Dr Shubham Upadhyay

© Medi - Lectures Dr Shubham Upadhyay

OVERVIEW
• Introduction
• Classification of Diarrhea
• Small Intestinal vs Large Intestinal diarrhea
• Acute Diarrhea
• Toxin Induced
• Inflammatory
• Chronic Diarrhea
• Non- Inflammatory
• Inflammatory
• High Yielding points
© Medi - Lectures Dr Shubham Upadhyay
© Medi - Lectures Dr Shubham Upadhyay
© Medi - Lectures Dr Shubham Upadhyay
INTRODUCTION
• Passage of abnormally liquid or unformed stools at an increased
frequency
• Stool wt. >200 gm/day on western diet

© Medi - Lectures Dr Shubham Upadhyay

INTRODUCTION
• Passage of abnormally liquid or unformed stools at an increased
frequency
• Stool wt. >200 gm/day on western diet

• Pseudodiarrhea - ↑ Frequency + ↑Liquidity + wt. <200 gm/day

• Fecal Incontinence - Involuntary discharge of fecal contents (NM
disorders or structural anorectal problems)
• Overflow diarrhea - Due to Fecal impaction

© Medi - Lectures Dr Shubham Upadhyay

CLASSIFICATION
ACUTE PERSISTENT CHRONIC
<2 WEEKS 2 - 4 WEEKS > 4 WEEKS

© Medi - Lectures Dr Shubham Upadhyay

CLASSIFICATION
ACUTE PERSISTENT CHRONIC
<2 WEEKS 2 - 4 WEEKS > 4 WEEKS
USUALLY INEFCTIOUS USUALLY NON-
INEFCTIOUS

© Medi - Lectures Dr Shubham Upadhyay

SMALL vs LARGE INTESTINAL DIARRHEA
FEATURE SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA
Volume Large Small
Colour Light Dark
Smell Very Foul Foul

© Medi - Lectures Dr Shubham Upadhyay

SMALL vs LARGE INTESTINAL DIARRHEA
FEATURE SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA
Volume Large Small
Colour Light Dark
Smell Very Foul Foul
Nature Watery/greasy Mucoid
Steatorrhea Present Absent
Blood in stools Rare Common
Pus in stools Rare Common

© Medi - Lectures Dr Shubham Upadhyay

SMALL vs LARGE INTESTINAL DIARRHEA
FEATURE SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA
Volume Large Small
Colour Light Dark
Smell Very Foul Foul
Nature Watery/greasy Mucoid
Steatorrhea Present Absent
Blood in stools Rare Common
Pus in stools Rare Common
Abdominal pain Mid abdomen (colic) Lower abdomen (continuous)

Tenesmus Absent Present

Urgency Absent Often Present

© Medi - Lectures Dr Shubham Upadhyay

SMALL vs LARGE INTESTINAL DIARRHEA
FEATURE SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA
Volume Large Small
Colour Light Dark
Smell Very Foul Foul
Nature Watery/greasy Mucoid
Steatorrhea Present Absent
Blood in stools Rare Common
Pus in stools Rare Common
Abdominal pain Mid abdomen (colic) Lower abdomen (continuous)

Tenesmus Absent Present

Urgency Absent Often Present
Pathogens V. cholera, E. coli, Viral, giardia, Shigella, E. histolytica, U. colitis,
TB(ileum), Crohn’s disease(ileum)
© Medi - Lectures Dr Shubham Upadhyay
Rectal colitis
ACUTE DIARRHEA

© Medi - Lectures Dr Shubham Upadhyay

 ACUTE DIARRHEA
TOXIN INDUCED INFLAMMATORY DIARRHEA

© Medi - Lectures Dr Shubham Upadhyay

 ACUTE DIARRHEA
TOXIN INDUCED INFLAMMATORY DIARRHEA
↑ electrolytes + water secretion into the lumen Exudation in the lumen

© Medi - Lectures Dr Shubham Upadhyay

 ACUTE DIARRHEA
TOXIN INDUCED INFLAMMATORY DIARRHEA
↑ electrolytes + water secretion into the lumen Exudation in the lumen
PREFORMED TOXIN ENTEROTOXIN
• B. cereus (IP < 6 Hr) (IP 1 -2 days)
• S. aureus (IP < 6 Hr) • ETEC
• C. perfringens (IP 12-16 • V. Cholerae
Hr)

© Medi - Lectures Dr Shubham Upadhyay

 ACUTE DIARRHEA
TOXIN INDUCED INFLAMMATORY DIARRHEA
↑ electrolytes + water secretion into the lumen Exudation in the lumen
PREFORMED TOXIN ENTEROTOXIN MILD MODERATE SEVERE
• B. cereus (IP < 6 Hr) (IP 1 -2 days) (only mucosa) (submucosa) (deeper)
• S. aureus (IP < 6 Hr) • ETEC • Rotavirus • Salmonella • Shigella
• C. perfringens (IP 12-16 • V. Cholerae • Norovirus • C. jejuni • E. histolytica
Hr) • Y. enterocolitica

© Medi - Lectures Dr Shubham Upadhyay

• B. cereus
• 2 forms of food poisoning

IP 1-6 hrs IP 6-12 hrs

• Uncooked Fried rice (Chinese • Pudding, Meat balls, dried
Restaurant Diarrhea) potato
• Preformed toxin • Toxin formed inside small
• Vomiting predominant intestine
• Diarrhea predominant
Requires only conservative management

© Medi - Lectures Dr Shubham Upadhyay

• Staphylococcus aureus
• Preformed toxin
• IP: 1-6 hrs
• Pork, Canned meat, custard
• Vomiting- predominant symptom with abdominal cramps due to preformed
toxins (vagal stimulation)
• Fever, Hypotension - Never seen
• Diarrhea- rare
• No role of antibiotics

© Medi - Lectures Dr Shubham Upadhyay

• Enterotoxic E. coli
• MCC of
1. Traveller’s diarrhea
2. Community acquired diarrhea
3. Toxigenic Diarrhea
• Produces heat labile toxin (LT) --> ↑ cAMP

• EHEC produces O157:H7 (Shiga like toxin) --> HUS

© Medi - Lectures Dr Shubham Upadhyay

• Vibrio cholerae:
• Pathogenesis
• Toxin A - + cAMP (inhibits Na in villus cell + activates Cl in crypt cells)
• Toxin B - bind toxin receptor
• Clinical features
• IP 1-2 days
• Cholera gravis(severe form)
• Rice water stools
• Loss of K and HCO3 - Hypokalemia + Metabolic acidosis
• Treatment
• iv fluid of choice- Ringer lactate
• DOC- Doxycycline
• DOC in pregnancy- Azithromycin

© Medi - Lectures Dr Shubham Upadhyay

• Salmonella
RISK FACTORS CLINICAL FEATURES INVESTIGATIONS & TREATMENT
• ↓ stomach • Most prominent - Fever (>75%) • Blood Culture - 40-80%
acidity • Abd pain - 30-40% sensitivity
• IBD • Cough - 30% • >15 org/ml should be present in
• Antibiotic use • Diarrhea - 25% blood for culture to be positive
• Constipation - 15% • Bone marrow culture - 55-90%
• HSM - 5% positive (positive upto 5 days
• rose spots - 30% even after antibiotic use)
• GI bleed - 10-20% • culture of intestinal secretions
• Neurological - Muttering delirium or (Duodenal string test)
coma vigil
• meningitis, GBS
• Chronic asymptomatic carrier- 1-4%
© Medi - Lectures Dr Shubham Upadhyay
• DOC- Ceftrixone
• Campylobacter jejuni
PATHOGENESIS CLINICAL FEATURES & COMPLICATIONS INVESTIGATIONS & TREATMENT
• IP - 1-7 days • Prodrome followed by diarrhea • Darting motility
• Site - SI+LI • Pseudoappendicitis • Culture
• Crypt abscess

• Hepatitis
• GBS (20-40% cases of GBS) • DOC- Erythromycin
• Alpha chain disease • For systemic infection -
(Immunoproliferative SI disease) Gentamycin

© Medi - Lectures Dr Shubham Upadhyay

• Yersinia enterocolitica
• Causes multiple autoimmune reactions - Thyroiditis, Pericarditis,
Glomerulonephritis
• Pseudoappendicitis

© Medi - Lectures Dr Shubham Upadhyay

• Shigella
PATHOGENESIS CLINICAL FEATURES & COMPLICATIONS INVESTIGATIONS & TREATMENT
• Feco-oral route, • Watery diarrhea (enterotoxin at jejunal • Gold std- Stool Culture
sexual route level) • Blood culture <5% sensitive
• Inoculum size - • Dysentry (distal colon+rectum)
100 • Resolve within 1 week untreated
• DOC- Ciprofloxacin
• Toxic megacolon
• Rectal prolapse
• Perforation
• Hypoglycemia
• Hyponatremia
• HUS - S. dysentriae type 1
• Reactive arthritis - S. flexneri
© Medi - Lectures Dr Shubham Upadhyay
• Entamoeba histolytica
PATHOGENESIS CLINICAL FEATURES & INVESTIGATIONS & TREATMENT
COMPLICATIONS
• 10% world population • MC symptom- Diarrhea • PCR for DNA in stool samples
• 10% symptomatic • MC extraintestinal symptom - • Endemic areas- ELISA to detect
• Male> Female (less Liver abscess (mortality 1-3%) Entamoeba Ag
effective complement • Other complications - Toxic • Liver abscess- USG
mediated killing of megacolon, Amebomas,
amoebic Cerebral abscess
trophozoites) • Asymptomatic carrier -Luminal
• IP - 2-6 weeks agent(Ioqoquinol/Paromomycin)
• Flask shaped ulcers • Acute colitis - Metronidazole +
Luminal agent
• Liver abscess- Metronidazole +
© Medi - Lectures Dr Shubham Upadhyay
Luminal agent
ACUTE DIARRHEA - TREATMENT
REHYDRATION ANTIBIOTICS ANTIMOTILITY DRUGS
• Essential in all cases, Indications Indications: Moderate to
etiologies 1. Moderate to Severe Severe dehydration
• IV fluid of choice- ringer inflammatory diarrhea despite iv fluids eg
Lactate Any 1 out of 3 Oliguria
features:- Contraindication:
a.fever>101 F Moderate to sever
b. Blood in stools inflammatory diarrhea
c. Pus in stools ( risk of perforation)
2. Immunocompromised Drug : Loperamide
(HIV)
3. Prosthetic Valves
© Medi - Lectures Dr Shubham Upadhyay
© Medi - Lectures Dr Shubham Upadhyay
CHRONIC DIARRHEA
NON-INFLAMMATORY DIARRHEA INFLAMMATORY DIARRHEA

© Medi - Lectures Dr Shubham Upadhyay

CHRONIC DIARRHEA
NON-INFLAMMATORY DIARRHEA INFLAMMATORY DIARRHEA
• Secretory Diarrhea • Ulcerative Colitis
• Osmotic Diarrhea • Crohn’s Disease
• Malabsorption induced Diarrhea
• Dysmotile causes
• Iatrogenic Causes
• Factitial causes

© Medi - Lectures Dr Shubham Upadhyay

SECRETORY vs OSMOTIC DIARRHEA
SECRETORY OSMOTIC
MECHANISM ↑ electrolytes + water in lumen Due to osmotically active agent in gut

© Medi - Lectures Dr Shubham Upadhyay

SECRETORY vs OSMOTIC DIARRHEA
SECRETORY OSMOTIC
MECHANISM ↑ electrolytes + water in lumen Due to osmotically active agent in gut
CLINICAL • Watery (>10 lit/day)
FEATURES • Painless/Effortless • Painful
• Persist with fasting • Stops with fasting
INVESTIGATIONS Stool Osmotic Gap <25 mOsm/kg Stool Osmotic Gap >50 mOsm/kg

© Medi - Lectures Dr Shubham Upadhyay

SECRETORY vs OSMOTIC DIARRHEA
SECRETORY OSMOTIC
MECHANISM ↑ electrolytes + water in lumen Due to osmotically active agent in gut
CLINICAL • Watery (>10 lit/day)
FEATURES • Painless/Effortless • Painful
• Persist with fasting • Stops with fasting
INVESTIGATIONS Stool Osmotic Gap <25 mOsm/kg Stool Osmotic Gap >50 mOsm/kg
EXAMPLES 1. Hormone Hypersecretion 1. Laxatives (eg Lactulose, PEG)
2. Small Intestine resection 2. Lactose Intolerance
3. Alcoholics
4. SAIO
5. Chronic Shigella infection

© Medi - Lectures Dr Shubham Upadhyay

HIGH YIELDING POINTS
• Organisms sensitive to acidic gastric pH - Salmonella, Giardia,
Heminths
• Organism resistant to acidic gastric pH - Rotavirus
• Cruise ship diarrhea- Norovirus
• Salami diarrhea - EHEC
• Inoculum size
• Shigella, EHEC, Giardia, Entamoeba = 10-100
• Salmonella = 103 - 106
• Vibrio >105
• HUS --> EHEC>Shigella dysentriae
• Reactive Arthritis
• MC Worldwide - Chlamydia trachomatis
• MC India - Shigella dysentria

© Medi - Lectures Dr Shubham Upadhyay

• Bone marrow supression -Salmonella
• GBS - C. jejuni
• Toxic megacolon - Clostridium difficile
• Intestinal hmg. - Salmonella
• Small bowel lymphoproliferative disorder - Campylobacter

© Medi - Lectures Dr Shubham Upadhyay

QUESTION
• Which of the following drug use is most commonly implicated in
development of pseudomembranous Colitis?
1. Cephalosporins
2. Clindamycin
3. Amoxicillin
4. Fluoroquinolones

© Medi - Lectures Dr Shubham Upadhyay

© Medi - Lectures Dr Shubham Upadhyay