HOW TO APPROACH PATIENT WITH DIARRHOEA
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Transcript of HOW TO APPROACH PATIENT WITH DIARRHOEA
8/7/2019 HOW TO APPROACH PATIENT WITH DIARRHOEA
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HOW TO
APPROACH PATIENT
WITH DIARRHOEASITI NUR ELLYANI BINTI MOHD
BOHARI
012010050482
NURHAFIZAH BT
MOHD KAMIL
012010050486
NURAZLIN SOFIA BINTI
MOHAMMAD MURAD
012010050504
NURLIYANA FATIN
BT DARIMIN
012010050485
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DIARRHEA
� A Greek word = to flow through
� It is a Symptom or a Sign
� NOT a Disease
� It is the most common cause of
clinical presentations ingastrointestinal practice.
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DIARRHEA
� AS A SYMPTOM
± Frequency of bowel action
± Looseness of stools ± Increase in stool volume
� AS A SIGN
± Stools weight more than 250 gm/24 hours
A CombinationA Combination
of theseof these
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Normal Physiology
� 8-10 liters of fluid enter the duodenum daily
± 2 liters from the diet
± About 8 liters from secretion;
� Salivary 0.5 L� Gastric 1.0 L
� Pancreatic 1.0 L
� Hepatic 1.0 L
� Small bowel 3.0 L
� The small intestine absorbs all but 1.5 liters of thisfluid
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Normal PhysiologyNormal Physiology
The maximum absorbing capacity of the smallThe maximum absorbing capacity of the small
intestine is unknown.intestine is unknown.
The absorbing capacity of the adult colon is 4The absorbing capacity of the adult colon is 4--
5 liters/day5 liters/day
From the 1.5 liters coming from small bowelFrom the 1.5 liters coming from small bowel
the colon absorbs all but 100 mlthe colon absorbs all but 100 ml
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Diarrhea
Diarrhea is mainly a disorder of the small or large
bowel
� If the small intestine is deranged
± The daily volume of intestinal contents presented to the
colon exceeds its absorbing capacity if > 5 liters
� If the colon is deranged
± It cannot absorb its daily capacity of 1.5 liters
Diarrhea is anDiarrhea is an imbalanceimbalance between absorption &between absorption &secretionsecretion
Pancreatic and Pancreatic and biliary biliary disorders can also causedisorders can also cause
diarrhea.diarrhea. It can also reflect rimar disorders outside the G.I.It can also reflect rimar disorders outside the G.I.
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TYPES� Diarrhea generally is divided into two types, acute
and chronic.
A
cute diarrhea lasts from a few days up to a week. Chronic diarrhea lasts more than three weeks.
� It is important to distinguish between acute and
chronic diarrhea because they usually havedifferent causes, require different diagnostictests, and require different treatment.
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CAUSES� Infective causes:
± Bacterial:
� Eg: salmonella sp, shigella, E.Coli
± Viral:
� Rotavirus ± Fungal:
� Histoplasmosis
±
Parasitic :� Amoebic dysentry
� Schistosomiasis
� Giardia intestinalis
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� Non-infective causes: ± Inflammatory bowel disease
±
Pseudo membrano coloitis ± Malabsorption
± Drugs (laxative, metformin, anti cancer drug)
± Irritable bowel syndrome
± Carcinoma of the colon
� Endocrine ± Zollinger-ellison syndrome
± VIPoma
± Thyrotoxicosis
� Factitious diarrhoea: ± Purgative abuse
± Dilutional diarrhoea
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PATHOPHYSIOLOGY
� Mechanisms:
±Osmotic diarrhea
±Secretory diarrhea
± Inflammatory and infectious diarrhea
± Diarrhea associated with deranged motility
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1.Osmotic diarrhea
� arise as a consequence of water
retention by unabsorbed substances in
the intestinal lumen� from one of two situations:
Ingestion of a poorly absorbed substrate
Malabsorption
Stop: fasting or stops consuming
the poorly absorbed solute.
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2.Secretory diarrhea
� Secretory diarrhea means that there is anincrease in the active secretion, or there is aninhibition of absorption.
� caused by hypersecretion of fluids andelectrolytes by the villus crypts
� e.g. in response to stimulation by E.Coli orhydroxylated fatty acids
� will not resolve during a 2-3 day fast.
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3. Inflammatory and Infectious Diarrhea
damage to the intestinal mucosal cell
(mucosal inflammation or infiltration)
or
increased intestinal hydrostatic pressure
(lymphatic obstruction or portal hypertension
increase hydrostatic pressure )
loss of fluid and blood.
� In addition, there is defective absorption of fluids and electrolytes.
� Common cause are infective condition and inflammatoryconditions.
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4. Diarrhea Associated with Deranged
Motility
intestinal contents must beadequately exposed to the
mucosal epithelium
retained long enough toallow absorption.
nutrients and water to beefficiently absorbed
Disorders in motility
accelerate transit time
decrease absorption
diarrhea
(even if the absorptiveprocess per sec wasproceeding properly)
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History Taking
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Personal Data
� Name
� Age
� Gender
� Home Address� Marital Status
� Occupation
� Registration Number
� Date and Time of Admission
� Date and Time of Clerking
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History of Presenting Illness
� Volume, frequency and character of stools?� Presence of blood or mucous in stools?
� Onset and duration?
± Onset in relation to pain (which came first?) if diarrhea
first then pain, it could be gastroenteritis� Does anything relieve or exacerbating the condition?
± E.g: Drinking or eating?
� Has the patient tried any medication for the diarrhea? Has itworked?
� Associated features?
± Nausea, vomiting, fever, abdominal pain, constipation,loss of weight , loss of appetite
� Is diarrhea the biggest problem, or are there other more
pressing concerns?
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Past Medical History
� Underlying diseases?
� Inflammatory bowel disease (IBD)
�Irritable bowel syndrome (IBS)
� Malabsorption syndrome
� Cancer
� HIVEndocrine diseases (diabetes, thyrotoxicosis,
Zollinger-Ellison syndrome)
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Past Surgical History
� Post-vagotomy
± History of gastric surgery destruction of the
pylorus or section of the vagus nerve may result in
diarrhea, often associated with dumping
� Transplants
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Drug/Allergy History
� Any recent consumption of drugs:
± Antibiotics
± Laxative abuse
± Ingestion of magnesium-containing antacids
± Cytotoxic drugs
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Family History
� Is there anyone in the family or living together
or nearby has similar condition?
� Family history of diseases ± E.g: IBD, cancer, diabetes, hypertension
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Travel History
� Any recent travel for holidays or outstations?
� Recent outdoor activities such as jungle
trekking? If so, what was the food and watersituation?
� Recent dietary history of recent consumptions
of meat (cooked/uncooked), eggs, seafood,
dairy foods and unusual food?
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Social History
� Smoking status?
� Alcohol consumptions?
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PHYSICAL EXAMINATION
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GENERAL EXAMINATION
� General appearance & mental status ± Anxiety, confusion, loss of consciousness
� Vital signs : ± Blood Pressure (hypotension)
±
Pulse (tachycardia, weak pulse) ± Respiratory rate (tachypnoeic)
� Hands ± Cold skin
± Clammy skin
± Pallor ± Loss skin elasticity
± Erythematous palms
± Plummers nail
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� Face and mouth
± Pale
± Hydration
± Exophtalmos
± Lid lag
± Oral ulcer
� Neck
± Lymphadenopathy
± Enlarged thyroid
± Reduced Jugular Venous Pressure
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SYSTEMIC EXAMINATION
Endocrine
� Thyroid mass
Cardiorespiratory
� Wheezing and right-sided heart murmurs(carcinoid syndrome)
Musculoskeletal
� Arthritis (IBD, Whipple's disease)
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SKIN LESIONS
� Dermatitis herpetiformis (celiac disease)
� Erythema nodosum and pyoderma gangrenosum(IBD)
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� H yperpigmentation (Addison's disease)
� Flushing (carcinoid syndrome)
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ABDOMINAL EXAMINATION
� Surgical scars
� Abdominal tenderness
� Masses
� Hepatosplenomegaly
� Borborygmus on auscultation ± malabsorption
± bacterial overgrowth
± obstruction, or rapidintestinal transit.
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PERINEAL AND RECTAL EXAMINATION
� Signs of incontinence ± skin changes from chronic irritation,
± gaping anus,
± weak sphincter tone.
� Crohn's disease ± perianal skin tags
± Ulcers
± fissures
± abscesses
± Fistulas
± stenoses.
� Fecal impaction or masses might be noted.
� Anal Sphincter Laxity
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INVESTIGATIONS
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INVESTIGATION
1. Full Blood Count WBC
2. Thyroid function test TSH & T3, T4
3. Serum electrolytes potassium, sodium
4. Serum albumin
5. Stool evaluation leukocytes, fat, ova ¶sites , laxative abuse
6. Endoscopy any lesion or mass in bowel
7. Mucosal biopsies rule out any malignancy
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TREATMENT
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NON-SPECIFIC THERAPIES
� Dietary modifications
±Smaller, more frequent meals
±
Decrease carbohydrates ±Decrease fat intake
±Avoidance of milk
±Avoid sorbitol and mannitol
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�
Bismuth subsalicylate (i.e., Pepto-
Bismol )
� Opioids and opioid agonists ±Loperamide: first line therapy
±diphenoxylate-atropine (Lomotil )
±Codeine and other narcotics forrefractory cases
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SPECIFIC THERAPIES
� Clonidine-
± Diabetic diarrhea
± moderate and severe diarrhea-predominant
irritable bowel syndrome (IBS
)
� Somatostatin
� AIDS,
� post chemotherapy,
� GVHD,
� and hormone secreting tumors.
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� Bile acid binders (ie, cholestyramine)
� Pancreatic enzyme supplementation
� Antimicrobials ²empiricfluoroquinolones therapy