what's up Ninja nerds in this video today we're going to be talking about diarrhea this is a part of our clinical medicine section if you guys like this video it helps you it makes sense please support us and some of the ways that you guys can do that is by hitting that like button commenting down the comment section and please subscribe also really urge you guys if you have the opportunity please do so which is going to be go down in the description box below click on the link that'll take you to to our website when you go to our website there's a lot of cool stuff that we offer here that I think will really augment and help and aiding in your learning process so we offer things like notes illustrations quizzes or even developing exam prep courses and so much more so go check it out if you have the time all right without further Ado though let's talk a little bit about diarrhea so we're going to do this in kind of a couple parts first thing is I want to talk about diarrhea within the acute setting so a patient comes in with acute diarrhea we'll talk about well we'll Define it now it's pretty straightforward in the sense that you have to have at at least three or more loose stools right per day for at least 2 weeks in duration all right we say at least less than two weeks in that particular scenario because if you cross over that two we barrier then you're into the chronic diarrhea so again we say greater than three or more loose stools per day for less than a two we duration that's a cute diarrhea but then when we take a patient who comes in they're saying hey Doc I've been having diarrhea for a couple days now and it's been pretty intense you have to then kind of create a framework in your head and I think the Frameworks that you should start thinking about is is this an acute non-inflammatory or secretory diarrhea or is it an acute inflammatory diarrhea this is really important all right the reason why is in a patient who has an acute non-inflammatory diarrhea often times these would just kind of get better on their own you just kind of give them support of care with fluids Etc and just hopefully they'll get better and they usually won't require any treatment the the concept the pathophysiology though behind a patient developing acute non-inflammatory diarrhea is interesting the location of the actual git that's most commonly affected is going to be the small bowel so this is the area here I'm just representing a piece of it but that's the ilium but it could be the ilium the Jenum or the duodenum so I think the big thing to remember for acute non-inflammatory diarrhea is you're going to have what's called small bowel involvement and I think right away this should hint to the way that these will present now the small bowel is primarily responsible for absorbing most of your nutrients it absorbs a decent amount of volume of things as well so if you damage the small bowel right you injure it for whatever particular reason you're going to affect absorption pretty significantly and whenever you have a massive decrease in absorption and plus a lot of that is actually getting pulled into the bowel but I really want you to think about decreasing absorption to make it easier for yourself massively decreased absorption one of the problems is that you have a intensely voluminous stool right so whenever there is decreased absorption it's not going to be moving from the small bound to the bloodstream it'll continue to Transit through the small bow eventually into the large bow the large bow will try its best to absorb some of those things like water and liquids but it won't be able to do as good enough a job and so one of the things about this stool is this stool is going to be super voluminous and extremely watery all right so that's one of the big things I think that's really helpful here is that this is going to be more of a let's term this a watery but let's kind of use this term high volume stool so you're going to be like peeing out your butt right and I think that's really one of the best things to remember here with these patients that they're going to have very heavy voluminous watery appearing stools that usually indicates small bound involvement now if we take this at the macroscopic view and say okay there's injury here we're not absorbing things I get that that's basic physiology but if I take and say how exactly is this happening a little bit the microscopic level I can go into that so one of the big things about acute non-inflammatory diarrhea is that the actual pathogens that are causing this they don't directly damage the mucosa so that's really important to remember is that there's no direct mucosal damage right right that's really important so let's actually write that down there's no direct mucosal damage all right what happens which is super kind of like cool in the sense is that these pathogens over here that we'll talk about what they do is let's actually just represent one here we'll do it in this kind of color here let's say here is a pathogen and we're just going to use the bacteria as an example here what it does is it releases something called an OT Toxin and there's so many of we're not going to focus on every type of OT toxin here but they can release these things called OT toxins and OT toxins what they'll actually do is they'll act on these mucosal cells and when they act on these mucosal cells what's really kind of cool about this is they activate specific channels that are present on these cells so imagine here I just kind of highlight a couple channels here on these these channels are super sensitive to these inter toxins and it'll activate like these different second messenger systems which is kind of cool but a little bit too deep Beyond this kind of concept so I won't go into it but the whole point is that you'll stimulate these things and what will happen is they'll drag things out into this particular area so these cells would begin to secrete things into the Lumen and that's what's really interesting you're not damaging them and per se you're causing them to become kind of utilized by these anxin and say hey secrete things and what it does it secretes things like sodium and potassium and chloride and lots and lots of water and so if I'm secreting a ton of these particular things what do you think is going to happen to the actual volume of my stool if I'm containing lots of water and electrolytes it's going to be pretty intense right because first off these are going to be hindered in a way that you can't absorb but on top of that you're going to have a significant degree of secretory activity so that's why oftentimes we call this type of diarrhea a increased secretory type of function or an increased secretory type of activity that's why it's sometimes also referred to as a secretory diarrhea all right but there's no direct mucosal damage in that sense it's just this is really kind of impairing absorption by kind of shutting these mucosal cells down and telling them hey SEC create a bunch of different things so it's kind of interesting now the question then comes okay if there's not direct mucosal damage OT toxin mediated lots of these where are these OT toxins coming from well it's coming from the pathogen right and that's something that we have to be able to talk a little bit about so there's a couple of these different types and I think some of the big ones that we're going to hit here um I think you should definitely take some time to try to memorize so I think one of them should be staf lakus arus and I think one of the particular things that may kind of cue you off uh to think about this one is think about picnics and I'll explain what I mean by that in just a second so in picnics you're having a lot of family members who bring over potato salad and things that are rich in mayonnaise and it sits out in the baking sun a lot of the time that's a potential ntis for lots of staf cocas orus they release these pre-formed toxins and you can get pretty bad vomiting and diarrhea pretty quickly another one is called basilis serus and I want you to think about right R so usually in people who eat a lot of rice and then they go and they preheat the rice sometimes this is just one of those bacteria that can sit in that rice a lot and can cause again this acute diarrhea along with vomiting Associated within the couple hours after eating it another one really high yield one is called OT toxen eoli this is a really big one that people often hear this is like traveler's diarrhea in the sense of Mont Zuma's Revenge so this is a really big one when those people who go and they go and travel they go to Mexico they drink some of the water they eat some of the food and they end up with this terrible terrible diarrhea that's a really really common one another one would be uh vibrio so vibrio chera is another one that I don't want you guys to forget as well this one's definitely associated with travel as well um and usually one of the key terms or buzzword that you'll kind of think about with this one is you hear that word rice water kind of stool tools heavy voluminous stools usually this is more of kind of an endemic so you'll definitely see this in kind of more of those third world country areas where it's less fortunate but I'd say that these are some of the big ones to potentially think about as anoxygenic types of causes now with that being the bacteria the other ones are viruses and these are often times pretty much the most common cuz they they're pretty self-limiting and I think they're going to be ones that you'll definitely see on the exam in some way shape or form one is called the noro virus and I want you to think when you hear norovirus think about cruise ships this is usually one of those where people are on these cruise ships they're either kind of coming in contact with another person who has that or there's it's in the water it's just one of those common areas where this can get passed pretty quickly another one is called the Roa virus and this one is a virus that I think is best to remember in dayc carees so it's us usually in kids who kind of pass this along they touch particular things after they've touched their you know their Boo Boo Boo and then they go and they kind of pass that along via the foamite so that's a big one to also remember daycares the next one is parasites and I think there's two that I really would want you guys to try to consider one is called Giardia and Giardia is one of those I want you to remember river water this is like also sometimes they call Beaver fever so this is one of those where Giardia is a very nasty protozoa that sits within river water and if people kind of ingest that they can definitely get this and get some really nasty diarrhea the other one that I would also want you guys to consider here would be uh cryptosporidium so this would be the other one I want you guys to remember is called crypto sporium now cryptosporidium is interesting in the sense that you have to be immuno compromised to really get get this one and I really want you guys to just associate this with AIDS patients with a CD4 count that's usually less than 100 that usually can tip you off in some way that this patient's imuno compromised in some way shape or form and they've encountered this usually um in an unfortunate way usually this can be potentially travel foodborn contact a lot but you need to be imuno compromised because it's an opportunistic infection but with that being said we kind of have an idea here about this particular process one thing I want you to understand though is that do you see any white blood cells here no there's no break in the mucosa that's causing these cells to be directly damaged so because of that one thing I really want you to understand here is that we kind of use this as a diagnostic test there is no fecal white blood cells and there's no chemical that these feal white blood cells release so there's no feal white blood cells and no molecule they release so write this down no feal white blood cells and no chemical that they release called feal Cal protectin all right and this is a chemical that's usually released by these particular types of feal white blood cells and then lastly do you see any blood that's present in the stool did we break the mucosal barrier and cause this Blood to leak in no so there should be no blood within the stool as well now take that with a grain of salt um and the reason why is sometimes when people have diarrhea they wipe and they wipe and they wipe and then they kind of create like these little areas of hemorrhoids or irritated tissue that they can have blood that doesn't mean that there's actually blood coming from their stool though it's just from them wiping aggressively all right that covers the first part here of the diarrhea the second part here is again same patient they come in they're saying hey Doc I've had three or more loose stools within a day for couple days as long as it's less than two weeks and then you say okay could it be acute inflam non-inflammatory or could it be acute inflammatory and I think one of the questions is does your stool look bloody does it look mucousy right have you had high voluminous types of watery stools or have you had the next one and so in this one small bowels preserved that's not the issue it's usually the colon and it's usually more the descending colon um more than anything that gets hit you might get a little bit of the be the last part of the transverse colon but you're going to get really large colon involvement or large intestine involvement so with this being said what you're going to see here is you're going to see colon involvement now with that being said because there's colon involvement it's not going to be this helps to reabsorb just a little bit of or absorb a little bit of water from the stool not a ton the interesting thing with this one is that the stool and we'll explain why in a second is going to be bloody right and it's going to be mucoid which means it's going to have like some mucus kind of look to it so it's going to look kind of stringy if you will and have some bloody tinge to it but it won't be like high volume right and I think that's the important thing to remember because you preserve the small intestin in this one so when you hear this term bloody mucoid diarrhea or stools you think of a very special term that we often utilize here and it's called dentary and so whenever you hear the term dentary thinking about Bloody mucoid containing stools because of colon involvement but preserved small intestine involvement now we talked about how this was related to absorption this isn't really related to absorption why am I having bloody mucoid stools here I'll explain and this scenario you're actually having pathogens I'll just represent it here in this again same kind of concept they may they very well may be releasing terot toxins that's definitely possible with a lot of these they do that but they're often causing direct mucosal injury and damage so do you see how this guy is all jacked up this one's all jacked up right so you're definitely getting heavy heavy muc mucosal damage now when you damage the mucosa you alter the barrier here right first off you're going to cause damage it's going to trigger an inflammatory reaction so when you trigger an inflammatory reaction what kind of cells are going to come to the area white blood cells and they're going to try to come into the Lumen to fight off whatever is causing this and so what often ends up happening here is that you're going to get a ton of these feal white blood cells and these are essentially kind of like your neutrophils if you will and they're going to be like okay I got to come into this area and I got to try to help out and so what they'll do is they'll often move through the bloodstream and they'll kind of come out here into the loom in a little bit and so that's one thing and all right they'll try to fight off some of this but what's going end up happening is they're going to propagate more inflammation when you propagate more inflammation you know there's these special cells here I'll kind of squeeze one in here let's do it right here here you have a cell it's called a goblet cell they're kind of naturally there and whenever there's lots of inflammation they hate inflammation and what they'll do is they'll start secreting a lot of mucus so here this go cell is spitting out a bunch of mucus in response to a lot of this inflammation into this area so you're going to get a lot of mucus because of the inflammation you're going a lot of white blood cells but also have you damaged the barrier here yeah so what else can start kind of leaking out here if you continue to cause more damage you can start having blood leak out here so now I'm going to have mucus I'm going to have blood and I'm going to have a lot of feal white blood cells out here so I'll notice that there's going to be lots of mucus because of like inflammation direct inflammation lots of blood because of again mucosal damage and then on top of that I'm going to have lots of feal white blood cells and then with lots of fecal white blood cells what do those bad boys release they release a lot of what's called feal calprotectin and so what should happen to the feal calprotectin levels they should go up as well and so you're kind of noticing here that in this one no blood no FAL Cal protected no FAL white blood cells here feal white blood cells FAL Cal protect in Blood and again that mucous appearance and again this is what's giving lending to this bloody mucoid appearance of the diarrhea all right and again it's not usually a high volume and I think that's one of the other big things to be able to remember remember so the question then arises okay if these are causing direct mucosal damage which is leading to all this kind of Downstream Cascade causing particularly colon involvement not small intestin involvement disiner kind of appearance of my stools what are the potential pathogens that would directly cause this damage and there's a lot of them so I think some of the ones that I want you guys to remember here is going to be salmonella and I think a lot of you guys know this just in General it's going to be undercooked like poultry or eggs and things like that so I just want you to remember that it's going to be more food born all right but I think the the key thing is here I'll just put down some type of poultry or again could be undercooked like eggs as well another one would be shagel all right shagel is a really scary one um and the reason why shagel again it can be related to travel and it can be related to food born usually poultry as well but this one man it can release toxins and it can cause direct damage all right another one is going to be um you have another one called camp abactor and Camp abactor is another nasty one as well and again I would go with the the fact that this is again more of a foodborn one often times the test question that comes up with this one is campor is linked to that gon Beret syndrome but again we're not going to go to crazy down that rabbit hole the next one that I want you guys to remember is going to be I think probably one of the big ones this is called EHC so Intero hemorrhagic ecolar 01757 right uh this one is really nasty and this is usually again this is foodborn and this is one of those that can really wreak a lot of havoc on the body this can cause what's called hemolytic aric syndrome and so can this one as well but definitely scary one to remember here um another one that I would actually NE definitely want you guys to not forget here um I think it's probably one of the likely ones that you'll get tested on in some way shape or form we're going to have a special lecture on this by itself but it's going to be claustrum defiler often kind of termed CI and the big thing to remember about this one is think about antibiotics has the patient been on any recent antibiotics this is usually a cause and it kind of triggers this kind of like process to occur all right the last thing is going to be parasites and parasites usually for these the ones that I would want you to remember here there's really only one specific one um it's a really nasty one it's super scary if you ever get it it's called inba histolytica and this one again is more travel it's more of that like river water type of a kind of things that you can got to become exposed to it's a nasty nasty amoeba that can cause a lot of problems but I definitely don't want you guys to forget this one so if a patient comes in and they have this mucoid bloody diara I want you to think okay how would I tell is there blood feal white blood cells and a mucous appearance of their stool think about these particular pathogens and think about the organ that's most commonly affected within the git if I think about acute non-inflammatory type but they're coming with a volume that's really really high it's watery appearance it's likely affecting the small bowel within region and think about these particular pathogens in this scenario and again think that this is not going to have inflammatory markers that I'd see here all right with that being said that covers the acute diarrhea what about the patient who has more than three loose stools per day for greater than two weeks now we're in the chronic diarrhea Camp let's talk about that all right my friends so now if a patient comes in and they have the chronic diarrhea picture right so they've been having at least greater than three or more loose stools per day for more than two weeks more than 14 days we're in that chronic diarrhea camp and I think the best thing to do is to start asking yourself the question okay if it's not acute diarrhea so it's not the non-inflammatory or inflammatory then we're in the kind of areas of where we may repeat some of these that we talked about in acute and so it's helpful but we're in Three camps here if it's chronic one is we're in the secretory camp the osmotic camp or the inflammatory camp and so let's talk about these in comparison to what we talked about with acute diarrhea which was the small bow large bow involvement believe it or not in all of these whether it's secretory osmotic or inflammatory it can hit any part of the bow so it could be in any of these it could be small bow or large bow so that's not going to be super helpful in that sense right and then even when you look at the diarrhea itself if you ask the patient like what's their diarrhea look like which I know sounds terrible um but it's can be helpful sometimes for secretory diarrhea it'll appear watery like so it won't be like bloody or mucoid or anything like that it'll definitely be more of like a watery type of diarrhea and then you would be like oh well Zach that's off of what we talked about before wouldn't that be more small bow involvement it definitely could be but it also could be large bow involvement so it's not necessarily like specific for one or the other in that particular sense you could definitely be hitting multiple parts of the GI system so okay if that's not super helpful then how can I really inv visualize this well it's the same concept is that there is something in you know the acute uh non-inflammatory diarrhea that were due to pathogens there in terot toxins that were stimulating these GI cells to secrete things in this situation it's the same thing except this something that's actually binding on to these uh anas sites and causing them to secrete things is usually something like a hormone or a stimulant of some sort and so let's just use this as an example let's say that this is the hormone or this is the stimulant laxative what does it do it's the same concept we talked about guys so you're going to stimulate these inter parasytes and they're specific channels on them and what they'll do is they'll secrete that's the name things like sodium pottassium chloride and water and then with this guess what you'll get you'll get a diarrhea that's relatively watery right but it doesn't point to where in the actual bow you've actually affected it just may say it could be hitting the small bow could be hitting the large bow as well but then the question comes okay I know that I'm going to have lots of like things like sodium and pottassium and water in my actual stool okay that's helpful I'll use that later when I talk about the stool osmolar Gap we'll get into that but I got to ask myself the question okay what are these hormones because this could be diagnostically useful right if I know that this is rich in electrolytes and I know okay that's a secretory diarrhea then I have to tie this to hormones what are some hormones that can definitely stimulate this process well I think a couple of them that I would actually want you guys to remember is if you have elevated levels of VIP vasoactive intestinal peptide and this is actually sometimes seen in a disease which we call a vioma and that's important to be able to remember so elevated levels of vasoactive intestinal peptide is helpful another one is if you have elevated levels of gastrin so there's a tumor and I think a lot of these are going to actually be pretty straightforward uh gastrin is another one that can cause secretion and guess what it's released by oh you'll never guess it it's a gastronoma so these can be seen in that disease called Zing or Ellison syndrome where you have like a pancreatic tumor or a tumor of the small bow that's pumping out lots of gastron the other one is usually going to be something like increasing levels of a molecule that eventually is related to serotonin and I'm just going to put down here it's called um you have a molecule called five hydroxy tryptamine but it's related to this one and we call this one carcinoid syndrome so it's related to serotonin carcinoid syndrome so this is a tumor that'll pump out these kinds of molecules that can cause diarrhea and wheezing and things of that effect okay so if it's hormone related I can then say all right I know that this secret diarrhea which is rich in electrolytes could be due to a hormone or could be due to a recent laxative that they've been taking and these stimulants are exhibiting the same type of effect and often times there's just two types of laxatives that you want to be able to look for one is called Senna and the other one is called dokus eight and often times they can be given together but in these scenario if a patient is taking stimulant laxatives this could give them that secretory diarrhea rich in electrolytes or if they're making too many of these hormones it could give them the secretory diarrhea all right so we now know that this could be more of a chronic secretory diarrhea from these mechanisms what about the osmotic type well the osmotic type it's the same exact process I'm not going to write them down I'm just going to highlight that often times you definitely hit the small bow but you may also hit the large bow as well so there definitely can be a mixture of small and large bow involvement when you look at the stool though this is what's interesting and it could be clinically helpful the stool sometimes could have let's say we represent half here is watery and the other half it could be fatty so sometimes you can have a watery diarrhea in this osmotic IC state or you can have a fatty diarrhea this fatty diarrhea we actually use the term Storia which is a fatty like kind of stool fatty greasy stools or it could be watery and I think the reason why this is kind of helpful to know is that in certain types of diseases such as celiacs disease or pancreatic insufficiency um or Whipples or tropical spru things to that effect they lose a lot of fat that can actually occur and anything that's a global malabsorption syndrome they lose a lots of fats in their stool and that can usually make you think about a malabsorption a mild digestive Ty type of syndrome if it's a watery stool though it's likely not malabsorption or mal digestion it's probably some type of laxative all right so that can be somewhat helpful but with that being said a patient comes in they have stools that are maybe watery or fatty the thing to think about here here for this type of osmotic diarrhea it's actually pretty straightforward is you have some type of osmotic substrate it's that we're just going to represent that in blue here this is a substrate that can actually pull water into the bowel so here's your substrate and it's literally yanking water from the vascular chis system around these cells into the actual stool and whatever this osmotic substrate is is the concept is that it's really yanking and pulling in water and other types of molecules into the stool so this will be a very watery type of stool it'll have lots and lots of water and osmotic substrate and I think that's the big thing to remember is you're going to have lots of we're going to call this guy here your substrate and we'll talk about what these substrates are but you have lots of them and they Jank out a lot of water into this tool that's what causes this diarrhea question is is what what are these osmotic substrates well these could be variable man so I think it go kind of goes back ask yourself the question in this particular scenario is it any kind of Mal absorbed um or is it a Mal digested substrate if it is the things I would like you to think about would be something like Celiac right celiac disease I would want you to think about um what we call Epi which is exocrine pancreatic insufficiency I would want you to think about another disease uh called tropical sprew or Whipples so think about tropical sprew or Whipples and I think the other one to not forget as well besides these is could it be lactose intolerance so let's actually make room for that it's either malabsorbed or mald digested material that are acting as these osmotic substrates and if they're acting as osmotic substrates they'll yank water into the actual bowels and so this would be the diseases that would cause this all right and again I think the important thing to remember is we will cover all of these in a separate lecture on malabsorption okay but these are going to cause lots of malabsorbed and mald digested osmotic substrate pull water into the bowel all right the other one is it actually could be due to laxatives but we call these osmotic laxative and we give this to people who are having constipation um or other diseases and it's unfortunately leading to diarrhea the ones I I think that are important to remember is three one is called lacos which is commonly given in patients who have some type of underlying liver disease with hepatic andyl apathy another one is called polyethylene glycol all right this is often times um given to patients again who have issues with constipation the last one I think that's also helpful to remember that can act as La laxative as well is magnesium citrate so these are something I think that's important to remember when you have a patient who comes in with chronic diara ask the question if it is osmotic is there any chance that it's kind of a mald digested or malabsorbed kind of like substrate that's causing this yank of water or is it a drug that we gave them that's causing this yank of water into the bowels the last one is going to be a chronic inflammatory diarrhea and again I think it's important to remember that again this could affect the small small bowels or it could affect the large bowels right the big thing to remember for this one though is that this type of diarrhea is bloody and mucoid so you're going to have that Bloody type of appearance of the stool and you're going to have that mucoid appearance of the stool as well and I think that's really really important to remember and it may say oh it's dissenter no they're not really going to be in that dissenter type but this will be kind of like bloody and a mucoid appearing stool okay now with that being said if you have a bloody mucoid containing stool and it's again greater than at least three or more of these a day for greater than two weeks we're not thinking about dissenter anymore we're thinking about a chronic type of diarrhea but we are knowing that this is going to be inflammatory so what we know is there is mucosal damage and from that mucosal damage we already talked about this a little bit you're going to cause activation of immune system cells so you cause damage here to these mucosal cells it'll alert your immune system your immune system particularly your white blood cells will try to come to the area and fight off all of this particular problem that's causing this in this particular scenario it's usually an inflammatory reaction in like IBD or a chronic infection but these immune system cells will try to leak into the bowels to fight off whatever is causing this usually it's unfortunately kind of like an autoimmune condition but there is damage there is white blood cells there is going to be damage to the actual mucosa which leads to blood that appears within the stool and there's going to be so much inflammation that it actually causes goblet cells to produce lots of mucus and so you get the point of why we get this bloody mucoid stool but the other important thing to remember is is that yes you'll have blood you'll have mucus but you'll also have lots of fecal white blood cells and the Cal protectin molecule that they release and all of these things usually kind of lead you to think that this is some type of inflammatory diarrhea all right you don't see this in osmotic which is rich in water and and a substrate you don't see this in secretory diarrhea which is rich in electrolytes you're seeing this in an inflammatory type and it's usually disease that's been associated with chronic inflammation of the bowel and the two types that I think are important to remember are going to be really inflammatory bowel disease so Crohn's an Aller of colitis and the last one is sometimes patients can have chronic infections like CMV um especially in amuno compromised States but chronic infections would be another one that you could definitely consider but I think by far the most common one to remember is going to be inflammatory bowel disease so with that being said we have a patient who comes in with chronic diarrhea think is it secretory lots of electrolyte Rich stool hormones stimulant laxatives is it osmotic substrates lots of water Rich tool think about again if it's statera Mal absorption Global malabsorption or mal digestive materials if it's not it's more watery think about the osmotic laxatives and then lastly is it inflammatory think about the inflammatory mediators and things like that that would be present within the stool and think about IBD all right now let's talk primarily about the complications only of acute diarrhea because for chronic diarrhea we're going to talk about malabsorption more specifically on its own in a separate video so we're going to focus only on the complications of aute diarrhea all right my friends so now we're going to move on to the complications of a diarrhea right so when a patient has acute diarrhea I think the biggest things to remember is when they come in with this intense either watery diarrhea or the bloody mucoid diarrhea it's important to be able to look out for these following complications I think one of the first ones is hypovolemia right if especially if a patient has more of that like non-inflammatory type of diarrhea they're having tons of High Vol volume very voluminous watery stools they're going to lose a lot of like fluids within their git right so if you're not absorbing things and on top of that you're secreting heavy amounts of fluid this is definitely a problematic issue and so what happens is is you're not getting a proper absorption of straightforward water right and even to some degree electrolytes like sodium and water I would also include something like that as well so sodium and water with that being said if you don't absorb these what happens to your blood volume it drops and if your blood volume drops what happens well now we consider this patient to have hypovolemia how does hypovolemia present well it really depends upon the severity of hypovolemia right this patient can present a variable amount of ways so they could present with Taco cardia maybe they have a high heart rate this is usually one of the signs of like a really bad hemia um they could have low blood pressure so they could be hypotension I'd say that this is usually when it's pretty bad I would also say that you're starting to maybe see signs of like you know physical exam findings so dry mucus membranes right so we'll say that they appear dry so we'll say dry mucus membranes dry membranes we also use that term skin turer that their skin tur is definitely affected as well and I think these are some of the definite findings here that would be suggested that the patient is hypo maybe the urine output's a little bit low as well and they have an acute kidney injury as well but these are some of the findings I would watch out for the other thing is that you also have a lot of problems particularly with electrolytes right so you you know you're you're constantly not allowing for proper absorption especially of potassium and that could definitely lead to patients developing low potassium which we call hypokalemia so watch out for hypokalemia but I think one of the other ones that's really helpful cuz it's like like it's one of those that you constantly being tested on between vomiting and diarrhea and vomiting you're losing lots of protons in diarrhea you're losing a lot of your basic bicarbonate and so because of that you're not giving an adequate amount of contact time for the absorption of bicarbonate and so bicarbonate is not going to be absorbed and if bicarbonate isn't absorbed what does that call whenever you're your bicarb is really really low within the bloodstream that's called a metabolic acidosis so if you have low bicarb we can see this patients developing what's called a metabolic acidosis and usually this is of the nonan Gap phena type right so I think this is important to remember that in patients who have diarrhea this is in small bow large bow but you're impairing all of these processes and that's one of the big things so really really really watch out for checking their chemistries to look out for any features of electrolyte disate looking for features of a patient having hypovolemia and watch out for that metabolic acidosis the other thing I would really watch out for in these patients more particularly is the patients who have that mucoid or bloody diarrhea so in those patients you're definitely concerned that they have that dissenter type of appearance right and with that being said that definitely just more colon involvement right and so these patients will often times we'll kind of highlight this in red here have intense kind of like citis inflammation of their large intestine I'd say we see this a lot with your emagi coli your shagel your ciff so these are really really scary ones so one of the things that you'll have is if patients develop colitis is they'll definitely have abdominal pain the other thing is that this is definitely inflammation it's going to really C crank up your white blood cells you're going to develop a cyto kind storm so you're going to see these patients developing high white blood cell counts and fevers and so I would really really be cautious in these patients if you have a patient with really terrible abdominal pain they have an increased white blood cell count and they have fevers in the setting of really bloody mucoid diarrhea and so in the scenario of dissenter I would definitely be concerned that these patients have a really bad colitis and they can get a lot worse so sometimes if this back you know these back IIA have the opportunity to these can really continue to cause a lot of damage and sometimes they can even translocate across the gut into the bloodstream it cause sepsis so really really careful to watch out for that one i' say the worst case scenario though is if this continues so if a patient continues to have Colitis as we talked about here what happens is this chronic inflammation it just shuts down the contractile activity and so what happens is these kind of these colon like the muscles and the myeric plexus here you just shut down a lot of the motor activity and so these muscles and nerves in that inflamed area of the colon stop working and so because of this massive inflammation here there we'll kind of continue to represent this this massive inflammation here of the colon you start to shut down the motor activity and as that happens the colon begins to dilate it's kind of like if you think about it like a localized ilas if you will right you're just kind of shutting and paralyzing this portion here and so this causes massive dilation of the colon the problem is is if this dilation gets to greater than 6 cm we just don't call this dilation we give this a very specific name we call it megacolon so it's a toxic megacolon so whenever this point has gotten to greater than 6 cm we now have a patient who has toxic megacolon what's the fear of a toxic Mega colon the fear is if this is really really big you can start to increase the risk of that intraluminal pressure being high enough that it can lead to perforation and if these patients perf if they develop a perforation then this can cause them to go downhill extremely quickly right because perforation can then lead to sepsis it could lead to peritonitis right so sometimes these patients can then quickly kind of deteriorate via the peritonitis or they can deteriorate via sepsis and so I think that's important to be able to remember in these patient populations so again patient comes in they have fevers abdominal pain hevor white counts with this mucoid and a bloody diarrhea think about colitis you'll be able to pick this up off of Imaging if that kind of gets to the point where their abdominal pain gets much much worse and then radiographic films show show that there's massive dilation to the point where it's greater than 6 cmet they have toxic megacolon due to that infection the scary thing about that is there are high risk for perforation they can develop peritonitis pneum perenium and sepsis finally the last complication I don't want to add it in here but I think it kind of comes up a couple times and it's called hemolytic ureic syndrome so in patients who have hemolytic ureic syndrome I think the big things to watch out for here are two particular types of bugs all right two part particular types and this is going to be your Intero hemorrhagic eoli and your shagel these are the ones that I really really want you guys to be very cautious of if you see these somewhere within the question stem these are two of the bacteria that are scary in the sense that they can undergo especially if they have massive inflammation so if they cause that sorry that colitis factor that we talked about remember how it causes massive inflammation here I told you that these bacteria can translocate and so if they do translocate so here we're going to say that there's a little bit of bacterial translocation here so there's some bacterial translocation what's the potential problem with this the potential problem here is that these bacteria once in the bloodstream can definitely kind of throw off your clotting process and what they'll do is they'll unfortunately lead to lots of clots the mechanism of this isn't completely understood as to why but it may increase some of the inflammatory sidey dein which activates your procoagulant Cascade and so what ends up happening is these patients start to experience some type of like coagulopathy where they start kind of clotting now the crazy thing is is that as red blood cells start moving AC across this kind of clots they start shearing some of the red blood cells up and consuming more of the platelets and so what ends up happening out of this is two things one is you actually consume platelets and what is that called whenever you consume the platelets and they drop it's called thrombocytopenia and so they'll develop something called thrombo cytopenia where those platelet levels will start to drop the other concept is that you will chew up the red blood cells what's that called when you chew them up and you drop the red blood cell levels anemia but we call this hemolytic anemia so now a patient has hemolytic anemia which is going to be busting open or ripping up one of those red blood cells consumption of the plet and that's now called thrombocytopenia the other problem is is that these kind of clots they start to occur in some smaller vessels in the body and one of the most per like unfortunate areas is the kidneys in these actual glami so another thing that actually happens here is that these glami get plagued and now you're altering the renal profusion and the filtration process and so what ends up happening here is these patients because of these altering the renal perus in the filtration process you drop off their GFR and if you drop off their GFR you can potentially lead to two things one is you could drop their urine output and the other one is you could potentially increase their creatinine which is kind of an example of a kidney injury and this would be an acute kidney injury so if these patients have well we've kind of like in this particular sense say an acute kidney injury which is kind of based on a rise in the creatinine uh decrease in the urine output I apologize decrease in the urine output and on top of that an increase in another molecule that's also helpful here which is BU blood Ura nitrogen increasing The Bu increasing the crine a droping the urine output suggests an acute kidney injury if on top of that you have thrombocytopenia and hemolytic anemia you have the Triad if you will of hemolytic uremic syndrome so again Q kidney inury thrombocytopenia and hemolytic anemia suggest hemolytic ureic syndrome in the setting of EHC and chela okay now we've covered the complications of acute diarrhea now let's move into the Diagnostics we talked about acute diarrhea which is can cause a lot of complications right it's really important to be able to identify that so let's actually go through this patient first thing that we have to do is rule out any kind of complications that they may have from their diarrhea which was hypovolemia hypokalemia IA metabolic acidosis hemolytic aric syndrome toxic megacolon or perforation so if I get a CBC and BMP this will help me to identify the hus and it'll help me to identify any acute kidney injury hypokalemia hypovolemia types of complications if I see that their hemoglobin hematocrit's low their platelet's low and they have an increase in their creatinine oh this is hus that's a complication I'm scared that they have uh some type of EHC or shagel infection if I see their bu and creatinine's high and I see that their potassium's low that definitely tells me that they have hypokalemia due to the poor profusion of the kidneys and low potassium is because they're they're actually kind of not allowing for the absorption of that potassium the next thing is I have to remember that if a patient has hypovolemia because of their diarrhea they have kitis which is maybe they have an increased white blood cell count maybe they have a fever they have you know some some definite large amounts of diarrhea or they have an amuno depressed state maybe they have HIV maybe they have some type of uh medication that they're taking like an immunosuppressant medication or they're just post transplant they're on immunosuppressives to prevent them from having a rejection of their transplant these patients are super high risk and can get really really sick so hypoy they can go into shock colitis they could develop toxic megacolon and perf amuno supression they could develop severe sepsis and if they're having diarrhea for three plus days and they're not getting any better they could start to develop severe hypovolemia this is a that's very high risk and they deserve a further work up of the type of pathogen that they have in that scenario and only in that scenario would we obtain a stool analysis if they're hypovolemic and requiring lots of fluids if they have a very high fever lucyisanerd to get a stool analysis and if had persistent diarrhea for more than three days you need to get a stool analysis what does this consist of the first thing that you want to look at is the feal white blood cells and the feal Cal protectin if it's elevated that tells me right away oh this is a inflammatory type of diarrhea that's not good all right I just don't know which type yet I get the stool culture and the benefit to that is it tells me what type of bacteria it is and believe it or not that's very very important because we don't prescribe antibiotics preferably to patients who have Intero hemorrhagic coli because they're at high risk for hus so culture will help me to guide which type of antibiotic I'm going to prescribe o and parasites will tell me if I have any type of parasites do I have intica cryptosporidium Giardia and the Norovirus and rotavirus testing will help a little bit to at least more particularly guide maybe um separating people from one another in other words if I have the Norovirus I should probably have this patient avoid human contact I should isolate them away from other people so they don't spread that infection if they have the Roda virus I should maybe have my child stay home home so that they don't go to the daycare and pass that on to another individual so that may be the benefit of that either way it'll help me to identify the type of infectious diarrhea that they have and guide my management all right guys let's move into the next part here which is the diagnostic approach of chronic diarrhea so we have a patient who comes in they've had greater than three loose stools per day for greater than four weeks pretty terrible we should definitely be able to figure this out I think the first thing that's really helpful to determine is if it's inflammatory or not that really kind of gives you the first start here so pain right away the feal white blood cells the feal calprotectin I didn't even get a FAL ult blood test the reason why is if these are elevated automatically tells me that there's inflammation in the fal cold blood test there's usually going to be some degree of blood in the stool that's going to help me right away to determine if this is inflammatory or not if it comes back elevated or positive FAL oul then it's inflammatory I just have to figure out if it's chronic infection or if it's an autoimmune disease or autoimmune attack in the form of IBD so what do I do get a stool analysis if I get a stool analysis and it shows me that the stool culture the OVA and parasites are negative it's unlikely a chronic infection that they've been kind of colonized with it's likely going to be IBD get a colonoscopy this will tell you if it's all sort of colitis or Crohn's disease based upon the appearance of the colonoscopy the biopsy findings and then from there you've diagnosed it as IBD treat that accordingly if you do the inflammatory testing again shows you that the feal white cells are up shows you the fal Cal protectant up shows you if FAL C blood test is positive it doesn't tell you if it's a chronic infection or if it's IBD you just know that it's inflammatory get the stool analysis if the stool analysis at this point shows you that it's positive stool culture maybe it contains a particular type of bacteria like seiff or their OV and parasites come back positive and it shows you that they have a chronic infection with inmah histolytica or cryptos spadium cool you know that it's a chronic infection and you'll treat that accordingly once you've ruled these out so in other words you say okay I have no feal white blood cells no FAL Cal proteum my feal co blood test is negative then I just need to say it's either osmotic or it's secretory so what I'll do is I'll get a stool osmotic Gap the purpose of this is you're just taking 290 subtracting it from a multiplication factor of two from their stool sodium and their stool potassium that right away should make me think okay if my stool sodium and my stool pottassium are high which is in secretory I'm taking 290 and subtracting from a big number that means that they'll have like a smaller osmolar Gap and if I take a patient who has osmotic diarrhea they'll have a norm noral sodium normal potassium so their osmotic Gap should be like a little bit on the and let's say higher side because I'm taking a big number and subtracting it from like a normalist number so if my osmotic Gap is less than 100 what that's telling me is is I'm taking 290 and subtracting it from a big number that means that there's a lot of sodium and potassium in their their stool this has to be secretory diarrhea from there I'll say okay it's either hormones or it's laxatives remember I told you that check their VIP levels their serotonin metabolite levels and gastron levels if VIP is elevated it's probably a vipoma if their five hia levels are elevated it's probably carcinoid syndrome and the gastron levels are elevated it's probably gastronoma right away that's pretty easy right if these come back negative then it's probably some type of laxative abuse or stimulate laxative and again we took the example of CNA and docusate sodium being the example think about this in a patient who has chronic constipation they're taking these regularly the other one is osmotic Gap greater than 100 that tells me that the stool sodium and the stool potassium is normal they're not very high all right so in that scenario if the osmotic Gap is greater than 100 it's osmotic diarrhea in this scenario I told you it's either mald digested or mal um absorbed nutrients or it's potentially some type of osmotic laxative so how do I determine this first thing I need to think about is in malabsorption and Mal digestion one of the biggest things is is I can tell if they have lots of fat in their stool or not so what I want to do is I want to get a fecal fat test and a hydrogen breath test and this will make a lot more sense when we go through the malabsorption lecture the reason why is if the fecal fat test is positive that tells me it's a global malabsorption something like celiacs disease tropical sprew um maybe Whipples or even exocrine pancreatic insufficiency if my feal fat is negative and my hydrogen breath test is positive it tells me that there's probably some type of large amounts of undigested carbohydrates in my uh my git such as lactose intolerance that's an example of a partial malabsorption and if in this scenario the fecal fat is negative and the hydrogen breath test is negative it's no malabsorption or mal digestive syndrome it's likely the laxatives and then look for a history of lactulose use um magnesium citrate or polyethylene glycol all right we've gone through it my friends now we got to talk about the treatment of diarrhea and these patients who have diarrhea acute greater than three loose stools per day for more than at least in this case less than two weeks is what we would Define it as for these patients it's all about treating the complications first do they have features of hypovolemia do they have low blood pressure do they have compensatory Tac cardia do they have dry mucous membranes do they have decreased skin triger are they not making a lot of urine and maybe they have an acute kidney injury because of this give them fluids if they can ingest fluids great if they cannot ingest fluids you want to give them IV fluids often time it's a combination of both just make sure that you as you're giving them fluids you're monitoring for improvement in their blood pressure their heart rate their urine output or their appearance of their dehydration severe colitis so if this patient has a high fever they have a white blood cell count they have evidence of a very inflamed colon on their Imaging that's a very sick patient and I really should consider if this patient has these to really start antibiotics on them another indication for antibiotics is if they're immuno compromised the reason why is if they have an infection like an infectious diarrhea yes it could be cleared but if they're immuno compromised they may not have the immune response that they can mount that's good enough to clear that infection and these patients are candidate for antibiotics question comes up okay which type of antibiotic do I put them on it really depends upon the type of pathogen that's why you would do a stool coold or stool analysis for example if it's really something for example like SEI that's usually vom or metronidazol if it's Gardia that's usually metronidazol um and generally if it's something like cample abactor that would be more like a ziyin really any other invasive pathogen you could treat with you know cicin so that's the big thing to remember is oftentimes a Flor quinolone is going to be sufficient aiy may be better for campor um metronidazol is going to be more preferred for giardia and then vom or metronidazol is preferred for cicil now with that being said I think it's important to remember that hemolytic remix syndrome is a definite complication of emagic coli or chagala infections if it's combined with an acute infectious diarrhea and again in these particular patients it is of utmost importance to avoid antibiotics the reason why is there's been a lot of studies that have showed that the utilization of antibiotics like for example floro Quinones in a patient with EHC or shagel it can actually cause a worsening destruction of those bacteria they pop open they worsen the coagulopathy they worsen the hemolytic aric syndrome same thing if you give them laramide laramide basically prevents them from having diarrhea so it decreases the contraction of the the actual bowels problem is is that you don't clear the effect the elimination or you don't clear the infection so I'm not eliminating the infection out of my stool therefore it stays in larger amounts in my colon and then worsens the infection of the colon worsens the release of these bacteria and seeding of them into the bloodstream which would can worsen their H us so it's oftentimes really important just to provide supportive care don't give them platelets because it actually could worsen the thrombocytopenia try to you know give them hemoglobin or give them U red blood cells only if their hemoglobin is less than seven and just monitor them for any s severe acute kidney injury do they need Dialysis in other words do they have refractory hyper hyper IA do they have a metabolic acidosis do they have um severe hypervolemia in those particular scenarios they may need dialysis the last thing I think that's important to remember is if you're going to treat acute diarrhea with a anti-diarrheal agent it is of utmost importance to avoid laramide so that they can clear the infection one that can be potentially beneficial and doesn't increase the risk of hemolytic aric syndrome or worsening of their colitis is bismuth subsalicylate so that's something to potentially can consider chronic diarrhea patients this is a little bit different you really have to be able to identify their underlying cause so you have to say are they on some type of like laxative discontinu that osmotic or um stimulant laxative is this some type of like hormone related problem you have to treat that underlying hormone related problem is this some type of malabsorption or mal digestive disorder you have to treat that problem and again is it some type of inflammatory bowel disease you have to treat that problem so that is the utmost importance for the other component here which is these patients they're not really as long as it's not like some type of infection that if it is blocked off it won't cause a worsen in colitis you can give these patients anti-ar agents like laramide that is safe it's just best to avoid this an acute infectious diarrhea all right my friends that was a lot and I really hope that this made sense thank you guys for watching this video I hope it helped I hope that you learned a lot as always love you thank you and until next time [Music]