DiarrheaWang,KanDec31,2009GIDepartment,SRRSHDefinition:increaseoffluidityand/orfrequencyofstool(>3times/dor250g/d)Acute:≤14dChronic:>14dAcuteDiarrheaInfectious&toxicdiarrheaDietary:alcohol,foodallergy,mannitolMiscellaneous:diverticulitis,GIhemorrhage,ischemiacolitis,Henoch–Sch?nleinpurpura,Stevens–JohnsonsyndromeCluestodiagnosisofinfectious&toxicdiarrhea

CausativeagentSymptoms&HistoryCommentsBacilluscereusrefriedChinesefood,vomitingisprominent,bloodisneverpresentCampylobacterreactivearthritis,Guillain-Barresyndrome,Reiter’ssyndromeE.coliO157:H7contaminatedhamburgermeat,ShigatoxinprovokinghemolyticuremicsyndromeantibioticsandplatelettransfusionarecontradictedSalmonellaChicken,eggs,dairyproductsVibrioparahaemolyticusrawshellfishVibriovulnificusrawshellfish,especiallyinpatientswithunderlyingliverdiseasesironmetabolismdisorder.AssociatedwithskinbulleaShigella,YersinianocluesarestrongenoughtopointtheetiologyuntiltheresultsofstoolcultureScombroidspatientsingestingcontaminatedfishexperiencesvomiting,diarrhea,flushing,andwheezingwithinminutesorganisminvade,producingthenreleasinghistamineintocontaminatedfishViralchildrenindaycarecanter,absenceofbloodandWBCEntamoebahistolyticabloodymucusdiarrhea,abdominalcramp,fever,liverabscessdirectsmearCryptosporidiafoundinHIV+patientswith<100/mm3CD4cellsGiardiaunfilteredwater,bloodabsent,bloatingandgasGiardiacansimulateaceliacdiseaseintermsoffatandvitaminmalabsorption,ifnoteradicatedClostridiumdifficiledaystoweeksafterantibioticuse,C.difficiletoxintest.Metronidazole,oralvancomycinClostridiumperfringenwaterydiarrhea,abdominalcramps,distention.Fever/vomitingisuncommonAntibioticsarenotusedasaprimarytreatment.Clostridiumbotulinumcontaminatedcanfood,constipation,doublevision,slurredspeech,muscleweaknessC.Botulinumtoxintest,antitoxingent,AntibioticsarenotusedasaprimarytreatmentInfectiousdiarrheaalgorithmNathanetal,NEnglJMed.2004;350:38-47.Chronicdiarrhea-DiseaseofthestomachDumpingsyndromeMénétrierdiseasePerniciousanemiaZollinger-EllisonsyndromeDumpingsyndrome:post-gastroectomy,rapidhypertonicchymeintothedudenum,whichactsanosmoticdraw.Perniciousanemia:macrocyticanemia,neurologicmanifestation,glossitisDiseaseofthesmallintestineInflammatorydisease:IBD(CD),intestinalTB,radiationenteritisIntestinal

lymphomaIBSMalabsorptiondisease:Whippledisease,Celiacdisease,Tropicalsprue,Chronicpancreatitis,CTD,Amyloidosis,Intestinallymphangiectasia,IntestineresectionIBD:diarrhea,bleeding,abdominalpain,fever,weightlossScleritis,iritis,sclerosingcholangitis,arthritis,skinmanifestationColonoscopy,ASCA,ANCA,biopsy5-SAS,steroids,immunomodulator;CD:ciprofloxacin,metronidazole,imfliximabIntestinalTB:abdominalpain,diarrhea,constipation,fever,nightsweats,weightloss;PPD,Stierlinsign,colonoscopy(patentileocecalvalve),biopsyIntestinallymphoma:abdominalpain,diarrhea,weightloss;biopsyIBS:afunctionalGIdisorder;atleast12weeksinthepreceding12monthsofabdominaldiscomfortorpainLactoseintolerance:LactasedeficiencyDiarrhea,bloating,gas,noblood,leukocyteorweightlossIncreasedosmolargap(>50mOsm/kg),H2testRemovethedairyproducts,theresolutionofthesymptomswilloccursin24-36h.Chronicpanceatitis,celiacdisease,tropicalsprue,WhipplediseaseStethorrea,foulsmell,weightloss,VitA,D,E,Kdeficiency(hypocalcaemia,bruising),anemia(microcyticmacrocytic)Chronicpancreatitis:repeatedepisodesofpancreatitisCTscan,secretintestreplacementofdigestiveenzymesCeliacdisease:dermatitishepertiformisoccuresin10%ofthepatients.D-xylosetest,antigliadin/antiendomysial/antitransglutaminaseAb,biopsygluten-freedietMalabsorptionsyndromesTropicalsprue:historyofbeinginatropiccountryD-xylosetest,findingorganisminbowelwallbiopsySMZ,doxycyclinWhippledisease:dementia,arthalgia,ophthalmopelgiaD-xylosetest,findingorganism(Tropherymawhippelii)inbowelwallbiopsy,PCRSMZ,doxycycline,ceftriaxoneCTD:SLE,RA,Scleroderma,Beh?etdisease……Amyloidosis:amyloidproteinsbuildupinorgans;biopsy(Congoredpositivity)Intestinallymphangiectasia:proteinloss;thebiopsyshowsenlargementofthelymphvesselsIntestineresection:DiseaseofcolonUCCDDiverticulitisColorectalcarcinomaMiscellanneousAddisondisease,hyperthyroidism,Diabetes-MellitusEndocrinetumors(Zollinger-Ellisonsyndrome,carcinoidsyndrome,pancreaticcholerasyndrome)Post-cholecystectomysyndromeHypogammaglobulinemiaDrugs:antiacid,antibiotic,MRcontrastagent,laxativeAddisondisease:weakness,restlessness,hypotension,anorexia,abdominalpain,diarrhea,vomiting,hyperpigmentation;Cortrosyn-cortisolHyperthyroidism:T3,T4,TSHDiabetes-Mellitus:BGZollinger-Ellisonsyndrome:Abdominalpainanddiarrhea,intractablemultiplepepticulcerGastrinomaoftheduodenumorpancreasproducingthehormonegastrin(MENI,IIA,IIB)Carcinoidsyndrome:Neuroendocinaltumors(bronchi,appendix,ileum),whichreleaseserotoninDiarrhea,tachycardia,hypotension,flushing,rash,Urinary5-HIAAOtretide,surgicalresectionPancreaticcholerasyndrome:VIPomaoriginatesinthepancreas,producingvasoactiveintestinalpeptidechronicwaterydiarrhea,dehydration,hypokalemia,achlor