Pain
Pathophys of Diarrhea
Abd Pain Diag
Diarrhea Diag
Treatment
100
This pain is localizable because it is due to irritation of myelinated fibers.
Parietal pain
Chpt 71, page 473
100
These two portions of your GI tract are responsible for the absorption of fluid from what you eat.
Jejunum and the Colon
Chpt 73, page 484
Jejunum absorbs 75% of the fluid it is exposed to, while the Colon absorbs 90% of the fluid it is exposed to. The Jejunum absorbs the most overall, but the colon is actually more efficient.
100
Most critically ill patients with abdominal pain should receive these lab tests at a minimum.
Electrolytes, BUN, Creatinine, CBC;
If Hemorrhage is a factor: aPTT, PT-INR, type/screen
Chpt 71, page 474
100
Abdominal pain and voluminous, mucoid diarrhea are concerning for these pathogens.
Vibrio cholerae and Enterotoxic E. coli (ETEC)
Chpt 73, page 485
Travel to Central and South America raises the likelihood of ETEC (Montezuma's revenge)
Travel to lower socioeconomic countries in Asia and Africa raises the likelihood of Vibrio (Cholera)
100
This class of drug is important in the initiation of remission of a Crohn's flare.
Hydrocortisone 300mg, methylprednisolone 48mg, or prednisolone 60mg per day.
Chpt 73, page 490
Crohn's is an autoimmune disease, so blunting the immune system to reduce the overall response and thus the disease severity makes sense.
200
Intermittent or constant, this pain is caused by stretching of unmyelinated fibers.
Visceral Pain
Chpt 71, page 473
200
Laxatives such as PEG, Lactulose, and Milk of Magnesia work by essentially causing this type of diarrhea.
Osmotic (increased osmotic load)
Chpt 73, page 485
The osmotic load is increased to a point where it is not easily digestible; this osmotic load attracts water into the lumen, causing increased bowel movement.
200
Patients are significantly less likely to have opportunistic infections with a CD4 count above this value.
200/mm3
Chpt 71, page 474
(diarrheal opportunistic infections include diseases such as cryptosporidium and CMV colitis)
200
Microscopy or antigen assay is necessary for diagnosis of this pathogen.
Entamoeba histolytica
Chpt 73, page 486
(it’s a protozoan)
200
Infectious diarrhea can be treated with these agents in addition to Abx and rehydration.
Loperamide or other anti-motility agents
Chpt 73, page 486
Loperamide and antibiotics improve outcomes. Specifically, Abx shorten disease course by about 24 hours, and loperamide shortens the duration of symptoms and therefore lessens fluid losses.
DO NOT USE loperamide in bloody or inflammatory diarrheas, as this can set the patient up for prolonged fever, toxic megacolon, or HUS depending on the pathogen of concern.
300
This type of pain is expressed along embryological segmental regions.
Referred pain (ex: ureterolithiasis, groin trauma)
Chpt 71, page 477
300
One of the 4 mechanisms of diarrhea, this type is most commonly due to unopposed crypt functionality and blunted villi within the small intestine.
Secretory diarrhea (increased intestinal secretion)
Chpt 73, page 484
(Villi are more susceptible to damage by diarrheal states, inflammation, ischemia, and enterotoxins; crypts are more resilient. Because of this, both contribute to cause secretory diarrhea)
300
The operator-dependent discriminatory zone, above which it is possible to see a gestational sac.
β-HCG >1500mIU/mL
Chpt 71, page 477
(Ectopic Pregnancy is an important part of the abd pain differential of any female of childbearing age.)
300
C. diff toxin assay has excellent sensitivity and specificity rates, but is problematic due to this statistical feature.
10% false-positive rate
Chpt 73, page 488
It has 71%-100% sensitivity and 73%-100% specificity with 1-hour turnaround, but due to its significant false positive rate, care must be taken when using it in your diagnostic plan.
300
This treatment for C. diff is an important step, but only works 20% of the time.
Stopping the patient's antibiotic if they are taking one.
Chpt 73, page 488
Tint's quotes a study that ranked cephalosporins, clindamycin, carbapenems, TMP/SMX, fluoroquinolones, and PCN combinations as the most frequent offenders.
400
Early appendicitis and Mesenteric ischemia are examples of this type of pain.
Visceral pain
Chpt 71, page 473
400
Oral rehydration solutions containing glucose are recommended largely due to this physiologic concept.
Active absorption of water during glucose absorption.
Chpt 73, page 484
400
CT abd/pelvis with Rectal contrast is useful for this focused question (diagnosis)
Distal large bowel obstruction
Chpt 71, page 477
(Knowing other routes of contrast usage is useful in a patient who cannot receive IV contrast)
400
Severe abdominal pain, fever, and bloody diarrhea are concerning for these 7 pathogens.
Shigella, Salmonella, Campylobacter, EHEC, Yersinia Enterocolytica, Entamoeba histolytica, or C. Difficile.
Chpt 73, page 485
You'll need stool samples.
*Wright's stain has fallen from favor as the test of choice.
400
This agent has replaced metronidazole as the treatment of choice for C. diff treatment.
Fidaxomicin 200mg PO BID for 10 days
Chpt 73, page 488
(Narrow-spectrum bactericidal macrolide that is minimally absorbed into the bloodstream and has little effect on normal gut flora; outperforms both metronidazole and and Vancomycin specifically against C. Diff)
500
Periumbilical pain can be present due to any of these 7 structures
3rd/4th part of the duodenum, the jejunum, Ileum, Cecum, Appendix, Ascending Colon, and first 2/3 of the Transverse Colon.
Chpt 71, page 473
TABLE 71-1
500
These four are significant but less common causes of severe diarrhea.
GI bleeding, Thyrotoxicosis, Toxins, and Mesenteric Ischemia.
Chpt 73, page 485
Good to know, but are detailed elsewhere in the text.
500
70 y/o F with RUQ pain, vomiting, diaphoresis, and hypotension should get this non-radiographic study as part of her workup.
EKG
Chpt 71, page 475
(always consider a Cardiac cause in the differential of upper abdominal pain in elderly patients)
500
When diagnosing a patient with Crohn's, these other causes of abdominal pain should be ruled out.
Infection, perforation, obstruction, abscess, hemorrhage, or Toxic megacolon
Chpt 73, page 489
(not an exhaustive list)
Crohn's pts often come to the ED with a diagnosis already made, but you may be the first clinician to start the work-up of undiagnosed patients.
500
Crohn's and UC treatment centers around these three main concepts.
Symptomatic relief, prevention of complications, nutrition maintenance.
Chpt 73, page 490
Diarrhea can be controlled with loperamide, diphenoxylate, or cholestyramine. Rule out toxic megacolon, obstruction, or perforation. Replace lost electrolytes and adequately rehydrate the patient.