Diarrhoea - Hyperexcision

Last updated: November 10, 2024

Table Of Contents

Overview
Acute Diarrhea

Overview

Diarrhoea is defined as increased volume or frequency of stool, generally of a more liquid consistency

Three or more loose liquid stools per 24 hours, and/or
Stools that are more frequent than what is normal for the individual, and/or
Stool weight greater than 200g/dL

Has a number of causes. Most are idiopathic/viral. The most important first step in managing a patient with diarrhea is to assess the fluid status of the patient. Hypotensive patients should get a normal saline bolus. Infectious causes should always be ruled out in acute diarrhea

Classification	Timeline
Acute	< 2 weeks
Persistent	> 2 weeks
Chronic	> 4 weeks

When to admit a patient with diarrhea
- Hypotension or orthostasis
- Severe pain
- Fever
- Abdominal tenderness
Outpatient treatment of diarrhea
- Remind the patient the importance of adequate hydration
- Gatorade, Pedialyte, and other isotonic drinks are preferable to water (but any hydration is better than none)
- Basic food safety education
- Return to the clinic if diarrhea has gone on for more than 2 weeks

Acute Diarrhea

Determine whether or not the diarrhea is bloody.

Investigations
- Stool studies
  - Stool lactoferrin (WBCs)
  - Stool RBCs
  - Ova and Parasites (O&P) or Giardia antigen
  - Culture
  - Stool PCR
  - C. diff toxin
  - Stool osmotic gap (normal btw 50-100 mOsm/kg)
  - Fecal fat
- Complete Blood Count
- BMP
- Blood cultures

Infectious Bloody Diarrhea

Has a + stool lactoferrin. Most cases are self-limited. Note for ischemic bowel disease in older patients (Pain will be a prominent symptom, needs abdominal x-ray)

Causes of bloody diarrhea
- Salmonella (MCC: poultry, eggs, and milk)
- Campylobacter (MCC: poultry, eggs, and milk; ass with Guillain-Barre syndrome, Reactive arthritis)
- Shigella
- Yersinia
- Enterohemolytic Escherichia Coli (EHEC)
- E. coli O157:H7 (Ass with HUS; never ever ever ever give antibiotics or platelets)
- Entamoeba histolytica
- Vibrio parahemolyticus (associated with shellfish consumption)
- Vibrio vulnificus (associated with patients with liver disease or high iron state)
Treatment if the patient is stable
- Observation and fluid replacement
Treatment if the symptoms are severe
- PO Ciprofloxacin (or another fluoroquinolone) +/- Metronidazole
- Doxycycline (If history points to V. vulnificus)
- DO NOT use antibiotics in patients with HUS

Infectious Non-bloody diarrhea

Has a negative stool lactoferrin. Again, most cases are self-limiting

Causes of non-bloody diarrhea
- Viral (Rotavirus, Norovirus)
- Giardia (associated with camping, consumption of (+O & p or + Giardia antigen) stream water, oral-anal sexual contact, severe bleeding )
- Bacillus cereus (associated with reheated fried rice, vomiting + diarrhea)
- Staphylococcus aureus (associated with dairy, coleslaw, picnics, vomiting + diarrhea; little mini outbreaks)
- Clostridium perfringens (associated with meat that has been sitting out too long)
- Listeria monocytogenes (deli foods, increased incidence in pregnancy)
- Cryptosporidium (associated with HIV CD4 < 100, high ALP, acid fast +)
- Isospora belli (associated with HIV CD4 < 100, high eosinophil, acid fast +)
Treatment if the patient is stable
- Observation and fluid replacement
Treatment if symptoms are severe
- PO Ciprofloxacin (or another fluoroquinolone) +/- Metronidazole
Treatment of a pregnant woman with severe symptoms
- IV Ampicillin
Treatment if the patient has AIDS
- HAART to get CD4 count up > 100
- TMP-SMX if isospora belli
- DO NOT use antibiotics in patients with HUS

Antibiotic-associated (Clostridiodes difficile)

Very common in hospitals. Due to overgrowth of C. difficile in large bowel. Any antibiotics can precipitate it but Clindamycin tends to be a common one.

Patient history
- Patient is on antibiotics and presents with diarrhea
Investigations
- C. difficile toxin: Positive
Treatment
- PO Metronidazole
Treatment if symptoms abate and recur
- Re-treat w/PO Metronidazole
Treatment if symptoms do not abate after 2 days
- PO Vanomycin
Complications of C. diff
- Toxic megacolon
- Perforation

Lactose intolerance

Human breast milk contains lactose, which is normally digested into glucose and galactose by a brush border enzyme lactase. In most populations, lactase activity declines throughout childhood. Usually, lactase deficiency is asymptomatic. However, in some, it may cause colicky pain, abdominal distension, increased flatus, borborygmi, and diarrhea after ingesting milk or milk products.

Primary lactase deficiency
- Genetic
- Jejunal morphology is normal
Secondary lactase deficiency
- Occurs due to a disease process that damages the jejunal mucosa eg. celiac disease, viral gastroenteritis
Diagnosis
- Clinical: Patient shows improvement after dietary lactose withdrawal.
- Lactose hydrogen breath test
Treatment
- Dietary exclusion of lactose

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

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