LLSA 2006 Acute Diarrhea!!!

[Hard24Get]

Hello! What follows is my summary of this article:

Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med. Jan 2004;350(1):38-46. from the 2006 LLSA reading list.

as well as my own personal opinion as to how this article should influence clinical practice in the ED. Please participate, and let me know if this is useful!

HIGHLIGHTS OF THE ARTICLE:

Case Study
An otherwise healthy 23-year-old man presets after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is febrile, with a temperature of 38.7. How should he be evaluated and treated?

Definition of Acute diarrhea – Less than 14 days of 200g of stool per day, or 3-4 times per day, can be accompanied by nausea, vomiting, abdominal cramping, fever

Most often responsible pathogens – salmonella, camplyobacter, shigella, cryptosporidium, vibrio, yersenia, listeria, cyclospora

Diagnostic tests available for: Clostridium Difficile, giardia, rotavirus, entamoeba histolytica

Diagnostic yield of stool cultures – 1.5-5.6% of the time, therefore $952-1200 per positive test!

Most bouts of diarrhea last only 1 day, so usually don’t bother working up if onset is within 24hrs unless dehydrated, tenesmus, febrile, or blood/pus (microscopy reveals neutrophils) in stool


Diagnostic Clues
(for a fun song, check out - This site )

Winter – VIRUSES – norovirus in elderly, rotavirus in kids (this should decrease over the next few years since the vaccine just got approved), supportive hydration
Beef hx with Acute, bloody, No fever, HUS - Shiga toxin-producing E. coli
Immunocompromise, sickle cell, atherosclerosis, prosthesis – salmonella (check blood and stool)
Appendicitis-like symptoms -Y. entercolitica (wouldn’t ever actually take a chance with this in the ED myself!)
Fried Rice - B. cereus (preformed toxin)
Raw seafood history - vibrio
Antibiotic use (and nosocomial) – C. Difficile
Traveler to 3rd world country – emperic single dose quinolones unless S. asia, where resistance to quiniolones is high
Traveler/hiker with extended diarrhea – giardia & cryptosporidium
AIDS with <50 CD4s - along with everything else, MAC, CMV
Already ruled out infectious agents but inflammatory diarrhea? – Consider inflammatory bowel disease




Treatment Notes
Salty crackers/soups & lots of water for most patients

For kids - Bananas, Rice, Applesauce, Toast (BRAT) diet, fluids, & avoidance of milk products (diarrhea can cause temporary lactose intolerance)

Anti-motility agents (ie, lopermaine, bismuth, kaolin) can be useful for limiting disease but also may cause prolonged disease for systemic illnesses, HUS, toxic megacolon, longer infectiousness, recurrence – DO NOT USE IN KIDS



Implications of this article for the ED (IMHO only!!!):

- We should probably never bother to order a stool culture – if the diarrhea is that bad, will probably admit to GI or ID and they can make that call. We can, however, take a quick peek under the microscope (for neutrophils, etc) to rule out/in the nasties before deciding whether to send home or admit.

- A quick history is often more useful than any test in determining treatment/course of action, and hydration level should always be assessed

- Repeat visits for diarrhea may indicate something more serious (HIV, giardia, cryptosporidium, IBD) that we can pick up

- Prescribing of anti-motility agents are perhaps best avoided in the ED – there is no follow-up and the side effects are potentially grave

- The ED is often the first line of defense in public outbreaks, so we should stay alert for patterns and report anything suspicious


Please discuss my recommendations for the ED. Do you agree or disagree? Why or why not?

[12R34Y]

Originally Posted by Hard24Get

Hello! What follows is my summary of this article:

Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med. Jan 2004;350(1):38-46. from the 2006 LLSA reading list.

as well as my own personal opinion as to how this article should influence clinical practice in the ED. Please participate, and let me know if this is useful!

HIGHLIGHTS OF THE ARTICLE:

Case Study
An otherwise healthy 23-year-old man presets after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is febrile, with a temperature of 38.7. How should he be evaluated and treated?

Definition of Acute diarrhea – Less than 14 days of 200g of stool per day, or 3-4 times per day, can be accompanied by nausea, vomiting, abdominal cramping, fever

Most often responsible pathogens – salmonella, camplyobacter, shigella, cryptosporidium, vibrio, yersenia, listeria, cyclospora

Diagnostic tests available for: Clostridium Difficile, giardia, rotavirus, entamoeba histolytica

Diagnostic yield of stool cultures – 1.5-5.6% of the time, therefore $952-1200 per positive test!

Most bouts of diarrhea last only 1 day, so usually don’t bother working up if onset is within 24hrs unless dehydrated, tenesmus, febrile, or blood/pus (microscopy reveals neutrophils) in stool


Diagnostic Clues
(for a fun song, check out - This site )

Winter – VIRUSES – norovirus in elderly, rotavirus in kids (this should decrease over the next few years since the vaccine just got approved), supportive hydration
Beef hx with Acute, bloody, No fever, HUS - Shiga toxin-producing E. coli
Immunocompromise, sickle cell, atherosclerosis, prosthesis – salmonella (check blood and stool)
Appendicitis-like symptoms -Y. entercolitica (wouldn’t ever actually take a chance with this in the ED myself!)
Fried Rice - B. cereus (preformed toxin)
Raw seafood history - vibrio
Antibiotic use (and nosocomial) – C. Difficile
Traveler to 3rd world country – emperic single dose quinolones unless S. asia, where resistance to quiniolones is high
Traveler/hiker with extended diarrhea – giardia & cryptosporidium
AIDS with <50 CD4s - along with everything else, MAC, CMV
Already ruled out infectious agents but inflammatory diarrhea? – Consider inflammatory bowel disease




Treatment Notes
Salty crackers/soups & lots of water for most patients

For kids - Bananas, Rice, Applesauce, Toast (BRAT) diet, fluids, & avoidance of milk products (diarrhea can cause temporary lactose intolerance)

Anti-motility agents (ie, lopermaine, bismuth, kaolin) can be useful for limiting disease but also may cause prolonged disease for systemic illnesses, HUS, toxic megacolon, longer infectiousness, recurrence – DO NOT USE IN KIDS



Implications of this article for the ED (IMHO only!!!):

- We should probably never bother to order a stool culture – if the diarrhea is that bad, will probably admit to GI or ID and they can make that call. We can, however, take a quick peek under the microscope (for neutrophils, etc) to rule out/in the nasties before deciding whether to send home or admit.

- A quick history is often more useful than any test in determining treatment/course of action, and hydration level should always be assessed

- Repeat visits for diarrhea may indicate something more serious (HIV, giardia, cryptosporidium, IBD) that we can pick up

- Prescribing of anti-motility agents are perhaps best avoided in the ED – there is no follow-up and the side effects are potentially grave

- The ED is often the first line of defense in public outbreaks, so we should stay alert for patterns and report anything suspicious


Please discuss my recommendations for the ED. Do you agree or disagree? Why or why not?

nicely done!

One thing to add........anti-diarrheals are OTC and used by EVERYBODY A LOT and I've never heard of any adverse effects from taking some kaopectate or immodium anecdotally at least. I mean if someone can buya case of it over the counter then I wouldn't be super shy from telling them to take if needed.

Also, I recently read in one of the journals (can't recall) that you can give kids anti-diarrheals without any problem and the potential problem of prolonging the illness is essentially a myth.

they had a study to back it up. anybody care to look it up?

later

[JackBauERfan]

I think the main differentiation to make early on is whether the diarrhea is inflammatory or non-inflammatory, as this will lead you down different diagnostic paths. Like one of the diagrams showed you are looking for fever, tenesmus, blood in stool, and these are generally more serious cases.

But, great job, nice reading!

Also, I found out that for Traveller's diarrhea (which they say the mechanisms is a change in the flora content in the particular water/food you are eating, not necessarily that the water is dirty with microbes) can be treated pretty good with Pepto-bismol because it has a antibiotic effect as well.

[Hard24Get]

Originally Posted by JackBauERfan

I think the main differentiation to make early on is whether the diarrhea is inflammatory or non-inflammatory, as this will lead you down different diagnostic paths. Like one of the diagrams showed you are looking for fever, tenesmus, blood in stool, and these are generally more serious cases.

But, great job, nice reading!

Also, I found out that for Traveller's diarrhea (which they say the mechanisms is a change in the flora content in the particular water/food you are eating, not necessarily that the water is dirty with microbes) can be treated pretty good with Pepto-bismol because it has a antibiotic effect as well.

Thanks, JackB, that's great insight into traveller's diarrhea, which I suppose is the category we're dealing with once the dangerous ones are ruled out. . The article was kind of vague on that point.
Yeah, I guess I should clarify that I don't think we should be PRESCRIBING anti-diarrheals, but judicious OTC use seems ok, though I would nevertheless avoid holding off if possible - what's another day on the can?
12R - I think the controvers you bring up with the anti-motiles is interesting and will look into it. In the meantime, I still think that there has to be a risk/benefit consideration in favor of least harm...

[JackBauERfan]

Originally Posted by Hard24Get

Thanks, JackB, that's great insight into traveller's diarrhea, which I suppose is the category we're dealing with once the dangerous ones are ruled out. . The article was kind of vague on that point.
Yeah, I guess I should clarify that I don't think we should be PRESCRIBING anti-diarrheals, but judicious OTC use seems ok, though I would nevertheless avoid holding off if possible - what's another day on the can?
12R - I think the controvers you bring up with the anti-motiles is interesting and will look into it. In the meantime, I still think that there has to be a risk/benefit consideration in favor of least harm...

Also, from Current Medical Diagnosis and Treatment (one of my favorite books!) they do say "antimotility drugs may relieve cramping and decrease diarrhea in midl cases. Their use should be limited to patients without fever and without dysentery, adn they should be used in low doses because of the risk of producing toxic megacolon." "Anticholinergics (diphenoxylate with atropine) are contraindicated in acute diarrhea because of the rare precipitation of toxic megacolon."

Oh and just to check on myself, it states that pepto bismol reduces symptoms because of its antiinflammatory and antibacterial properties, and it also reduces vomiting associated with viral enteritis.

[JackBauERfan]

Originally Posted by Hard24Get

Thanks, JackB, that's great insight into traveller's diarrhea, which I suppose is the category we're dealing with once the dangerous ones are ruled out. . The article was kind of vague on that point.
Yeah, I guess I should clarify that I don't think we should be PRESCRIBING anti-diarrheals, but judicious OTC use seems ok, though I would nevertheless avoid holding off if possible - what's another day on the can?
12R - I think the controvers you bring up with the anti-motiles is interesting and will look into it. In the meantime, I still think that there has to be a risk/benefit consideration in favor of least harm...

Also, from Current Medical Diagnosis and Treatment (one of my favorite books!) they do say "antimotility drugs may relieve cramping and decrease diarrhea in midl cases. Their use should be limited to patients without fever and without dysentery, adn they should be used in low doses because of the risk of producing toxic megacolon." "Anticholinergics (diphenoxylate with atropine) are contraindicated in acute diarrhea because of the rare precipitation of toxic megacolon."

Oh and just to check on myself, it states that pepto bismol reduces symptoms because of its antiinflammatory and antibacterial properties, and it also reduces vomiting associated with viral enteritis.