Diarrhea

Diarrhea

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Diarrhea is increase in volume, fluidity, and frequency of bowel movement as compared to the normal habit of an individual. It is a health condition that involves loose bowel movement that is often and rapid. The condition may involve more than three loose stool passed in a day. It is a major cause of infant’s death globally and very prevalent in developing countries. Imbalance of electrolytes and dehydration as a result of fluid loss occur in individuals with diarrhea. Common treatment involves use of Zinc tablets, and Oral Rehydration salts. Acute diarrhea is a benign form of diarrhea and very common in United States. It is usually as a result of acute gastroenteritis which is caused by protozoa, bacteria or a virus. Diarrhea is also caused by irritable bowel syndrome also known as mucous colitis, functional diarrhea or irritable colon. Ingestion of anti-inflammatory agents, antibiotics, intolerable lactose, alcohol and substances with magnesium has been known to cause diarrhea. Diarrhea is common for diabetic patients (Seller, 2000).

History

Physicians evaluate a patient by assessing and inquiring from the patient asking several questions. Questions asked include: What is the usual pattern and frequency of bowel movement? How is the present pattern of movement of the bowel? Is there presence of mucous or blood in the stool? Do you experience nocturnal diarrhea? Are there recent changes in your diet? Have you had changes in food nature? Are you having symptoms such as, nausea, vomiting or fever? Could diarrhea exacerbation been as a result of the dairy products you have taken? How often does this happen after ingesting such food? Where do you come from and how old are you? Have you recently ingested any drug? Do you have important previous surgical or medical history such as diabetes, AIDS or sickle cell? Have you had recent travels abroad or within U.S? If the patient is an infant, questions directed to the parent may include: How old is he or she? Since when have the child had the diarrhea? Does it happen in other seasons or it happens during winter? How spacious and clean is your home environment?

Rationale for the Questions

Patient’s Nature

The grounds on which the questions are based are on the significant causes of diarrhea, Patient’s nature and symptoms nature. Acute diarrhea is majorly caused by viral gastroenteritis. In adults this is a self limiting benign condition although it may cause severe dehydration for children and infants. Rotavirus is the significant cause of gastroenteritis that is nonbacterial in infants less than three years of age especially during winter. For children at the age of one to four years, salmonella is the major gastroenteritis cause. Shigella epidemic is prevalent among children of one to four years of age and for individuals living under substandard sanitation in enclosed surroundings such as custodial institutions and prisons. Giadiasis is a condition susceptible in infants and common in children which may cause sub-acute or acute diarrhea. It is common for hikers and campers who have higher chance of taking water infested with Giardia. Infant diarrhea as a result of higher intake of dairy products, there are higher chances that it may be as a result of lactase deficiency which may cause lactose intolerance. This type of diarrhea is common in adults of Mediterranean origin where individuals’ lactase production declines with age. The decline of lactase is especially pronounced for some individuals where diarrhea result t from high ingestion of lactose present in ice cream, milk, dairy products such as cheese. Transient deficiency of lactase is notable after experiencing infectious gastroenteritis (Seller, 2000).

Irritable colon is common in women who are middle aged and experiencing chronic diarrhea. The condition occurs in young women with children and another job responsibility outside home. Stressed individuals also experience irritable colon. Diarrhea as a result of misuse of purgatives is common in women who are middle aged. Patients who surreptitiously take laxatives demonstrate hysterical behavior and abuse of laxative is noted by adding sodium hydroxide to a sample of stool where a color change is noted.

Diabetic patients and those with neurological dysfunction have been noted to experience chronic diarrhea. Diabetic patients usually have bowel motility that is poor and experience gastric stasis. Under those conditions, there is bacterial overgrowth which might lead to postprandial, explosive and uncontrollable diarrhea. Therefore, it is advisable that these patients refrain from careless eating which may inconveniently cause uncontrollable diarrhea. Bacterial overgrowth may be therapeutically combated by Intake of tetracycline. Acute and chronic diarrhea exposes patients to other serious complications. The patients who are prone to these conditions are elderly, neonates, patients of sickle cell and immunocompromised individuals from a disease or chemotherapy. Diarrhea which is a result of enteric infections from fungal, protozoa, viral and bacterial pathogens is significantly notable in individuals who have Acquired Immunodeficiency Syndrome (AIDS) (Dunphy, 2007).

Symptoms Nature

Differential diagnosis of acute diarrhea and chronic diarrhea is crucial. Acute diarrhea onsets abruptly, lasts less than a week and is associated with fever, vomiting, nausea and viral prodrome. Chronic diarrhea has an initial period which last for more than two weeks and recurrence of the diarrhea may occur after several months or even years. Acute diarrhea onset on healthy individuals with no other sign of involvement of other organ systems suggests a viral infection. If a patient vomits with a sudden start of diarrhea for a number of people along the same period bacterial infection e.g. from Staphylococcus enterotoxin may be the cause. After ingesting contaminated food, symptoms usually start after two to eight hours. Refrigeration of food in summer may cause food contamination. Infection with Salmonella, Campylobacter and Shigella, reveals symptoms after twenty four to seventy two hours as there is multiplication of the pathogenic microorganisms. Giardia infection shows symptoms after one to two weeks after exposure.

Chronic diarrhea is especially as a result of irritable bowel syndrome, colon cancer, dietary factors, medication, and chronic inflammatory bowel disease. Irritable bowel syndrome may occur as intermittent diarrhea alternating with constipation or during stressful times. Stool is loose, more frequent and painful. History of hard stool alternating with soft ones with mucus is as a result of irritable bowel syndrome although viral gastroenteritis, giardiasis and salmonellosis must not be ignored. Persistent diarrhea with times of floating, frothy and smelly stool may suggest a pancreatic cause. Foul odor, explosive, mucous and watery diarrhea may be due to giardiasis. Onset of diarrhea as a result of giardiasis may be gradual persisting for several weeks. Functional diarrhea does not occur during the night. It often occurs in the morning with copious mucus. Blood in the stool may be due to haemorrhoidal bleeding. From the stool, Patients may notice undigested food and rectal urgency. Nocturnal diarrhea is mostly associated with organic cause (Seller, 2000).

Acute diarrhea can be classified into toxin-mediated diarrhea and infectious diarrhea. The former is characterized by abrupt onset where patients diarrhea after few hours of intake of contaminated food. It is watery and in large amounts accompanied by nausea increased salivation, vomiting, general malaise, abdominal pain and less fever. Neurologic symptoms after diarrhea could be as a result of botulism or clostridia toxin. Infectious diarrhea is majorly caused by colonic mucosal invasion commonly known as dysentery syndrome. It is characterized by fever, nausea, vomiting, headache, abdominal cramps, and general malaise. Myalgia accompanied by watery diarrhea could be as a result of viral gastroenteritis and Campylobacter or salmonella (Dunphy, 2007).

Diagnosis

Bacteria that infect colonic mucosa include shigella, salmonella, Escherichia Coli and Yersinia. Presence of fecal leukocytes, stool should be culture. If the patient has high fever, a blood sample is then cultured. Fecal leukocytes are also associated with ulcerative colitis incase there is no remarkable results of the cultures. Toxin production by organisms such as E. coli, Staphylococcus, Clostridium Perfringens, and Vibrio Cholerae cause diarrhea. Others such as viruses and Giardia induce bowel lesions that are small causing watery stool with no presence of fecal leukocytes. In addition, amebic dysentery is not related to fecal leukocytes. Microscopic examination of stool shows Giardia cysts in patients suffering from giardiasis. Negative results could be confirmed with Giardia antigen test, jejuna biopsy or aspiration. Patients with diarrhea as a result of abuse of a laxative, a proctoscopic examination could be used to show melanosis coli. Stool and urine test with sodium hydroxide is positive where phenolphthalein is used as an indicator. Patients with deficiency of lactase test pH which is less than six and sugar more than one gram percent in the stool (Seller, 2000).

Differential Identification of Acute and Chronic Diarrhea

Acute Diarrhea

Abnormal stool increase in liquidity in persons that are healthy. It is self limiting and lasts for less than fourteen days. It caused by acute viral or bacterial infections. Acute viral diarrhea is most common and self limiting. Acute bacterial diarrhea develop six to twenty four hours after ingesting contaminated food

Chronic Diarrhea

Decline in fecal consistency for less than four weeks. It is caused by Inflammatory diarrhea, secretory diarrhea intestinal immobility and mal-absorption.

Etiology:

Bacterial: Salmonella, Escherichia coli , Shigella, Staphylococcus aureus, Vibrio cholerae , Clostridium difficile ,Campylobacter jejuni , Bacillus cereus, Yersinia enterocolitica, and Vibrio parahaemolyticus

Viral: Rotavirus and Norovirus

Protozoal: Cryptosporidium, Giardia lamblia, Isospora belli and Entamoeba histolytica Etiology

Inflammatory diarrhea: Radiation enterocolitis , Inflammatory bowel disease, hypersensitivity, AIDS and Eosinophilic gastroenteritis

Infectious diarrhea: Bacterial such as Clostridium difficile and Mycobacterium avium intracellulare Parasites such as Isospora and Giardia lamblia,

Osmotic diarrhea: Bacterial overgrowth, pancreatic insufficiency, celiac disease, lactase deficiency.

Post surgical: Peptic ulcers and short gut

Secretory diarrhea: e.g. carcinoid syndrome

Diarrhea as a result of laxatives, toxins, irritable bowel syndrome, neurological diseases, diabetes, drugs

History

Headache, Anorexia with or without vomiting, Malaise and Myalgia.

Assess characteristics of the stool, quantity Frequency, consistency and presence of blood or mucous.

Inquire about day care attendance, Intake of raw meat, raw seafood, contact with sick individuals, travel history and intake of unpasteurized milk

History

Assess the onset, duration, pattern, frequency and characteristics of loose stool.

Asses fecal incontinence, mitigating factors such as drugs and diet, exposure and travel, aggravating factors such as stress and diet

Check for loss in weight

Review underlying causes such as diabetes mellitus, hyperthyroidism, collagen vascular disease, AIDS and tumor syndromes.

Physical exam

Examine liquid and loose stools with or without mucus or blood, Fever, Determine hydration, assess skin turgor, mucosal membranes which are dry, decreased urination, Abdominal distension and pain or hypotension.

In children, assess tears absence, dry diapers and depressed fontanelles.

Physical Exam

Nutrition and fluid balance. Flushing and rashes on the skin, mass of the thyroid, wheezing chest, murmuring heart, abdominal mass, hepatomegaly, and tenderness.

Anal-rectal exam of Sphincter competence, blood test for fecal occult.

Assess for Edema along the extremities

Diagnostic test

Serum electrolytes, CBC, stool samples and ,creatinine test

Diagnostic Test

Initial Laboratory tests include CBC test with differential, total protein, electrolytes, , albumin, and TSH

Determine transglutimase antibody (TGA) and

Anti-endomysial antibody (AEA).

Stool analysis: analyze for parasites and ova in the stool.

Initial Imaging Approach with Barium enema

Computed tomography (CT) is performed to rule out chronic pancreatitis if there is abnormal presence of pancreatic enzymes or mal-absorption

Diagnostic Procedures/Other

Colonoscopy for inflammatory lesions if there is presence of blood in the stool with or without iron deficiency.

If there is negative barium enema and persistence of diarrhea, the patient should be referred to a specialist.

First line Medication

30 ml of Bismuth subsalicylate for every half an hour for eight doses useful in treating mild diarrhea

Persistent of diarrhea with identification of the pathogen, antibiotic therapy is administered.

250 mg/d of Metronidazole is given for 5 days for patients with Giardiasis

750 mg /d Metronidazole is given for 10 days in patients infected with E. histolytica:

160 mg/800 mg/d Bactrim DS or Trimethoprim-sulfamethoxazole. Is given for 5 days, or 500 mg/d ciprofloxacin is administred for 3 days in patients with Shigella infection

500 mg /d of Erythromycin is administered for 5 days or 500 mg /d of ciprofloxacin administered for 3 days for patients with Campylobacter infection.

Discontinue use of antibiotics and administer 500 mg/d metronidazole for ten to forteen days if there is persistence of dirrhoea for patients infected as a result of. C. difficile

A single dose of 750 mg of Ciprofloxacin if severe case, or 500 mg taken twice a day for three days.

A single tablet of Bactrim DS taken twice a day for three days for patients with traveler’s diarrhea First Line medication

For symptomatic relief and treatment of diarrhea prescribe Opioid agonists 5to 20 mg/d of Lomotil or Diphenoxylate-atropine Imodium or operamide 4 to16 mg/d. The doses are given according to the needs and weight of a patient.

The medication is Contraindicated in ulcerative colitis, and infectious diarrhea

Diet

Consider Early re-feeding. Avoid alcohol, coffee, vegetables, most fruits, red meat, food that is heavily seasoned and dairy products in times of diarrhea. Initially, eat salted crackers, rice and clear soup, sherbet and dry bread. Slowly add baked potatoes to the diet, eat noodles with chicken soup. Eventually, addition of baked fish, bananas, applesauce and poultry can be included in the diet as stool starts to shape up.

Diet

Refrain from products containing lactose, sorbitol and food allergens.

Add twenty to thirty g/d of dietary fiber for a case of irritable bowel syndrome

Reference

Dunphy L. M. et al (2007). Primary Care: The Art and Science of Advance Practice Nursing. Philadelphia: F.A. Davis Company

Seller R. H. (2000). Diarrhea: Differential Diagnosis of Common Complaints. Philadelphia: Saunders.