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GI Gas: Belching -> Give a definition and some likely causes.
- -Def: Involuntary or voluntary release of gas from the stomach or esophagus.
- -Causes: Swallowed air, gum chewing, smoking, rapid eating, or carbonated drinks
What is the normal volume and frequency of flatus?
- Volume: 500-1500ml/day
- Frequency: 6-20 times/day
Gases with little odor are derived from _____
Plant carbohydrates (hydrogen and methane)
Gases that are malodorous are derived from ______
Meat and eggs (sulfur dioxide)
Excessive amounts of flatus may be an indication of ________
What are some treatment methods for GI gas?
- -Lactose-free diet
- -Avoid common gas-producing foods
- -"Beano" -> reduces gas associated w/beans
What do patients commonly use the term "diarrhea" to refer to?
- -increased frequency of bowel movements
- -increased stool liquidity
- -a sense of fecal urgency
- -fecal incontinence
What is the official definition of diarrhea?
-> Increase in stool weight >200 gm/day that may be associated with increased liquidity, stool frequency, perianal discomfort, and urgency with or without fecal incontinence
Acute, persistent, and chronic diarrhea are classified by what time frames?
- Acute < 2 weeks
- Persistent 2-4 weeks
- Chronic >4 weeks
What volume of liquid passes through the ligament of Treitz each day?
9-10L of fluid
How much does the Jejunum absorb?
Approx. 6 L
How much does the Ileum absorb?
Approx. 2.5 L
How much fluid passes through the colon each day, how much is absorbed by the colon, and how much is left in the feces?
- -1.5 L passes through colon
- -Colon absorbs more than 90% of this load
- -Approx 0.1 L is left in the feces
The overall absorptive efficiency for water is 99%. Why is it important to know this, as well as possible reduction in efficiency?
Reduction of this efficiency by as little as 1% may lead to diarrhea.
Name some causes of acute diarrhea.
- -Infectious agents -Bacterial toxins
- -Drugs -Community outbreaks (viral, food)
- -Day care or swimming (protozoal)
- -Antibiotic-associated (C. Diffcile colitis)
- -Sexually transmitted
- -Traveler's diarrhea
What is part of the Acute Diarrhea evaluation process?
- -Distinguish between mild and serious illness
- -For > 7 day duration: check stool culture, O & P, fecal leukocytes
- -Bloody diarrhea, fever, abd pain: Work-up
- -Physical exam: Tilts, addt'l tests depending on history
What are the four ways of treating acute infectious diarrhea?
- -Diet: rest bowels -> avoid high-fiber foods, fats, milk products -> take in easily digestible foods
- -Rehydration: Oral rehydration is best.
- -Anti-diarrheal agents
- -Antibiotic therapy -> for select patients
What is the BRAT diet?
Bananas, Rice, Applesauce, Toast
Why is the BRAT diet effective?
These foods are low in fiber and digestive residue.
What do you need to rule out during chronic diarrhea evaluation?
- -acute diarrhea causes
- -lactose intolerance
- -previous gastric surgery
- -systemic disease
True or false: During chronic diarrhea evaluation, you should perform a physical exam, to include an abdominal exam.
What tests should be performed during a chronic diarrhea evaluation?
- -Fecal leukocytes, stool culture, O & P
- -CBC, electrolytes, LFTs, albumin, TSH
- -Flex sig or C-scope w/biopsy
- -UGI, BE
What are some causes of chronic diarrhea?
- -Osmotic -Secretory
- -Inflammatory -Malabsorption syndromes
- -Motility disorders -Chronic infections
- -Irritable bowel
What is the main clue for osmotic chronic diarrhea?
-Stool volume decreases with fasting
What are the causes for osmotic chronic diarrhea?
- -Medications: antacids, Lactulose, sorbitol
- -Disaccharides deficiency- Lactulose intolerance
- -Factitious diarrhea - magnesium use
What is the main clue to indicate secretory chronic diarrhea?
-Large volumes (>1 L/day) -> little change with fasting
What are the causes of secretory chronic diarrhea?
- -Hormonal: Carcinoid, ZE, thyroid ca
- -Factitious diarrhea - laxative abuse
- -Villous adenoma
- -Bile salt malabsorption (post-op, Crohn's)
- -Celiac Sprue
What are the main clues for inflammatory chronic diarrhea?
- -abdominal pain
- -> Systemic symptoms/signs: arthralgias, rash
What are the causes of inflammatory chronic diarrhea?
- -ulcerative colitis
- -Crohn's disease
- -Malignancies - lymphoma, adenoma
- -Radiation enteritis
What are the main clues for malabsorption chronic diarrhea?
What are the causes for malabsorption chronic diarrhea?
- -Small bowel mucosa disease: Sprue, Crohn's, Whipple's, short bowel syndrome
- -Lymphatic obstruction- lymphoma, TB, carcinoid
- -Pancreatic disease- chronic pancreatitis, pancreatic carcinoma
- -Bacterial overgrowth-motility disorders (DM, vagotomy, scleroderma), fistulas, small intestinal diverticula
What are the main clues for chronic diarrhea motility disorders?
- -systemic disease
- -prior abdominal surgery
What are the causes of chronic diarrhea motility disorders?
- -Post surgical: vagotomy, partial gastrectomy, blind loop with bacterial overgrowth
- -Systemic disorders: scleroderma, DM, hyperthyroidism
What is the main clue for chronic diarrhea -> chronic infections?
What are the causes for chronic diarrhea -> chronic infections?
- -Parasites- Giardia lamblia, Entamoeba histolytica, Cyclospora
- -AIDS-related (viral, bacterial, protozoal)
What does voluminous stool suggest?
-small bowel or proximal colon
What does small stool with urgency suggest?
-left colon or rectum
What does blood suggest?
-mucosal damage or inflammation
What does frothy stool and flatus suggest?
What does foul smelling or greasy stool suggest?
What kinds of items need to be included in the patient's diarrhea history?
- -Patient's normal bowel pattern
- -Medications -Past medical history
- -Past surgical history
- -Family history -Social history
- -Alarm symptoms
What information needs to be included in a patient's History of Present Illness (OPQRST)?
- -Onset and location -Provocation or Palliation
- -Quality of the pain -Region and radiation
- -Severity -Time (history): determine whether pt's symptoms are acute or chronic
- -USE NARRATIVE FORMAT
What are the diarrhea alarm symptoms?
- -Signs of dehydration -bloody stool
- -Fever >101
- -Passage of greater than 6 stools per 24 hrs or illness that lasts more than 48 hrs
- -Severe abdominal pain -weight loss
What elements make up a stool analysis test?
- -24 hour stool collection for weight and quantitative fat
- -Stool laxative screen -Stool osmolality
- -Fecal Leukocytes -Stool for ova and parasites
- -stool cultures
What are the routine lab tests for diagnosing chronic diarrhea evaluation diagnostic tests?
- -CBC -Electrolytes
- -Liver function tests
- -TSH -PTT
What are some other labs used in diagnostic tests for chronic diarrhea?
- -Suspected sprue: serologic tests
- -Secretory diarrhea due to tumors: VIP, calcitonin, gastrin, glucagon, VMA, metanephine
What types of endoscopic evaluation tests are there for chronic diarrhea?
- -Inflammatory bowel dz: Flex sig/C-scope
- -Malabsorption: Upper endoscopy w/Bx
What are some other imaging tests used for chronic diarrhea evaluation?
- -Plain abdominal radiographs: Calcification of pancreas
- -UGI w/small bowel follow through: Lymphoma, Crohn's, carcinoid
What do you do for chronic diarrhea treatment?
- -Diphenoxylate with atropine (Lomotil)
- -Clonidine: Inhibits electrolyte secretion
BUT -> CORRECT THE UNDERLYING CONDITION!