Flow with us through Diarrhea Disemboweled Part 1 as Dr. Xiao Jing (Iris) Wang @IrisWangMD walks us through the evaluation and management of acute diarrhea.
NOTE: CME will not Go LIVE until Wed 4/7/21 for both #266 and #267. Then, claim 2 hours credit in one shot!
Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!
Join the American College of Physicians today! Post-training physicians can take advantage of a special limited-time $100 dues discount. Visit acponline.org/acp100 and use the code CURBSIDERS. Membership discount is available only until May 31, 2021.
This podcast is sponsored by BetterHelp and Curbsiders’ listeners get 10% off their first month at betterhelp.com/Curb.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
Diarrhea is defined as (Riddle 2016)
Categorize by Timing (Riddle 2016)
It is important to clarify what a patient means by “diarrhea”. Is it loose stools, frequent stools or stool leakage (incontinence issue)? Different people have different baselines for what is normal. Ask about: 1) recent food exposures 2) sick contacts 3) travel or travel of close contacts 4) timeline of symptoms 5) stool characteristics. Understanding if the diarrhea is small volume with increased frequency or less frequent, voluminous diarrhea helps localize the most likely source of pathology. The small bowel is primarily responsible for fluid reabsorption (PO intake and GI tract production) and the large intestine reabsorbs what remains. So, with large volume diarrhea the etiology is likely located from the small bowel to the right colon. The left colon, especially the rectum, serves as a stool reservoir, so pathology there will lead to reduced ability to hold on to stool and increased irritation. Rectal irritation is what causes the sense of needing to pass frequent bowel movements (tenesmus). As a result, frequent bowel movements with small amounts of stool indicate pathology located in the left colon or rectum.
Diarrhea often results from a change in absorption rate that is the result of a change in 1) surface area or 2) contact time. For example, the presence of a large number of unabsorbed osmoles or fat will inhibit water binding for reabsorption and lead to diarrhea.
Fever, Duration (>72 hours in the immunocompetent patient and <72 in immunocompromised patients), bloody stools, signs of hypovolemia (AKI, weakness, dizziness, decreased UOP). Dysentery=grossly blood stools (Riddle 2016). This is important because it is important to differentiate grossly bloody stools from less concerning sources of blood (ie irritation of skin or hemorrhoid from excessive wiping).
Check a BMP and CBC to evaluate hydration status, WBC, and Hgb/Hct to evaluate cell counts for infection and anemia.
A microbiologic assessment is recommended in the following cases (Shane 2017):
*See ACG guideline flowchart to evaluate this (Riddle 2016; Fig 1)
If hospitalization is required, consider early microbiologic assessment for severity. Kashlak Pearl: Dr. Wang recommends considering etiologies of diarrhea that improve with fasting or dietary changes such as osmotic diarrhea if it resolves rapidly following hospital admission.
In patients who are immunocompromised the infectious workup for acute diarrhea should be broadened (Shane 2017). PCR based panels for infectious etiologies are particularly helpful in these cases and testing for additional infectious causes including cytomegalovirus, Cryptosporidium, Cystoisospora, Mycobacterium avium complex, microsporidia and disseminated TB should be considered. Endoscopy is more often indicated in the case of acute diarrhea in the setting of immunosuppression, specifically in the setting of treatment with mycophenolate, certain checkpoint inhibitors (ie pembrolizumab), or concern for CMV (Shane 2017, Bellaguarda 2020). Serologic CMV testing does not equal CMV induced gastrointestinal disease. To diagnose CMV colitis, a biopsy confirming the presence of CMV (by inclusions or immunohistochemistry testing) in the colon is necessary as serologic CMV testing is not diagnostic (Beswick 2016).
For patients with mild illness supportive management = rehydration and loperamide or bismuth (Riddle 2016).
A decrease in surface area from loss of villi is often the etiology of diarrhea immediately following an infection (aka Post-infectious IBS). Dr. Wang notes that patients often develop lactose intolerance because lactase is at the very tip of microvilli and lactase is the disaccharidase most likely to get damaged following acute gastroenteritis.
Listeners will develop an approach to the basic evaluation and initial management of acute diarrhea
After listening to this episode listeners will…
Dr. Wang reports no relevant financial disclosures. Drs. Watto, Williams and Gibson report no relevant financial disclosures.
Gibson Elena, Wang Iris, Williams PN, Brigham SK, Watto MF. “#266 Diarrhea Disemboweled Part 1: Acute Diarrhea with Dr. Iris Wang”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date April 5, 2021.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Notice
We and selected third parties use cookies or similar technologies for technical purposes and, with your consent, for other purposes as specified in the cookie policy. Denying consent may make related features unavailable.
Close this notice to consent.
Comments
I went to a pharmacology review conference a few years back, and the lecturer said (regarding poop) “if you can throw it, then it’s not c.diff”. That saying just seems like something you all would say. Also, I think Dr. Iris is my spirit animal and we need to be bff’s.