cyn dudud.ppt

8/12/2019 cyn dudud.ppt

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Definition

Diarrhea is an increase in the frequency of

bowel movements or a decrease in the form

of stool (greater looseness of stool).


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Frequency of bowel movements.

Absolute diarrheais having more bowel movementsthan normal. Thus, since among healthy individualsthe maximum number of daily bowel movements isapproximately three, diarrhea can be defined as anynumber of stools greater than three, more thanfive bowel movements a day or liquid stools

Relative diarrheais having more bowel movementsthan usual. Thus, if an individual who usually hasone bowel movement each day begins to have two

bowel movements each day, then diarrhea ispresent-even though there are not more thanthree bowel movements a day, that is, there is notabsolute diarrhea.


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Consistency of stools

Absolute diarrheaStools that are liquid orwatery are always abnormal and considered

diarrhea. Relative diarrheais easier to define based

on the consistency of stool. Thus, anindividual who develops looser stools than

usualhas diarrhea--even though the stoolsmay be within the range of normal withrespect to consistency.


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Classification

Acute diarrhealasts from a few days up to a

week.

Chronic diarrheacan be defined in several

ways but almost always lasts more than three

weeks.


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Etiology of acute diarrhea

Viral gastroenteritis

Viral gastroenteritis(viral infection of the stomach and

the small intestine) is the most common cause of

acute diarrhea worldwide. Symptoms of viral

gastroenteritis (nausea, vomiting, abdominal

cramps, and diarrhea) typically last only 48-72

hrs. Unlike bacterial enterocolitis (bacterial infection

of the small intestine and colon), patients with viral

gastroenteritis usually do not have blood or pus intheir stools and have little if any fever.
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Food poisoning

Food poisoningis a brief illness that is caused by toxinsproduced by bacteria. The toxins cause abdominal pain(cramps) and vomiting and also cause the small intestine tosecrete large amounts of water that leads to diarrhea. The

symptoms of food poisoning usually last less than 24 hours.

Staphylococcus aureusis an example of a bacterium thatproduces toxins in food before it is eaten. Typically, foodcontaminated with Staphylococcus (such as salad, meat or

sandwiches with mayonnaise) is left un-refrigerated at roomtemperature overnight.

Clostridium perfringensis an example of a bacterium thatmultiplies in food (usually canned food), and produces toxinsin the small intestine after the contaminated food is eaten.
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Traveler's diarrhea

Certain strains of E. coli, however, are pathogenic(meaning they can cause disease in the smallintestine and colon). These pathogenic strains of E.

col icause diarrhea either by producing toxins(called enterotoxigenic E. colior ETEC) or byinvading and inflaming the lining of the smallintestine and the colon and causing enterocolitis(called enteropathogenic E. coli or EPEC).

Traveler's diarrheausually is caused by anETECstrain of E. colithat produces a diarrhea-inducingtoxin.
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Bacterial enterocolitis

Campy lobacter jejun iis the most common

bacterium that causes acute enterocolitis in

the U.S Shigella, Salmonel la, and EPEC. These

bacteria usually are acquired by drinking

contaminated water or eating contaminated

foods such as vegetables, poultry, and dairy

products.
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Clostridium difficileis unusual because it

often is caused by antibiotic treatment.

Clostridium difficileis also the most common

nosocomial infection (infection acquired whilein the hospital) to cause diarrhea


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E. coli O157:H7is a strain of E. colithat produces a

toxin that causes hemorrhagic enterocolitis

(enterocolitis with bleeding). There was a famous

outbreak of hemorrhagic enterocolitis in the U.S.

traced to contaminated ground beef inhamburgers (hence it is also called hamburger

colitis).Approximately 5% of patients infected with

E. coli O157:H7,particularly children, can develop

hemolytic uremic syndrome(HUS), a syndromethat can lead to kidney failur
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Parasite

Giardia lamb l iaoccurs among individuals who hike

in the mountains or travel abroad and is transmitted

by contaminated drinking wate

Cryptospor id iumis a diarrhea-producing parasite

that is spread by contaminated water because it can

survive chlorination.

Cyclosporais a diarrhea-producing parasite that has

been associated with contaminated raspberries

from Guatemala


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Drugs

nonsteroidal anti-inflammatory drugs(NSAIDs),

chemotherapy medications,

antibiotics,

medications to control irregular heartbeats

(antiarrhythmics), and

medications for high blood pressure.
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Etiology of chronic diarrhea

Irritable bowel syndrome.The irritable

bowel syndrome(IBS) is a functional cause of

diarrhea or constipation. Inflammation does

not typically exist in the affected bowel. Itmay be caused by several different

underlying problems, but it is believed that

the most common cause is rapid passage

of the intestinal contents through thecolon.


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Infectious diseases.There are a few

infectious diseases that can cause chronic

diarrhea, for example, Giardia lamblia.

Patients withAIDSoften have chronicinfections of their intestines that cause

diarrhea


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Bacterial overgrowth of the small

intestine.Because of small intestinal

problems, normal colonic bacteria may

spread from the colon and into the smallintestine.The mechanism that leads to the

development of diarrhea in bacterial

overgrowth is not known.


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Inflammatory bowel disease (IBD).Crohn's

diseaseand ulcerative colitis, diseases

causing inflammation of the small intestine

and/or colon, commonly cause chronicdiarrhea


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Colon cancer.Colon cancercan causeeither diarrhea or constipation. If thecancerblocks the passage of stool, it usuallycauses constipation. Sometimes, however,there is secretion of water behind theblockage, and liquid stool from behind theblockage leaks around the cancer andresults in diarrhea. Cancer, particularly in

the distal part of the colon, can lead to thinstools. Cancer in the rectum can lead to asense of incomplete evacuation


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Carbohydrate (sugar) malabsorption.Carbohydrate or sugarmalabsorption is an inability to digest and absorb sugars. Themost well-recognized malabsorption of sugar occurs withlactase deficiency(also known as lactose or milkintolerance) in which milk products containing the milk

suga. The lactose is not broken up in the intestine because of the

absence of an intestinal enzyme, lactase, The undigestedlactose reaches the colon and pulls water (by osmosis) intothe colon. This leads to diarrhea. Although lactose is the mostcommon form of sugar malabsorption, other sugars in the diet

also may cause diarrhea, including fructose and sorbitol.


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Fat malabsorption.Malabsorption of fat is

the inability to digest or absorb fat. Fat

malabsorption may occur because of

reduced pancreatic secretionsthat arenecessary for normal digestion of fat (for

example, due to pancreatitis or pancreatic

cancer) or by diseases of the lining of the

small intestine that prevent the absorptionof digested fat(for example, celiac disease).


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Endocrine diseases.Several endocrine

diseases (imbalances of hormones) may

cause diarrhea, for example, an over-active

thyroid gland (hyperthyroidism) and an under-active pituitary or adrenal gland (Addison's

disease).


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Laxative abuse.The abuse of laxatives by

individuals who want attention or to lose

weight is an occasional cause of chronic

diarrhea.


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Complication

1. Dehydrationoccurs when there is excessive loss offluids and minerals (electrolytes) from the body dueto diarrhea, with or without vomiting

Patients with milddehydration may experience only

thirst and dry mouth. Moderate to severedehydration may cause

orthostatic hypotensionwith syncope (faintinguponstanding due to a reduced volume of blood, whichcauses a drop in blood pressure upon standing), a

diminished urine output, severe weakness, shock,kidney failure, confusion, acidosis (too much acid inthe blood), and coma.
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Examination of acute diarrhea

Measurement of blood pressure in the

upright and supine (lying) positionscan

demonstrate orthostatic hypotension and

confirm the presence of dehydration. Ifmoderate or severe dehydration or electrolyte

deficiencies are likely, blood electrolytes can

be measured.


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Examination of a small amount of stool

under the microscope may reveal white

blood cellsindicating that intestinal

inflammation is present and prompting furthertesting, particularly bacterial cultures of stool

and examination of stool for parasite


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if antibiotics have been taken within the

previous two weeks, stool should be tested

for the toxin of C. difficile

Testing stool or blood for viruses isperformed only rarely, since there is no

specific treatment for the viruses that cause

gastroenteritis.


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If there has been recent travel to

undeveloped countries or the mountains,

stool may be examined under the microscope

for Giardia and other parasites


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Examination of chronic diarrhea

This may require X-raysof the intestines (uppergastrointestinal seriesor barium enema), orendoscopy (esophagogastroduodenoscopyorEGD, or colonoscopy) with biopsies.

Fat malabsorptioncan be diagnosed bymeasuring the fat in a 72 hour collection of stool.

Sugar malabsorptioncan be diagnosed byeliminating the offending sugar from the diet or byperforming a hydrogen breath test. Hydrogen

breath testing also can be used to diagnosebacterial overgrowth of the small intestine.
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An under-active pituitary or adrenal gland

and an overactive thyroid glandcan be

diagnosed by measuring blood levels of

cortisol and thyroid hormone, respectively. Celiac diseasecan be diagnosed with blood

tests and a biopsy of the small intestine.


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Treatment

Absorbents.Absorbents are compounds that

absorb water. Absorbents that are taken

orally bind waterin the small intestine and

colon and make diarrhea stools less watery.They also may bind toxic chemicals

produced by bacteriathat cause the small

intestine to secrete fluid


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Anti-motility medications.Anti-motility

medications are drugs that relax the

muscles of the small intestine and/or the

colon. Relaxation results in slower flow ofintestinal contents. Slower flow allows more

time for water to be absorbed from the

intestine and colon and reduces the water

content of stool


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Bismuth compoundsThe salicylate is anti-

inflammatory and could reduce secretion of

water by reducing inflammation. Bismuth also

might directly reduce the secretion of waterby the intestine.


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Antibiotics

(1) patients have more severe and persistent

diarrhea,

(2) patients have additional debilitating diseases

such as heart failure, lung disease, and AIDS,

(3) stool examination and testing discloses parasites,

more serious bacterial infections(for example,

Shigella), or C. difficile, and

(4) traveler's diarrhea.


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LO 2


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Symptom rotavirus Shigella salmonella ETEC EIEC Cholera

Incubation 17-72 hr 24-48 hr 6-72 hr 6-72 hr 6-72 hr 48-72 hr

Fever + ++ ++ - ++ -

Vomiting often rare often often - Often

Headache - + + - - -

Stool volume many little little many little Many

Frequency 5-10x/day >10x/day often often often Often

Consistency liquid flabby flabby liquid flabby Liquid

Blood - + + - + -

Leukocyte - + + - - -

etc anorexia convulse sepsis


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LO 3


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Definition

Dehydration occurs when the amount of water

leaving the body is greater than the amount being

taken in.

We lose water routinely when we:

1. breathe and humidified air leaves the body (this can

be seen on a cold day (the breath you see in the air

is water that has been exhaled);

2. sweat to cool the body; and

3. eliminate waste by urinating or having a bowel

movement.


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Etiology

Diarrhea:Diarrheais the most common reason for a person tolose excess amounts of water. A significant amount of water canbe lost with each bowel movement.

Vomiting:Vomitingcan also be a cause of fluid loss. It is lost inthe vomitus, but it is difficult for a person to replace water by

drinking it if they have nausea and are unable to tolerate liquids. Sweat:The body can lose significant amounts of water when it

tries to cool itself by sweating. Whether the body is hot becauseof the environment (for example, working in a warmenvironment), or because a feveris present due to aninfection.

a brisk walk may generate up to 16 ounces of sweat (apound of water) to allow body cooling, and that water needsto be replaced by the thirst mechanism signaling the person todrink fluids.


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Diabetes:In people with diabetes, elevated bloodsugar levels cause sugar to spill into the urineand water then follows, which may cause significantdehydration. For this reason, frequent urinationandexcessive thirst are among the early symptoms of

diabetes. Burns:The skin acts as a protective barrier for the

body and is also responsible for regulating fluid loss.Burn victimsbecome dehydrated because thedamaged skin cannot prevent fluid from seeping out

of the body Inability to drink fluids:The inability to drink

adequately is the other potential cause ofdehydration.


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Symptoms

Dry mouth

The eyes stop making tears

Sweating may stop

Muscle cramps Nausea and vomiting

Heart palpitations

Lightheadedness (especially when standing)

Weakness

Decreased urine output


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Level of dehydration in Children

Level of dehydration Estimated fluidloss Signs andsymptoms

Minimal


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Diagnose

Mental statustests to evaluate whether the

patient is awake, alert, and oriented. Infants

and children may appear listless and have

whiny cries and decreased muscle tone. Vital signsmay include postural readings

(blood pressure and pulse rate are taken

lying down and standing).With

dehydration, the pulse rate may increase andthe blood pressure may drop because the

blood is depleted of fluid.


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Temperaturemay be measured to assess fever.

Skinmay be checked to see if sweat is present and to

assess the degree of elasticity (turgor). As dehydration

progresses, the skin loses its water content and

becomes less elastic.

The mouth can become dryand the health care

practitioner may look or feel the tongue for fluid.

Infantsmay have additional evaluations performed,

including checking for a soft spot on the skull (sunken

fontanelle),


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Pediatric patientsare often weighed during

routine child visits, thus a body weight

measurement may be helpful in assessing

how much water has been lost with the acuteillness.


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Laboratory testing

The purpose of blood tests is to assess potentialelectrolyte abnormalities(including sodium,potassium, and chloride levels) associated with

the dehydration. Hemoglobin and red blood cellcounts may be elevated because the blood ismore concentrated with water loss.

Kidney function tests including BUNand creatininemay be elevated, and is a sign of dehydration.

Urinalysismay be ordered to determine urineconcentration, the more concentrated the urine,the more dehydrated the patient.
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Complication

Kidney failure

is a common occurrence, although if it is due

to dehydration and is treated early, it is often

reversible. As dehydration progresses, thevolume of fluid in the blood decreases,

and blood pressure may fall. This can

decrease blood flow to vital organs like the

kidneys, and like any organ with a decreasedblood flow


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Coma

Decreased blood supply to the brain may cause

confusionand even coma. If enough organs begin to

malfunction, the body itself may fail, and death can

occur

Shock

When the fluid loss overwhelms the body's ability to

compensate, blood flow and oxygen delivery to

the body's vital organs become inadequate andcell and organ function can begin to fail.


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Heat-related illnesses and associated

complications

In heat-related illness, the body's attempt to cool itself

by sweating may cause dehydration to the point that

muscles may go into spasm(heat cramps). It isoften the muscles that are being stressed that will

spasm (for example, in athletes, leg muscles may

cramp from running). As fluid loss increases, the

patient may be so dehydrated that there is notenough water to sweat and heat exhaustionor

heat strokemay occur.


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Electrolyte abnormalities

In dehydration, electrolyte abnormalities may

occur since important chemicals (like sodium,

potassium, and chloride) are lost from thebody through sweat

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