Get documents about "S BM bowel movement
Document Sample
S/O Etiology Tx Options Recommended Dose Goals/Monitor Pt Education
S/O Etiology Tx Options Recommended Dose Goals/Monitor Pt Education
Diarrhea: Bugs Infx diarrhea: 2nd lead cause of M/M worldly Fluid repletion: -Suppress organism If Diarrhea and fever >2 days, call
=watery or liq stools, usu with stool Bacterial Repletion acute wt loss -Treat relapses MD
wt above 200g/d and qd stool -Ecoli (EHEC or STEC) Treatment DM = 100* 1st 10kg + 50mg * 2nd -Avoid dehydration, elyte imbalance,
freq -C.difficile Rehydration 10kg + 20ml * rest of wt. Add 12% malnutrition Check stool for blood vs stool
= nl bowel movements, water -Campylobacter spp -1 goal of tx: replete fluid/lytes for 1deg > 37C darkening by BSS, etc.
content, vol, freq of stools -Salmonella spp -mild-mod: Fluids (water, ginger ale, chicken Monitoring
=Greater than 3 BM/day -Shigella spp soup, Gatorade, Pedialyte) -# stool / day
-Aeromonas spp WHO recomd: oral rehydration soln -Volume of stools / day
Infectious Diarrhea: -Vibrio spp ◦Na 90mEq/L -# oocytes in stool prn
=diarrhea d/t infectious etio often c -Yersinia spp ◦K 20mEq/L -Wt of pt
sx of nausea, vomiting or abdom Viral ◦Cl 80mEq/L -Hydration
cramps -Rotavirus, Norwalk ◦HCO3 30mEq/L
Protozoan ◦Glucose 2% -SE of meds
Time Length Classification -Cryptospordium spp -Mod-Severe: IV fluids
-Acute Diarrhea: 14 days -Giardia lamblia
-Persistent: > 14 days -Entamoeba histolytica Symptomatic
-Chornic: > 30 days -Isospora spp -APAP prn feer/aches
-Cyclospora spp -Antidiarrheals: loperamide, diphenoxylate
Diagnosis -Microsporidium spp -Antisecretory: Bismuth subsalicylat, atropine
Careful history -Adsorbant: Kaopectate
-PMHx, meds, sexual orientation, Predisposing factors
diet, recent travel, exposure/onset Drugs Antimicrobials
Evaluation of sx -Abx -Usu not recommended for acute, self-limiting
-small vs large intestine -Antineoplastics, IMS -Reserve for mod-severe case:
-Antacids, H2B, PPI ◦T>38.5C, fecal WBC, bloody stools
Stool exam/cx -Laxatives ◦Marked dehydration
-Fecal WBC -AntiHTN (Reserpine, Guanethidine, ◦>6 BMs with a 24h period
-C.dif toxin Methyldopa, Guanabenz, ◦host-related factors (eg IMC)
-Ova and Parasite Guanadrel)
-usu for inpt or outpt c severe and/or -Cholinergics (Bethanechol,
chronic diarrhea Neostigmine) Food Poisoning Travelers Abx-assoc Cryptosporidiosis
-Cardiac agents (Quinidine, Digoxin) P.colitis
Small Intestine MOA S.aureus E.coil C.difficile Cryptosporidium
Bugs: S.aureus, Ecoli, Vibrio, Viral, -Eradicate nl flora E.coli (include Campylobacter parvum
Giardia -Inhibit gut immune system EHEC) Salmonella
Sx: -gastric pH, viable bugs pass to B.cereua Shigella
-N/V lower gut C.perfringens Aeromonas
-Cramps Pt condition Salmonella Viral
-Large volume stools (explosive) -Age C.botulinum Giardia
-may have watery, light-colored, -Travel history Campylobacter E.histolytica
greasy, foul-smelling stool -IMC (eg HIV ) Invasive s/sx
Shigella Non-invasive s/sx
-may have undigested food particle -Achlorhydria (lack of gastric HCl) Fever, HA, abdominal pain, Usu limited to N/V/D, cramps
myalgia Usu afebrile
Large Intestine blood/mucus in stool
Bugs: Salmonella, Shigella, Differential: org Non-invasive and enterotoxin
Camphylobacter, Cdifficile, invade/penetrate mucosa releasing org
Ehistolytia Cause inflam, necrosis, Cause irritation, inflam leading to
S/sx: systemic complications fluid and nutrient absorption
-Flatus Eg EHEC, Salmonella, Shigella, S.Aureus, B.cereus, Vibrio,
-urge to defecate Campylobacter, C.difficile, Giardia, ETEC, viral
-Painful defecation (Tenesmus) vibrio
-Small vol stool – mucus/jelly-like,
dark in color, contain blood
06793631-4644-449c-8631-ac83bd5e850b.doc 7/24/11 1
S/O Etiology Tx Options Recommended Dose Goals/Monitor Pt Education
Antibiotic-associated diarrhea -Usu d/t abx or chemotx intestinal Supportive: fluids ٠Metronidazole = DOC (PO better Resuolution of ID Avoid antiperistaltic agents
flora C.difficile overgrowth than IV) Prevent complication: P.colitis, Maintain hydration
Sx: Abx: Oral route preferred over IV 250-500mg po or IV tid x 10 - dehydration, colon perforation
-mild-mod to severe diarrhea Commonly implicated abx: -vanco reserved for documented cases of 14days Avoid alcohol if on MTZ: disulfram
-cramps, pain ٠Cephalosporins C.difficile after Monitor -flushing, HA, vomiting,
-posslbe pseudomembraneous ٠Clindamcin ◦failure of 2 courses of metronidazole or ٠Vancomycin 125mg po qid x 10 - Diarrhea, WBC, Fever, elytes nausea,hypotension, weakness,
colitis ٠Ampicillin ◦rare metronidazel allergy or 14 days tachycardia
◦contraindications (ex warfarin) MTZ SE -severe: respiration depression,
-foul smelling -GI upset, N/V shock, acute CHF, MI
-Cdif toxin Consider d/c braod abx if possible, if not, then -Dysgeusia unconsciousness, convulsions
continue abx and tx diarrhea -Dizzness, HA
-Metalic taste
-Disulfuram rxn with alcohol
Traveler’s diarrhea Bugs: Usu self-medicated and self-limiting Prophylaxis Treatment Cook food
-recent travel h/o Toxigenic E.coli Bismuth Chew 525mg (2tabs) po 2 tabs (525mg) po Avoid tap water, ice; boil/purify
-ate improperly Shigella, salmonella Mild-nondysentary: subsal cmeals and qhs q30min Peel fruits
-usu afebrile Campylobacter Loperamide + Cipro 750mg x1 dose NTE 8 doses/d Total 8 doses/d Wash hands
Amebiasis, cyclospora, cryptosporidia Lopera None 4mg po load; then Keep food refrigerated
Severe-dysentary: mide 2mg po after each
Loperimade + Cipro 500mg bid x 3 days loose stool Avoid Loperamide if bloody stool,
check loperiamde contraind (max16mg/d) fever, invasive diarrhea-(can cause
Ciproa 500mgpo qd 500mg bid x3 day toxic megacolon)
TMP/S 1 DS po qd 1 DS po bid x 3 day
MX Avoid BSS in 3rd trimester or
Doxy 100mg po qd --- hypersen to salicylates) and children
aalso oflox or levo recovering from chicken pox/flu
(REYES syndrome)
Parasitic infection Giardia MTZ 250-750mg tid x 7-10d Cysts, trophozoites in stool Water purification, handwashing
Non-invasive diarrhea
Fecal oral, water contamin
Entamoeba histolytica MTZ 750mg tid x 5-10d Trophozoite, cyst in stool Water purification, handwashing
Amebic dysentery, liver abcess + paromomycin 750mg tid x 7d Sero testing for invasive dz
Fecal oral; (0r diiodohydroxyquine 650mg tid x 20 days)
Usu in topics; ck travel
history/immigrant
Cryptosporidium Tx: fluids, lyte repletion, nutrition (TPN prn), Oocysts with acid fast stain
Persistent Diarrhea, dehydration, sx relief (antimotility, antisecretory) possibly -Stool screening for ooctyes, PCR, ELIZA
lytes abx
Fecal oral -No available drug with definite cure.
Malabsorption Following tx demonstrated efficacy in sx
(HIV CD4<150 have persistent
diarrhea) IMC: Paromomycin 500mg tid x 7 days
Healthy: usu no tx management
Other parasites Microsproidium
Isospora
06793631-4644-449c-8631-ac83bd5e850b.doc 7/24/11 2
S/O Etiology Tx Options Recommended Dose Goals/Monitor Pt Education
Tables from syllabus
Parasitic infxn Immunocompetent Immunocompromised Abx treatment prn Immunocompetent Immunocompromised
Giardia Metronidazole 250-750mg tid x 7-10 days Same Campylobacter ERY 500mg bid x 5 days Same, but may
duration
Cryptosporidium* Paromomycin 500mg tid x 7 days Paromomycin 500mg tid x 14-28 E.coli TMP-SMZ 160/800mg bid x 3 days or Same
days, then bid prn Enterotoxigenic, enteropathogenic, FQ (cipro 500mg / oflox 300mg / norflox 400mg bid x 3
enterovasive
days
Microsporidium Not determined Albendazole 400mg bid x 3 weeks E.coli Avoid antimotility drugs, antibiotic role unclear, avoid use Same
(Enterohemorrhagic)
Isospora TMP-SMX 160/900mg bid x 7-10 days TMP-SMX 160/800mg qid x 10 days, Salmonella Non-Typhi Not recommended routinely; but if sever or <6mos or 14 days or longer if
then TMP-SMX tiw >50yo or comorbiditis relapsing
TMP-SMX or FQ x 5-7 days
Entamoeba histolytica2 Metronidazole 750mg tid x 5-10 days PLUS Same Shigella TMP-SMX 160/800mg bic x 3 days 7-10days
either FQ bid x 3 days
Diiodohydroxyquine 650mg tid x 20 days
or
Paromomycin tid x 7 days
Aeromonas/Plesiomona TMP-SMX 160/800mg bid x 3 days or Same
Cryptosporidiosis Dose SE FQ bid x 3 days
Paromomycin 500mg po q6h x 2-4 weeks D/N, cramps Vibrio Doxy 300mg x 1 dose or Same
TCN 500mg qid x 3 days or
Spiramycin (Canada, Europe) 1g po t-qid x 2-4 weeks GI disturbances, LFT’s, leukopenia, thrombocytopenia
TMP-SMZ 160/800mg bid x 3 days or
Loperamide 4mg Load, then 2mg after each loose Sedation, fatigue, dizziness, nausea, vomiting, abdom cramp
stool NTE 18mg/qd FQ x 1 dose
Yersinia spp Abx not usu req’d Doxy + AG or TMP-
BSS 525mg q30min. Total 8dose/d Darkening of tongue/stools, tinnitus SMZ or FQ
Diphenoxylate/Atropine (Lomotil) 1-2 tabs po q6h prn Nervousness, dizziness, HA, mental depression, anticholinergic
Octreotide 100mcg SQ q8h. 500mcg q8h prn. Nausea, cramps, gallbladder emptying cholelithiasis,
pancreatitis
Food Poisoning and Traveler’s Diarrhea
Bug Possible source Incubation Sx Labs/micro Tx
S.aureus Poultry, ham, raw milk, 2-4h N/D onset <4h Stool cx Self-limiting, Supportive
creams/custards, salads c mayo Resolves in 24-48h
Bacillus cereus Poultr, ham, raw milk, 4-18h N/V Stool cx Self-liming, Supportive
creams/custards, salads c mayo, May progress to diarrhea, cramps
rice
E.coli (and EHEC) Beef, raw milk, dairy, cheeses, 48-96h Diarrhea (blood), cramps, HA Stool cx on Macconkey’s sorbitol (maybe Θ if Usus self-limiting unless complication.
unpeeled fruits, veges, water, May progress to hemolytic uremic done >6days post onset) Supportive, no antimotility agents
unpast juice syndrome, thrombotic Monitor UOP, dark urine, BUN/Scr, bruising
thrombocytopenia purpura
Campylobacter jejuni Eggs, raw milk, water, daycare 24-72h Mild-severe diarrhea blood fecal WBC, stool cx Self-limiting. Usu supportive
center, foreign travel Fever, malaise. Sx may wax/wane
Clostridium Botulinum Meats, veges, alkaline canned N/A Blocks release of ACh leads to None ICU with antitoxin
foods, smoked fish musculoskeletal paralysis
Salmonella Poultry, eggs, meat, dairy, 12-36h N/V/D Blood, cramps, HA, fever, Fecal WBC, stool cx Usu self-limiting unless systemic
custards/creams chills, tenesmus
Duration < 7days
Shigella Contaminated foodwater, contact, 12-24h Large vol watery diarrhea, fever, Fecal WBC Usu self-limiting, supportive.
houseflies. cramps, genesmus, fecal urge Abx may duration and severity
Min infective dose 10-100bact
Vibrio Raw or undercooked seafood 5-92h Explosive, watery diarrhea, mild- Stool cx Self-limiting, supportive
severe cramping, low gread fever,
chills, HA
Cryptosporidium IMS (HIV CD4<150), daycare N/A Mild-severe diarrhea (chronic or Stool screening for oocytes, PCR, ELIZA Usu Self-limiting (immunocompetent)
centers, contaminated water, animal self-limited); Large fluid Treat if persistent diarrhea
handlers
06793631-4644-449c-8631-ac83bd5e850b.doc 7/24/11 3
S/O Etiology Tx Options Recommended Dose Goals/Monitor Pt Education
06793631-4644-449c-8631-ac83bd5e850b.doc 7/24/11 4
