Gastroenterology - consultation - dr. Gergely Peskó SEMMELWEIS UNIVERSITY - Peskó
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Gastroenterology - consultation
dr. Gergely Peskó
SEMMELWEIS UNIVERSITY
Faculty of Medicine
3rd Department of Internal Medicine
Director: Professor Tamás MassziCase I. – source NEJM A 40 year-old man presented to the ER with a 6-week long andominal pain and diarrhea. The pain was epigastric at the begining and occured after eating. Than it became more constant and diffuse: 7/10. The diarrhea started gradually and was watery, 6-7x daily (including when the patient fasted, at night). It was associated with urgency and tenesmus. The stool was partially black, there was no fress red blood, it was not oily, foul smelleing or difficult to flush in the toilet. He lost 14kgs, but not his appetite. He has no fevers, night sweats, chest pain, cough, SOB, nausea, vomiting, dysuria, oral ulcerations or rashes.
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Voting is anonymousCase I. By definition diarrhea is defined as the passage of loose or watery stools, typically at least three times in a 24-hour period. It reflects increased water content of the stool, whether due to impaired water absorption and/or active water secretion by the bowel.
Case I. –chronic diarrhea Acute — 14 days or fewer in duration Persistent diarrhea — more than 14 but fewer than 30 days in duration Chronic — more than 30 days in duration Acute diarrhea most often caused by infections. Noninfectious etiologies become more common as the course of the diarrhea persists and becomes chronic. In developing countries, chronic diarrhea is frequently caused by chronic bacterial, mycobacterial, and parasitic infections, although functional disorders, malabsorption, and inflammatory bowel disease are also common. In developed countries, common causes are irritable bowel syndrome (IBS), inflammatory bowel disease, malabsorption syndromes (such as lactose intolerance and celiac disease), and chronic infections (particularly in patients who are immunocompromised).
Functional diarrhoe
The typical example is IBS: the symptom complex of chronic lower abdominal pain and
altered bowel habits remains the nonspecific yet primary characteristic of IBS. (Rome IV
criteria for IBS)
Rome IV criteria for IBS — According to the Rome IV criteria, IBS is defined as recurrent
abdominal pain, on average, at least one day per week in the last three months,
associated with two or more of the following criteria:
Related to defecation
Associated with a change in stool frequency
Associated with a change in stool form (appearance)
Most bowel movements are preceded by extreme urgency and may be followed by a
feeling of incomplete evacuation
Post-infectious IBS can occur following recovery from Clostridium difficile and other
bacterial infections
Large volume diarrhea, bloody stools, nocturnal diarrhea, and greasy stools
are not associated with IBS
Rather organic: weight loss of more than 5kgs, nocturnal diarrhea, GI bleeding, anemia,
hypalbuminemia, elevated inflammatory markersOsmotic diarrhoe Fecal osmotic GAP 290-2x(stoolNa+stoolK) >150msom is diagnostic luminal substances are responsible for the induction of the fluid secretion Typical: osmotic laxatives, sweeteners, CH/fat malabsobtion most common cause of carbohydrate malabsorption is lactose intolerance uncommon defects in carbohydrate absorption — including sucrase– isomaltase deficiency it is essential to determine whether steatorrhea is present Typically ceases with fasting!
Secretory endogenous substances (often referred to as “secretagogues”) induce fluid secretion that persists even when the patient is fasting Watery voluminousus stools with narrow GAP (
Inflammatory
The intestinal mucosa is distrupted by an inflammatory process
The hallmark is bloody stool (or melena) combined with systematic
symptomes (abdominal pain, fever)
IBD: ulcerative colitis and Crohn disease
Invasive infectious diarrhea (bloody, fecal leukocytes, lactoferrin)
When there is bloody diarrhea with few or no fecal leukocytes, stool should be
sent for evaluation for amebiasis, which can be diagnosed on stool by microscopy,
antigen testing, or molecular methodsSteatorrheic The absorbtion of fat in the small intestine is impaired Greasy, bulky, malodorous stool that floats in water and difficult to flush Typical: chronic pancreatitis, bacterial overgrowth, celiac disease
Differential diagnosis of chronic diarrhea
Don’t forget:
• IBS
• Overflow diarreaDDx of chronic diarrhea - bloody
Clinical exam RDV: rule out hemorrhoids and fissures
Type of diarrhea inflammatory
subtype infections IBD other
Clostridium difficile, Ulcerative colitis, Eosiniophilic
Mycobacterium, Crohn’s disease gastroenteritis,
Aeromonas, Chronic GVHD,
Pleisiomonas, Radiation colitis,
Campylobacter, Ischemic colitis, Colon
Yersinia, CMV, HSV, Cancer, Lymphoma,
Entamoeba Diverticular colitis
histolytica,
Strongiloides, Giardia,
Cryptosporidium,
CyclosporaDDx of chronic diarrhea - watery
Clinical exam Continues while fasting Normal osmotic gap Decrease while fasting
Low osmotic gap High osmolar gap
Type of diarrhea Secretory diarrhea Rome IV criteria met Osmotic diarrhea
no red flags
subtype
Mucosal malabsorbtion (celiac IBS, post-infectious Lactase deficiency
disease, bacterial overgrowth, irritable bowel syndrome Osmotic laxatives
Whipple’s disease, short gut Non-absorbable CH-s
syndrome)
Endogenous sectretagogues
(NET hormones, malabsorbtion
of bile acids)
Exogenous sectretagogues
(alcohol, stimulant laxatives –
Senna, toxins)
Endocrin disorders
(hyperthyreodism, Addison’s,
diabetic autonomic neuropathy)
Microscopic colitis
Chronic infectionsDDx of chronic diarrhea - fatty
Clinical exam Stool elastase < 200ug
Type of diarrhea Steatorrheal diarrea
subtype
Pancreatic insuffitiency
Bile-salt deficiency (hepatic
disease, disease of the
terminal ileus)
Mucosal malabsorbtion (celiac
disease, bacterial overgrowth,
Whipple’s disease, short gut
syndrome)Let’s see some examples for chronic diarrhoe!
44-year old woman who has diarrhea for several years reports fatigue
and weight loss. She got the diagnosis of osteoporosis and iron-
deficiency anemia.
A. Bacterial overgrowth
B. Celiac disease
C. Dumping syndrome
D. Giardiasis
E. Microscopic colitis
F. Whipple's disease
G. Zollinger-Ellison syndome
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started a session.Celiac disease Common cause of chronic diarrhoe Aberrant inflammatory response to gliadin (component of gluten) Resolves with removal of gluten from diet
60 year-old woman with hypothyroidism has profuse watery diarrhea,
sometimes nocturnal for the past year. She lost weight. No blood or
mucus in the stool. She takes high doses if ibuprofen for osteoarthriris.
A. Bacterial owergrowth
B. Celiac disease
C. Dumping syndrome
D. Giardiasis
E. Microscopic colitis
F. Whipple disease
G. Zollinger-Ellison syndrome
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started a session.Microscopic colitis chronic, inflammatory disease of the colon that is characterized by chronic, watery diarrhea, 50% nocturnal female predminance, with a mean age at diagnosis of 65 years At endoscopy the mucose seems to be normal, but biopsy reveals mucosal inflammation (always get a biopsy!) Two types: lymphocytic (intraepithelial lymphocytic infiltrate) and collagenous (colonic subepithelial collagen band) associated with celiac disease, autoimmune thyroiditis, type 1 diabetes mellitus, and nonerosive, oligoarticular arthritis autoantibodies are found in approximately one-half of patients (RF, ANA, AMA, ANCA, ASCA, TPO) should be advised to avoid nonsteroidal anti-inflammatory drugs Th: budesonide, cholestyramine, bismuth salicylate
26-year-old mother of healthy children of kindergarden age reports
having abdominal cramps, loose stool, flatulance and weight loss for 1
month.
A. Bacterial overgrowth
B. Celiac disease
C. Dumping syndrome
D. Giardiasis
E. Microscopic colitis
F. Whipple's disease
G. Zollinger-Ellison syndrome
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started a session.Giardiasis Giardia duodenalis (also known as G. lamblia or G. intestinalis) is a protozoan parasite capable of causing sporadic or epidemic diarrheal illness important cause of waterborne, foodborne, or fecal-oral transmissions in daycare center outbreaks, and illness in international travelers It has two morphological forms: cysts and trophozoites: Cysts are the infectious form of the parasite; following cyst ingestion, trophozoites are released in the proximal small intestine Trophozoites that do not adhere to the small intestine move forward to the large intestine where they revert to the infectious cyst form; these cysts are passed back into the environment in excreted stool Giardia can lead to acute and chronic diarrhea with malabsobtion and malaise: half of exposed individuals clear the infection in the absence of clinical symptoms 15 percent of individuals shed cysts asymptomatically 35 to 45 percent of individuals have symptomatic infection Acquired lactose intolerance occurs in up to 40 percent of patients
Small intestine bacterial overgrowth (SIBO)
colonic bacteria are present in increased numbers in the small intestine
can occur in association with anatomical abnormalities; motility disorders; metabolic and systemic
disorders; immune disorders
May lead to diarrhea, malabsobtion, abdominal pain, bloating, weight loss in patients
Carbohydrate malabsorption results from the intraluminal degradation of sugars by enteric bacteria. This leads to
the production of short-chain fatty acids, carbon dioxide, hydrogen, and methane.
Fat malabsorption results from bacterial deconjugation of bile acids and the toxic effect of free bile acids on the
intestinal mucosa. Hydroxylated fatty acids and free bile acids stimulate the secretion of water and electrolytes,
leading to diarrhea.
Protein malabsorption results from decreased mucosal uptake of amino acids and the intraluminal degradation of
protein precursors by bacteria. SIBO may also be associated with a reversible form of protein-losing enteropathy.
Deficiency in vitamin B12 results from utilization of vitamin B12 coupled to intrinsic factor by anaerobic bacteria.
The endoscopic appearance and histopathology of the small intestine and colon is normal in most patients
with SIBO
The diagnosis of SIBO should be suspected in patients with bloating, flatulence, abdominal discomfort, or
diarrhea, and is established with a positive carbohydrate breath test or jejunal aspirate culture
Oral antibiotics are effective in many patients: rifaximinDiseases causing diarrhea with skin manifestation Celiac disease: In patients with this condition, other autoimmune disorders, cancer, or dermatitis herpetiformis may develop. This symmetric, intensely pruritic, papulovesicular eruption appears on the elbows, knees, and trunk. The vesicles are often sparse or absent (as pictured), since patients typically scratch them off as soon as they appear, leaving excoriated remnants.
Case I. Patient has chronic, secretory, inflammatory diarrhea Medical history: Type-2 DM for 5 years Chronic back and neck pain for 20 years One time uveitis 3 years ago treated with steroids Nephrolithiasis Smoked for 30 years Meds: insulin, metformin, ibuprofen
Case II. Maybe: celiac disease, Whipple’s disease, IBD or colonoc ulcers due to NSAIDs Physical exam: Normal vitals – afebrile Tenderness to palpation in epigastrium Hemoccult positive stool decreased mobility of lumbar spine spondyloarthritis Back pain in a patient younger than 45 years, with insidious onset and duration for more than 3 months, accompanied by morning stiffness and improvement with exercise inflammatory back pain = axial spondyloarthritis Dg: sacroileitis + 1 clinical feature or HLA-B27 + 2 clinical features
Which is NOT one of the clinical features of spondyloarthritis?
A. enthesitis
B. uveitis
C. dactylitis
D. fever
E. IBD
F. response to NSAIDs
G. positive family history
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started a session.Case I. What is the diagnosis that gonna explain it all? chronic, secretory, inflammatory diarrhea (bloody) weight loss back pain nephrolithiasis
Given the patient's diagnosis of ulcerative colitis, which one of the
following conditions do not endanger him?
A. Hepatocellular carcinoma
B. Fatty liver disease
C. PBC
D. PSC
E. psoriasis
F. pyoderma gangrenosum
G. erythema nodosum
H. DVT The question will open when you
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started a session.Diseases causing diarrhea with skin
manifestation
Ulcerative colitis: The classic presentation of pyoderma gangrenosum is an
undermined leg ulcer, but the ulcer may occur anywhere on the body. Lesions
may appear in response to trauma and are often located near stomas or
surgical wounds. Pyoderma gangrenosum occurs in Crohn’s disease but is more
common in ulcerative colitis. Other causes include rheumatoid arthritis and
myeloproliferative disorders. Lesions respond to local or systemic
glucocorticoids
Erythema nodosum is also a skin manifestation of the disease:Case II. acute diarrhea A 43-years-old man seeks help at the doctor’s office: Past medical history: HTN, tonsillectomia Meds: ACEi+amlodipine No medical allergies. No tobacco. No alcohol. Present illness: diarrhea started yesterday: 5-6x small amount watery (nonbloody, nonblack), it waked the patient up; nausea but no vomitus; fever+chills (over 38.5Celisus); cramping abdominal pain; no xanthema; others have not developed diarrhea
Acute diarrhea diarrheal diseases represent one of the five leading causes of death worldwide most cases of acute diarrhea in adults are of infectious etiology dilemmas in assessing patients with acute diarrhea is deciding when to perform stool testing and if and when to initiate therapy most cases of acute diarrhea are due to infections and are self- limited most cases of acute infectious diarrhea are likely viral, as indicated by the observation that stool cultures are positive in only 1.5 to 5.6 Among those with severe diarrhea, however, bacterial causes are responsible for most cases
Try to guess the patogen
Characteristics (small or large bowel)
small bowel origin is typically watery, of large volume, and
associated with abdominal cramping, bloating, and gas, fever is
rare, occult blood/inflammatory cells/lactoferrin is rare
large intestinal origin often presents with frequent, regular, small
volume, and often painful bowel movements, fever and bloody or
mucoid stools are common, red blood cells and inflammatory cells
can be seen routinely
inflammatory signs associated with large bowel infection (fever,
bloody or mucoid stools) suggest invasive bacteria
(Salmonella, Shigella, Campylobacter), enteric viruses
(cytomegalovirus [CMV], adenovirus), Entamoeba histolytica, cytotoxic
organism such as C. difficile
Visibly bloody acute diarrhea is relatively uncommon, raises the
possibility of enterohemorrhagic E. coli (EHEC) (eg, E. coli O157:H7)
infection. Other bacterial causes of visibly bloody diarrhea
are Shigella, Campylobacter, and Salmonella (sometimes Yersinia)
species. Bloody diarrhea can also reflect noninfectious etiologies such
as IBD or ischemic colitis
syndromes that begin with diarrhea but progress to fever and
systemic complaints, such as headache and muscle aches:
typhoidal illness, infection with Listeria monocytogenesTry to guess the patogen
Food history: it is often difficult to know which food
exposure was the potential source, the timing of symptom
onset following exposure to the suspected offending food can
be an important clue to the diagnosis
Exposure to animals (poultry, turtles, petting zoos) has
been associated with Salmonella infection
Occupation in daycare centers has been associated with
infections with Shigella, Cryptosporidium, and Giardia
Medical history: recent antibiotic use (C. difficile infection),
other medications (such as proton pump inhibitors), past
medical history (immunocompromised host or the possibility
of nosocomial infection)
pregnancy increases the risk of listeriosis
cirrhosis has been associated with Vibrio infectionPatogenic mechanism Organisms that make a toxin in the food before the food is consumed. Consumption of the toxin-contaminated food will usually lead to the rapid onset of symptoms (6 to 12 hours) that are predominantly upper intestinal. (Staphylococcus aureus, Bacillus cereus emetic toxin, botulism) Pathogens that make toxin once they have been ingested. This usually takes longer (approximately 24 hours or longer), causes diarrhea that may be watery (Vibrio cholerae or Enterotoxigenic E. coli) or bloody (Shiga toxin-producing E. coli) Microbes that cause pathology by either damaging the epithelial cell surface or by actually invading across the intestinal epithelial cell barrier. Wide spectrum of clinical presentations: watery diarrhea (Cryptosporidium parvum, enteric viruses) to inflammatory diarrhea (Salmonella, Campylobacter, Shigella) or systemic disease (L. monocytogenes)
Foodborne? The incidence of laboratory-confirmed
cases per 100,000 persons in 2014 was
one in five episodes of diarrhea is likely to be due to a as follows (USA):
foodborne disease
Salmonella – 15.45
patient presents with gastrointestinal symptoms including
nausea, vomiting, abdominal pain, diarrhea and fever Campylobacter – 13.45
HOWEVER Shigella – 5.81
patients with foodborne illness may present initially with other Cryptosporidium – 2.44
complaints such as neurologic symptoms (eg, headaches,
paralysis or tingling), hepatitis, and renal failure Shiga-toxin producing E. coli, O157
– 0.92
What are the probable microbial causes of foodborne disease?
Shiga-toxin producing E. coli, non-
How do time course and types of symptoms serve as clues?
O157 – 1.43
How can a food history help to narrow the diagnosis?
Vibrio – 0.45
Listeriosis, Shiga toxin producing Escherichia coli, and
Yersinia – 0.28
nontyphoidal Salmonella are particularly associated with severe
morbidity Listeria – 0.24
Foodborne disease outbreak: 1. Norovirus (associated with leafy Cyclospora – 0.05
vegetables) 2. Salmonella (associated with poultry and beef)VOMITING AS THE MAJOR PRESENTING
SYMPTOM
Sudden onset of nausea and vomiting is likely due to the ingestion of a preformed
toxin - there is no risk of person-to-person spread.
Staphylococcus aureus – enterotoxin: symptoms usually begin within one to six
hours of ingestion with nausea, vomiting and abdominal cramps
toxin is heat-stable and is often associated with the consumption of foods prepared by a
food handler such as dairy, produce, meats, eggs, and salads; the food handler usually
contaminates the product [clinical dg.]
Bacillus cereus: capable of producing a heat-stable emetic enterotoxin in starchy
foods such as rice
rapid (within one to six hours) onset of nausea and profuse vomiting; self-limited
[clinical dg.]
Noroviruses (Norwalk-like viruses): major foodborne diseases that typically cause
vomiting as the predominant symptom
most common foodborne diseases and the most frequent cause of acute gastroenteritis
low infectious dose (around 10 particles); transmitted from the vomitus and the stool of
an infected person; usually transmitted from a food handler via food (salads,
sandwiches, fruit)
illness usually lasts for 48 to 72 hours with a rapid and full recovery but without long-
lasting immunity
diagnosis of several viruses (rotavirus, enteric adenovirus) can be madeWATERY DIARRHEA AS THE MAJOR
PRESENTING SYMPTOM
Many foodborne microbes cause watery diarrhea, the presence of this symptom
alone is of little help in the differential diagnosis. Organisms that produce toxins
once ingested typically have an incubation period of 24 to 48 hours.
Clostridium perfringens: spores of C. perfringens can germinate in foods
such as meats, poultry or gravy (large quantity needed); toxin is produced in
the host GI tract
psychiatric inpatient facilities: impaired intestinal motility caused by antipsychotic
medications
C. perfringens type C produces a beta toxin, which can cause enteritis necroticans
(pigbel)
Enteric viruses: norovirus, rotavirus, enteric adenoviruses, and astroviruses
Enterotoxigenic Escherichia coli: common cause of traveler's diarrhea [no
specific test]
both transmitted via fecal contamination of food or water from an infected person
Prepared food is therefore at the top of the list of likely sources for these
pathogensWATERY DIARRHEA AS THE MAJOR
PRESENTING SYMPTOM
Cryptosporidium parvum: 10 percent is foodborne
persistent chronic diarrhea in immunocompromised patients
endemic in cattle; acquired from contaminated water, fresh produce, unpasteurized milk or
person-to-person spread
Incubation period 7-28 days; dg: acid-fast staining of stools, immunofluorescence microscopy,
enzyme immunoassay
no current reliable therapy
Cyclospora cayetanensis : 90 percent is foodborne
fecally contaminated water, berries, fresh basil
diagnosis of C. cayetanensis is important because it is readily treatable with
trimethoprim/sulfamethoxazole
Intestinal tapeworms: Taenia saginata, Taenia solium, Diphyllobothrium latum
consumption of undercooked beef, pork and fishINFLAMMATORY DIARRHEA AS THE
MAJOR PRESENTING SYMPTOM
Presence of inflammatory cells or a marker of inflammatory cells, such as fecal lactoferrin, defines
an inflammatory diarrhea
Clinical clues: diarrhea with blood or mucus, severe abdominal pain, fever
Statistically the most likely pathogens in patients with inflammatory diarrhea
are Salmonella or Campylobacter
Salmonella: divided into two broad categories: those that cause typhoid and enteric fever and
those that primarily induce gastroenteritis
typhoidal Salmonella, such as S. typhi or S. paratyphi primarily colonize humans, are
transmitted via the consumption of fecally contaminated food or water, and cause a systemic
illness usually with little or no diarrhea
nontyphoidal Salmonella are found in the intestines of other animals and are acquired from the
consumption of products that have become contaminated with animal feces. Associated withraw
meat, poultry; foods such as fresh produce (sprouts, hot peppers, tomatoes, lettuce, melons);
spices such as black and white pepper, peanut butter, chocolate and dried milk; egg
incubation period for non-typhoidal Salmonella is usually one to three days, and the diagnosis is
undertaken with routine stool culturesINFLAMMATORY DIARRHEA AS THE MAJOR PRESENTING SYMPTOM Campylobacter: Campylobacter jejuni accounts for the vast majority of foodborne campylobacteriosis, with Campylobacter coli responsible for most of the remainder incubation period usually ranges from two to five days, and poultry is a frequent source of the organism diagnosed using routine microbiologic techniques on selective plates Shiga toxin producing E. coli (also known as enterohemorrhagic E. coli (EHEC)): most frequent cause of acute renal failure in children in the United States. associated with diarrheal disease as well as the hemolytic uremic syndrome (HUS) found in ground beef, unpasteurized juice, raw fruits and vegetables incubation period ranges from approximately one day up to a week, usually begins with watery diarrhea that becomes bloody STEC can be diagnosed using Shiga toxin based assaysimportant therapeutic implications, since data indicate that antibiotic treatment of STEC-infected patients may increase the risk of developing HUS
INFLAMMATORY DIARRHEA AS THE MAJOR PRESENTING SYMPTOM Shigella: only colonize humans and some nonhuman primates; therefore, transmission of Shigella in food or water is most likely from either fecal contamination or direct contamination from a food handler foods have been implicated in the spread of Shigella, including salads , raw vegetables, milk and dairy products and poultry, as well as common-source water supplies isolated routinely in clinical microbiology laboratories Vibrio: raw shellfish in the proceeding 48 hours and develop diarrhea should be cultured for Vibriospp. Most likely organism is V. parahaemolyticus laboratories do not routinely culture for any Vibrio spp Yersinia: unusual cause of foodborne disease that will cause an inflammatory diarrhea is Yersinia enterocolitica consumption of undercooked pork, unpasteurized milk, or fecally contaminated water
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