Duration of symptoms • Alcohol • Frequency • Illicit drugs • Stool characteristics • Sexual history: MSM, anal intercourse • Signs/symptoms of volume depletion • Occupation (exposures) • Fever • Travel • Peritoneal signs • Pets • Extraintestinal symptoms • Recreational activities Food History • Exposure to particular type of food associated with foodborne disease (in the Important Clues in week preceding illness) Acute Diarrhea • Time interval between exposure and onset of symptoms 2 Small bowel vs Large Acute Diarrhea with Fever Bowel Indicates intestinal inflammation • Small Bowel • Large Bowel 1. Invasive Bacteria – Large volume – Small volume -Salmonella, Campylobacter, Shigella – Watery – Frequent 2. Enteric viruses – Abdominal – PPainfulainful bobowelwel cramping, movements -Norovirus, Rotavirus, Adenovirus bloating, gas – Bloody/mucoid 3. Cytotoxic organism – Weight loss – Fever -C. diff, E. histolytica *Enterohemorrhagic E. coli fever is absent or low grade (EHEC/STEC) – Rarely fever – Positive occult 4. Inflammatory bowel disease blood and stool – Negative occult 5. Severe ischemic colitis blood and stool WBC WBC Differential Diagnosis of Bloody Indications for Medical Evaluation of Diarrhea Diarrhea: Severe Illness 1. Shiga toxin producing E.coli (O157:H7) • Profuse watery diarrhea with dehydration 2. Shigella • Passage of many small volume stools with 3. Salmonella visible blood and mucus (dysentery) 4. Campylobacter 5. Clostridium difficile • Fever (≥38.5°C or 101.3°F) 6. Ischemic colitis • ≥6 unformed stools/24h or >48h duration 7. Inflammatory Bowel Disease 8. Entamoeba Histolytica • Severe abdominal pain 3 Indications for Medical Evaluation of Ordering Stool Cultures Diarrhea • Routine • Elderly (≥ 70yo) – Salmonella – Shigella • Immunocompromised – Campylobacter – Yersinia (most strains) * • Signs/symptoms of systemic illness along with - E.coli O157:H7** diarrhea (esp. pregnant women—suspect - Aeromonas and Plesiomonas * listeriosis) *Grow on routine culture but notify lab as frequently overlooked • Hospitalized patients or recent use of antibiotics **Specific order for other Shiga toxin producing E.coli When to Obtain Stool Ordering Stool Cultures Cultures • Severe Illness • One time is sufficient • Patients with comorbidities that increase – Continuous excretion of pathogens the risk for complications • UdUnder lilying IBD • Require specific orders: • Occupation (daycare workers or food – Shiga toxin producing E.coli handlers) requires negative cultures to return to work – Vibrio • Untreated persistent diarrhea – Listeria • (+) stool WBC, lactoferrin, or occult blood 4 Salmonellosis • Symptoms: watery diarrhea, fever, cramps, Bacterial Gastroenteritis vomiting (colitis less common) (Foodborne Illness) • Duration: 4-10 days • Treatment in healthy persons with mild symptoms may prolong excretion Salmonellosis Salmonellosis Complications • Non-typhoidal salmonella • Bacteremia (5%) • Leading foodborne disease in the U.S. – Endovascular infections (arteritis, • Transmission: poultry, eggs, milk aortitis, mycotic aneurysms, stent/graft products, produce, raw meats, infections) pets/animals – Orthopedic prostheses • Incubation: 8-72 hrs – Prosthetic heart valves – Osteomyelitis in sickle cell patients 5 Campylobacter Shigellosis • S. sonnei or S. flexneri • C. jejuni or C. coli • Transmission: person to person; nd • 2 leading cause foodborne disease U.S. contaminated water or food (raw vegetables, salads, sandwiches) • Transmission: poultry/cross- contamination, unpasteurized milk, • Increased risk: children (toddlers); animals daycares and institutional settings Campylobacter Shigellosis • Incubation: 2-5 days • Incubation: 3 days (1-7) • Symptoms: Watery or hemorrhagic, fever, cramps, vomiting • Syypmptoms: watery ypg progressing to dy sentery (bloody/mucoid), fever, tenesmus, N/V • Duration: 2-7 days • Duration: 2-7 days • Complications: reactive arthritis and Guillain- Barré syndrome • Complications: HUS and TTP (children) 6 Enterohemorrhagic E.coli (Shiga- HUS and TTP toxin producing E.coli) • Life threatening complication of STEC • (EHEC/STEC) – 5-10% – O157:H7 most common serotype – Children, elderly (40% mortality) • Clinical diagnosis • Transmission: undercooked ground beef, – Bloody diarrhea unpasteurized, cattle, petting zoos/exhibits – Microangiopathic Hemolytic Anemia – Purpura/thrombocytopenia – Anuria/Acute renal failure • Two-thirds cases June-September – Neurologic symptoms • Incubation: 1-7 days Rx: supportive care, dialysis/plasmapheresis (<10% mortality) EHEC Yersinia • Symptoms: • Y. enterocolitica (U.S), Y. pseudotuberculosis – Watery diarrheahemorrhagic (Europe) – Abdominal pain • Uncommon; undercooked pork, unpasteurized – Absent/low grade fever milk, contaminated water • Self-limiting enterocolitis • Few or no fecal leukocytes – Watery or bloody diarrhea – Fever • Self-limiting terminal ileitis (pseudoappendicitis) • Rx: NO ANTIBIOTCS OR • Increased risk of infection in hereditary ANTI-PERISTALTIC AGENTS hemochromatosis (siderophilic bacteria) 7 Empiric AntibioticTreatment for Acute Diarrhea • Fever and bloody • >1 week duration stools Anti-Diarrheal • Fever and Aggents hlflhemoccult, fecal • Hospitalization leukocyte or being considered lactoferrin positive stools • Immuncompromised • >8 stools/d • Volume depletion Empiric Antibiotic Loperamide Treatment • *Fluoroquinolone x 3-5 days • Drug of Choice when stools are nonbloody and – Cipro 500mg BID fever is low grade or absent and low suspicion of C. diff – Norfloxacin 400mg BID – Significant reduction in stools when combined with – Levofloxacin 500mg qd cipro – Dose: 2 tabs initially (4mg), then 2mg after each * Avoid in EHEC unformed stool (max 16mg/d) for <= 2 days • If suspect campylobacter: *Could facilitate HUS in EHEC **Aggresively hydrate as fluid loss may be masked by – Azithromycin 500mg qd x 3d pooling in the intestine – Erythromycin 500mg po qd x 5d 8 Lomotil (Diphenoxylate and Atropine) Clostridium difficile • 2 tabs (4mg) qid <= 2 days • Antibiotic associated colitis • Central opiate effects • Most common nosocomial infection • Cholinergic side effects – > 3 million hospital infections U.S/yr – 10% patients hospital admission >48hrs • Rising incidence *Could facilitate HUS in EHEC **Aggresively hydrate as fluid loss may be • Occuring outside hospitals (20,000/yr) masked by pooling in the intestine • IBD patients without antibiotics Bismuth Subsalicylate (Pepto-Bismol) Risk Factors for C.diff • Antibiotics • Consider in patients with febrile bloody • Advanced age diarrhea • Hospitalization • Improves vomiting • Severe illness • 30mL or 2 tabs q 30 min x 8 doses • Cancer chemotherapy • Gastric acid suppression 9 Severe CDAD C.Diff Treatment • Stop inciting abx ASAP • Systemic toxicity • Mild/Moderate: Flagyl 500mg PO TID x 10-14d – Fever – IV only when not able to tolerate po – Abdominal tenderness • If severe: Vancomycin 125mg po qid x 10-14d (enemas if ileus) +/- IV Flagyl – Acu te men tltal s tttatus c hanges – Consult ID • WBC >15k • If underlying infection requiring abx – Continue for additional week after completion • Albumin <2.5 • Repeat initial antibiotic for initial recurrence if of • Elevated Cr same severity • Tapered or pulse regimen vancomycin for 2nd or • Age >60 later recurrences C.Diff Testing C. Diff and PPI Use • One time testing is sufficient • FDA warning Feb. 2012 • C. diff toxin PCR: – Evaluate the clinical necessity – Highly sensitive and specific – Use lowest dose and shortest duration – Rapid – H2B being reviewed • EIA C.diff toxin A/B – Less sensitive – Variation: GDH +, cytotoxicity on + samples only – Only repeat if neg and clinical suspicion remains high 10 Traveler’s Diarrhea (TD) Traveler’s Diarrhea • Low risk: US, Canada, Australia, Northern and • 80-90% bacterial Western Europe • Enterotoxigenic E. coli • Intermediate risk: Eastern Europe, Carribean, S. • 80% watery diarrhea Afr ica, China, Russ ia • 5-10% dysentery (Shigellosis, Campy) • High risk: Africa, Asia, Middle East, Central and • Course: 1-2 -7 days South America • Important cause of post-infectious IBS TD Preventive Measures TD Prophylaxis • Eat freshly cooked foods that are steaming • High risk hosts hot (avoid buffets and street vendors) • Critical trips • Avoid salads (washed in water) • High risk areas • Avoid unpeeled fruits and veggies • Avoid tap water, ice/beverages diluted with 1) Bismuth 2 tabs qid (<3 weeks) water 2) Antibiotic prophylaxis • Safe beverages: bottled and sealed, • Ciprofloxacin 500mg once daily carbonated • Rifaximin ? • Carry alcohol-based (60%) hand cleaner 3) Insufficient evidence for probiotics 11 TD EmpiricTreatment Norovirus (Norwalk-like) • Loperamide + • Most common cause