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Diarrhea [Ddx]History Tenderness, fever, wt loss IBD, neoplasm, amebiasis, Tb Wt loss despite good appetite malabsorption, hyperthyroid LLQ diverticulitis Bloody diarrhea HUS, TTP, 0157:H7, Shigella, mesenteric ischemia Diarrhea + PUD gastrinoma Arthritis IBD, Whipple’s Physical Flushing, bronchospasm carcinoid Arthritis, iritis, uveitis, erythema nodosum IBD Abdominal mass cancer, diverticular abscess, IBD Fever infectious, IBD, lymphoma Lymphadenopathy neoplasm/lymphoma, Tb, AIDS, Whipple’s Sx of hyperthyroidism hyperthyroidism Labs Occult blood Fecal WBC SSYC (and O157:H7) +/- N. gonorrhea O&P +/- E. histolytica C. difficile Cryptosporidium, Giardia ESR, CRP Hep A, Legionella Ur Ag Stool fat, Stool Osm (see below) Fe, folate, B12, vitamin K, vitamin D Serum 5HT, urine 5HIAA, serum gastrin, VIP TSH, A1C
Calcitonin, somatostatin, histamine, PG 24 hour stool protein Stool SO4 , PO4, Mg (and others) to detect factitious diarrheas H2 breath test (lactase or pancreatic deficiency, small intestinal mucosal Dz, bacterial overgrowth) Stool Osmotic Gap = Stool Osmolality (normal 290) – 2 [StoolNa + StoolK] >125 caused by osmotically active particles (laxatives, sorbitol-containing foods, meds) No gap hyperthyroid, IBD, sprue, etc. Markers of intestinal inflammation INR raised by vitamin K Malabsorption Alk phos elevated by vitamin D malabsorption Albumin – lowered by malabsorptive/protein losing inflammation Stool a1-AT – raised by malabsorptive/protein losing inflammation ESR/CRP
Radiography (in general, not that helpful for watery diarrhea)
obstruction, toxic megacolon, pancreatic calcifications, mesenteric ischemia (esp. w/ perforation)
previous surgery, fistulas, blind loops, strictures, abnormal motility
Uniform thickening amyloidosis, lymphoma, Whipple’s Uniform or patchy lymphoma Sprue may show characteristic small bowel dilatation
can sometimes detect IBD not seen on endoscopy Endoscopy Malabsorption or Steatorrhea? EGD w/ duodenal biopsy malabsorption (Whipple’s, Sprue, etc) Severe watery or elusive diarrhea? Colonoscopy to rule out villous adenoma, microscopic or collagenous colitis, mastocytosis, IBD (terminal ileum is best)
Note: Campylobacter often resistant (must use macrolide)FQ and Bactrim Do Treat: Shigella, Salmonella, Yersinia, Campylobacter, cholera, travelers’ diarrhea = E. coli (ETEC not 0157:H7), pseudomembranous enterocolitis (C. difficile), parasites, sexually transmitted (N. gonorrhea) Do not treat: viral diarrhea, cryptosporidiosis (because it doesn’t help) or E. coli 0157:H7 (because it may increase incidence of HUS) Exceptions: immunocompromised, very young, very old, prosthetic + (valvular, vascular, orthopedic), congenital hemolytic anemias Traveler’s diarrhea ETEC (50% in Latin America, 15% in Asia) / Mexico (ETEC > E. histolytica and V. cholerae / Campylobacter more common in Asia and in winter in subtropics / Giardia common in Northern American wilderness and in Russia General Treatment of Diarrhea Bulk-forming agents cholestyramine useful with bile acid diarrhea but can worsen fatty acid malabsorption by depleting bile salt pool Medium-chain fatty acids for short gut syndrome Anti-peristaltics: bismuth salicylates, opiates*, loperamide, clonidine**, PZ, SS Good for reabsorption Bad for assessing fluid replacement needs (fluids trapped in intestine) Bad because stasis may enhance bacterial invasion and delay clearance opiates can precipitate megacolon in IBD ** clonidine good for opiate withdrawal and diabetic diarrhea (sometimes)
Somatostatin (Octreotide) Good for carcinoid syndrome and neuroendocrine tumors NSAIDs* Always acute radiation, AIDS, and villous adenomas Sometimes neuroendocrine tumors, irritable bowel, food allergy may be harmful in IBD
Steroids IBD et al. Note: if no diagnosis made and diarrhea persists, can give empiric trial of FQ or bactrim or metronidazole or tetracycline Oral cavityInfectious origin HSV Syphilis
Candida [pic] Histoplasmosis Oral hairy leukoplakia [pic] hyperkeratotic thick tongue / lesions are more lateral tongue (usu. not involving other parts of oral mucosa) / precancerous lesion, requires biopsy (homogeneous and non-homogeneous; homogeneous more likely malignant) / associated with EBV / respond to high-dose acyclovir / may recur after treatment / may have super-imposed Candida (esp. in HIV patients) Ddx: smoker’s leukoplakia, erythroplakia (SCC), candida, warts Immunologic dysfunction aphthous ulcers chancre sores / tiny ulcers in mouth Behçet’s syndrome mouth, GU ulcers Reiter’s arthritis, urethritis, conjunctivitis, oral ulcers SLE can produce oral lesions Systemic disease hypertrophic gingiva scurvy, pregnancy, leukemia, polycythemia oral pigmentation melanotic - Peutz-Jeghers, Addison’s Disease heavy metals dark line along gingival margin / lead (blue), bismuth (gray), mercury (purplish) enlarged tongue cretinism or amyloidosis atrophic tongue loss of papillae, atrophic glossitis / vitamin B or iron deficiency [pic][pic] xerostomia Sjogren’s (destruction of salivary, lacrimal, conjunctival) / lymphocytic and plasma cell infiltrate / radiation therapy / anticholinergic agents Malignancies mature to old white men / multiple primary lesions / precursor lesions are leukoplakia (white) and erythroplakia (red) carcinoma of lip (better) lower lip / wedge resection, irradiation, nodal dissection if necessary carcinoma of mouth (worse) aggressive / resection, irradiation, dissection / tongue (worse), cheek (better) verrucous carcinoma large, fungating / tobacco / slow growth, locally aggressive, recurs Salivary glandsSialoadenitis mumps, Sjogren’s, Mikulicz’s (salivary, lacrimal inflammation w/ xerostomia), stones Pleomorphic adenoma (benign mixed tumor) most common / benign / superficial parotid / painless, movable / epithelial and myoepithelial proliferation / pseudopodia extend into surrounding / parenchyma complete excision / malignant transformation uncommon monomorphic adenoma only epithelial proliferation Warthin’s tumor (papillary cystadenoma lymphomatosum) smoking / parotid gland / second most common / double layer of columnar over lymphoid tissue 10% multicentric or bilateral malignant 20% of salivary gland tumors / most arise de novo (not from benign tumors) Adenoid cystic carcinoma (worse) common / all gland types / nests or cords / invades perineural spaces Mucoepidermoid carcinoma (variable) common / all gland types / children / radiation induced / mucous and epidermoid cell mixture Acinic cell carcinoma (variable) uncommon / usually parotid / females 2:1 / sheets of acinic cells / 7th nerve involvement resection, frequent recurrence Esophagus Congenital atresia with fistula Pulsion diverticulum false diverticulum from mucosal weakness / Zenker’s diverticulum (hypopharynx esophagus junction) / obstruction may result from incomplete emptying / only large ones treated surgically Traction diverticulum adherence to mediastinal structures / mid-distal esophagus / associated with inflammation (Tb, etc.) Epiphrenic diverticulum Distal esophagus above LES / usually asymptomatic Esophageal Webs upper 1/3 / may be associated with Plummer-Vinson (Paterson-Kelly) Esophageal Rings Schatzki’s rings occur mainly at squamocolumnar junction Hernias Sliding most common / congenital predisposition / hiatal junction / increases with age Paraesophageal pouch of stomach alongside esophagus / more likely to strangulate, hemorrhage Esophageal injury iatrogenic, chemical (corrosives, KCl, doxycycline, Fosamax), infection, radiation, neoplasm, mechanical injury Burns: give steroids and broad spectrum antibiotics / increased risk of stricture, carcinoma Tears: Boerhaave’s spontaneous rupture – surgical emergency Mallory-Weiss mechanical injury from forceful emesis / initial nonbloody vomitus followed by hematemesis (surgery required in 10%) Infections: Candida diabetic, immunocompromised, poor emptying / odynophagia / nystatin, ketoconazole, fluconazole, (resistant cases – amphotericin B) HSV immunocompromised / acyclovir CMV large ulcerations / ganciclovir HIV treat with steroids
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