Dr. Christenson treated us to a great noon report where she reviewed the case of a female in her mid-twenties who presented with bloody diarrhea and abdominal pain and was ultimately diagnosed with salmonella enteritis.
Diarrhea can be broken into acute versus chronic depending on the duration (more or less than 4 weeks).
Chronic diarrhea can be further subdivided into:
Osmotic-presents with bloating and gas in addition to diarrhea. It often stops with fasting (i.e. not in the middle of the night). It is most commonly caused by lactase deficiency in the US.
Secretory-these are large volume watery stools that continue despite fasting. Think of infections, neuroendocrine tumors, bile acid deficiency, motility disorders, and structural causes.
Inflammatory- presents with inflammatory symptoms, including abdominal pain as well as potentially blood, weight loss, and fever.
Malabsorptive-these are bulky stools. Differential diagnoses include celiac disease, SIBO, pancreatic disease, lactulose, and short bowel.
Stool testing can be helpful in making this diagnosis:
Acute Diarrhea
Acute diarrhea should be treated symptomatically for the first week, because the majority in developed countries is secondary to viral gastroenteritis or food poisoning: therefore, it is often self-limited. If diarrhea doesn't resolve within one week, evaluation is recommended to look for common bacterial pathogens.
However, there are several alarm features that should prompt the physician to do a full workup earlier. These features are:
Severe abdominal pain
Bloody Stools
Fever
Recent hospitalization or antimicrobial use
Elderly patient
Immunocompromised patient
IBD
Pregnancy
Additionally, any patient over 50 years of age with bloody diarrhea should undergo colonoscopy.
Acute Bloody Diarrhea
Acute bloody diarrhea is a specific-subset of acute diarrhea. In patients less than 50, common causes include inflammatory bowel disease and infectious colitis. In older patients, consider ischemic colitis, C. diff colitis, diverticular bleed, and colon cancer.
When working up acute bloody diarrhea, first rule out a brisk GI bleed. Consider also the following workup:
C. diff NAAT and toxin (especially if there is a history of antibiotic exposure, PPI use, or nursing home residence)
Stool cultures (Salmonella, Campylobacter, and Shigella)
E. coli 0:157:H7 testing and Shiga toxin
Consider testing for Entamoeba
Consider CT scan w/ contrast if patient is at risk for ischemic colitis or if there are peritoneal signs
Management of infectious diarrhea is generally supportive. You can give intravenous fluids for rehydration & correct electrolyte imbalances. Avoid anti-motility agents if possible!
You can give Loperamide if all of the following criteria are met:
No fever
Non-bloody diarrhea
C. diff has been ruled out
You can also consider bismuth subsalicylate if severe, bloody diarrhea or fever.
References
Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis 2017; 65:e45.
Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111:602.
Thielman NM, Guerrant RL. Clinical practice. Acute infectious diarrhea. N Engl J Med 2004; 350:38.
McDowell C, Haseeb M. Inflammatory Bowel Disease (IBD) [Updated 2019 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470312/
ACG clinical guideline update 2018 on Management of Crohn’s disease in adults. Am J Gastroenterol 2018 Apr; 113:481. (http://dx.doi.org/10.1038/ajg.2018.27)
Barr, W., & Smith, A. (2014). Acute diarrhea. American family physician, 89(3).
Holtz, L. R., Neill, M. A., & Tarr, P. I. (2009). Acute bloody diarrhea: a medical emergency for patients of all ages. Gastroenterology, 136(6), 1887-1898.
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