Sandbox:DAMI

Revision as of 16:18, 30 November 2017 by Damola (talk | contribs) (→‎Overview)
Jump to navigation Jump to search

RESIDENT SURVIVAL GUIDE

Resident Survival Guide
Introduction
Team
Guide
Page Template
Examine the Patient Template
Navigation Bar Template
Checklist
Topics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

Differential diagnosis of abdominal pain

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + − − − − + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + − − + − − − − − − − N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + − + + − − − − − − − Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute pancreatitis Epigastric + − + ± − − − − ± − − N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Chronic pancreatitis Epigastric − − ± ± − + + − − − − N
  • Increased amylase / lipase
  • Increased stool fat content
  • Pancreatic function test
 CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric − − + + − + + − − − − N

Skin manifestations may include:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Primary biliary cirrhosis RUQ/Epigastric − − − + − − − − − − − N
  • Increased AMA level, abnormal LFTs
  • ERCP
  • Pruritis
Primary sclerosing cholangitis RUQ + − − + − − − − − − − N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
 The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± − ± ± − − − − − − − Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Gastric causes Peptic ulcer disease Diffuse ± − + − − − + Positive if perforated Positive if perforated Positive if perforated N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Gastritis Epigastric ± − + − − − Positive in chronic gastritis + − − − N H.pylori infection diagnostic tests Endoscopy H.pylori gastritis guideline recommendation
Gastroesophageal reflux disease Epigastric − − ± − − − − − − − − N N Gastric emptying studies Esophageal manometry, Endoscopy for alarm signs
Gastric outlet obstruction Epigastric − − ± − − − + − − − − Hyperactive Succussion splash
Gastroparesis Epigastric − − + − − − + − ± − − Hyperactive/hypoactive
  • Hemoglobin
  • Fasting plasma glucose
  • Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer
  • HbA1c
  • Scintigraphic gastric emptying
  • Succussion splash
  • Single photon emission computed tomography (SPECT)
  • Full thickness gastric and small intestinal biopsy
Gastrointestinal perforation Diffuse + ± - ± − − − + + + ± Hyperactive/hypoactive
  • WBC> 10,000
 Air under diaphragm in upright CXR Hamman's sign
Dumping syndrome Lower and then diffuse − − + − − + + − + − − Hyperactive
  • Glucose challenge test
  • Hydrogen breath test
  • Upper GI series
  • Gastric emptying study
 Postgastrectomy
Intestinal causes Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis + − − ± − − Positive in perforated appendicitis + + Hypoactive Ct scan and

Ultrasound

Nausea & vomiting, decreased appetite
Acute diverticulitis LLQ + ± + − + ± − + Positive in perforated diverticulitis + + Hypoactive CT scan and ultrasound shows evidence of inflammation History of constipation
Inflammatory bowel disease Diffuse ± − − ± − + + + − − − Normal or hyperactive String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

Irritable bowel syndrome Diffuse − − − − ± ± + − − − − N Normal Normal Symptomatic treatment
Whipple's disease Diffuse ± − − ± − + + − ± − − N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Toxic megacolon Diffuse + − − − − + − − + ± + Hypoactive CT and Ultrasound shows:
  • Loss of colonic haustration
  • Hypoechoic and thickened bowel walls with irregular internal margins in the sigmoid and descending colon
  • Prominent dilation of the transverse colon (>6 cm)
  • Insignificant dilation of ileal bowel loops (diameter >18 mm) with increased intraluminal gas and fluid
Tropical sprue Diffuse + − − − − + + − − − − N Barium studies show dilation and edema of mucosal folds Steatorrhea- 10-40 g/day (Normal=5 g/day)
Celiac disease Diffuse − − − − − + + − − − − Hyperactive USG
  • Bull’s eye or target pattern
  • Pseudokidney sign
 Gluten allergy
Infective colitis Diffuse + − ± − − + − + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Colon carcinoma Diffuse/localized − − − − ± ± + + ± − −
  • Normal
  • Hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography
 PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Hepatic causes Viral hepatitis RUQ + − + + − Positive in Hep A and E + − Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
 US Hep A and E have fecoral route of transmission and Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + − ± + − + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + − − + − − + − − − −
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Budd-Chiari syndrome RUQ ± − − ± − − − Positive in liver failure leading to varices − − − N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ − − − − − − − Positive in cirrhotic patients − − − N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
 Ultrasound shows evidence of cirrhosis Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis RUQ − − − + − − + + + − − N USG
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + − − Positive in cirrhotic patients − + − − ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
 Ultrasound for evaluation of liver cirrhosis
Renal causes Pyelonephritis Unilateral + ± + − − − − − + − − Hypoactive
  • Urinalysis
  • Urine culture
  • Blood culture
  • CT
  • MRI
  • CVA tenderness
Renal colic Flank pain − − + − − − − − − − − N Hematuria CT scan and ultrasound
Hollow Viscous Obstruction Small bowel obstruction Diffuse + − + − + − + − + + ± Hyperactive then absent Leukocytosis with left shift indicates complications Abdominal X ray
  • Dilated loops of bowel with air fluid levels
  • Gasless abdomen
  • "Target sign"– , indicative of intussusception
  • Venous cut-off sign" – suggests thrombosis
Volvulus Diffuse Positive in perforated cases − + − + − − − Positive in perforated cases + + Hyperactive then absent Leukocytosis CT scan and abdominal X ray
  • U shaped sigmoid colon
 "Whirl sign"
Biliary colic RUQ − − + + − − − − − − − N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Vascular Disorders Ischemic causes Mesenteric ischemia Periumbilical Positive if bowel becomes gangrenous − + − − + + + Positive if bowel becomes gangrenous Positive if bowel becomes gangrenous − Hyperactive to absent CT angiography
  • SMA or SMV thrombosis
 Also known as abdominal angina, worsens with eating
Acute ischemic colitis Diffuse + ± + − − + + + + + + Hyperactive then absent Leukocytosis Abdominal x-ray
  • Distension and pneumatosis

CT scan

  • Double halo appearance, thumbprinting
  • Thickening of bowel
 May lead to shock
Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse ± − + − − − + + + − − N Focused Assessment with Sonography in Trauma (FAST) Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± − ± − − − − + + − − N Anemia CT scan History of trauma
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Gynaecological Causes Tubal causes Torsion of the cyst RLQ / LLQ − − + − − − − − − ± ± N Increased ESR and CRP Ultrasound Sudden onset & severe pain with nausea and vomiting
Acute salpingitis RLQ / LLQ + ± − − − − − − − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Cyst rupture RLQ / LLQ − − + − − − − − + ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy RLQ / LLQ − − + − − − − − + + + N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Extra-abdominal causes Pulmonary disorders Pleural empyema RUQ/Epigastric + ± − − − − + − − − − N Thoracentesis Chest X-ray
  • Pleural opacity
  • Localization of effusion
 Physical examination
Pulmonary embolism RUQ/LUQ ± − − − − − − − ± − − N
  • ABGs
  • D-dimer
  • Dyspnea
  • Tachycardia
  • Pleuretic chest pain
Pneumonia RUQ/LUQ + + + − − ± − − + − − Normal or hypoactive
  • ABGs
  • Leukocytosis
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
  • Shortness of breath
  • Cough
Cardiovascular disorders Myocardial Infarction Epigastric ± − + − − − − − Positive in cardiogenic shock − − N ECG

Echocardiogram

  • Wall motion abnormality
  • Wall rupture
  • Septal rupture
  • Chest pain, tightness, diaphoresis

Complications:

<figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline>
<figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline>
<figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline></figure-inline></figure-inline>

The following is a list of diseases that present with acute onset severe lower abdominal pain:

Disease Findings
Ectopic pregnancy History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.[1]
Appendicitis Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%.[2]
Rupturedovarian cyst Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic.[3]
Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic.[4]
Hemorrhagic ovarian cyst Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic.[4]
Endometriosis Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic.[4]
Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain.[5][6]

References

  1. ↑ Morin L, Cargill YM, Glanc P (2016). "Ultrasound Evaluation of First Trimester Complications of Pregnancy". J Obstet Gynaecol Can. 38 (10): 982–988. doi:10.1016/j.jogc.2016.06.001. PMID 27720100.
  2. ↑ Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C (1994). "Acute appendicitis: CT and US correlation in 100 patients". Radiology. 190 (1): 31–5. doi:10.1148/radiology.190.1.8259423. PMID 8259423.
  3. ↑ Bottomley C, Bourne T (2009). "Diagnosis and management of ovarian cyst accidents". Best Pract Res Clin Obstet Gynaecol. 23 (5): 711–24. doi:10.1016/j.bpobgyn.2009.02.001. PMID 19299205.
  4. ↑ 4.0 4.1 4.2 Bhavsar AK, Gelner EJ, Shorma T (2016). "Common Questions About the Evaluation of Acute Pelvic Pain". Am Fam Physician. 93 (1): 41–8. PMID 26760839.
  5. ↑ {{Cite journal | author = W. E. Stamm | title = Etiology and management of the acute urethral syndrome | journal = Sexually transmitted diseases | volume = 8 | issue = 3 | pages = 235–238 | year = 1981 | month = July-September | pmid = 7292216
  6. ↑ {{Cite journal | author = W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes | title = Causes of the acute urethral syndrome in women | journal = The New England journal of medicine | volume = 303 | issue = 8 | pages = 409–415 | year = 1980 | month = August | doi = 10.1056/NEJM198008213030801 | pmid = 6993946

Template:Gastroenterology


Template:WikiDoc Sources |}

Causes

Life Threatening Causes

  • Central Diabetes Insipidus
  • Nephrogenic Diabetes insipidus
  • Psychogenic Diabetes insipidus
  • Gestational Diabetes insipidus
  • Autoimmune Diabetes insipidus

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References


Template:WikiDoc Sources

Differentiating Protein energy malnutrition from other Diseases

Differentiating kwashiorkor from marasmus[1]

Distinguishing Features Kwashiorkor Marasmus
Cause Deficiency of protein in the diet of child Deficiency of protein as well as energy nutrients (that is carbohydrates and fats) in the diet
Age Occurs in children in the age group 1-5 years Typically occurs in children below the age of 1 year
Association More common in villages where there is small gap period between successive pregnancies More common in towns and cities where breast-feeding in discontinued quite early
Edema Presence of edema Absence of edema
Muscles Wasting of muscles Wasting of muscles is quite evident. The child is reduced to skin and bones
Skin changes Dermatitis and Hyperpigmentation noticed Dry and atrophic skin but no changes in color
Serum cortisol Decreased/Normal Increased
Fasting blood glucose Decreased Decreased
Growth retardation Mildly retarded in growth Severely retarded in growth
Facial appearance Moon-like face Elderly man face
Abdomen Protuded Shrunken
Vitamin deficiency Present Present
Weight 60-80% of normal weight for age <60% of normal weight for age

Differential diagnosis of childhood malnutrition

Kwashiorkor
Marasmus
Vitamin A deficiency
Iron deficiency
Iodine deficiency
Congenital heart disease
Dehydration
Sepsis
Shigella and campylobacter
Inflammatory bowel diseases

Causes in Alphabetical Order

Causes by Organ System

Cardiovascular Hypovolemic shock
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect Amphotericin B, Demeclocycline, Lithium , Radiation - for CNS and nasopharyngeal malignancies , Pituitary radiation , Netilmicin , Kanamycin, Carbamazepine , Amikacin
Ear Nose Throat No underlying causes
Endocrine Ischemia of the pitutary gland , Sheehan syndrome , Pituitary tumour , Panhypopituitarism , lymphocytic hypophysitis , Familial hypopituitarism , congenital nephrogenic , Congenital hypopituitarism , Apoplexy , pituitary cysts
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic Inherited genetic kidney disorders , Genetic diseases - pit-1 mutation
Hematologic Sickle cell disease , Langerhans cell histiocytosis
Iatrogenic Neurosurgery , Pituitary surgery
Infectious Disease Tuberculous meningitis , Meningoencephalitis , Infections
Musculoskeletal / Ortho No underlying causes
Neurologic Dipsogenic diabetes insipidus , Ischemic encephalopathy , Subarachnoid hemorrhage , Mass lesions hypothalamus , Ischemic stroke , Intracranial space-occupying lesion , Intracranial bleeding , Hypoxic encephalopathy , Hypothalamic radiation , Brain aneurysm
Nutritional / Metabolic Hypercalcemia , hemochromatosis , Anorexia nervosa
Obstetric/Gynecologic Gestational diabetes insipidus
Oncologic Pituitary Cancer , pituitary adenomas , malignant tumors infilterating hypothalamus from lung and breast , Histiocytosis , Craniopharyngioma
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte Polycystic kidney disease, Renal failure , Interstitial nephritis , Hypokalaemia , Hypercalcaemia
Rheum / Immune / Allergy Sarcoidosis , Autoimmune Hypophysitis , Autoimmune Diabetes Insipidus
Sexual No underlying causes
Trauma Head injury , Trauma - fracture of skull base
Urologic Partial blockage of the ureters
Dental No underlying causes
Miscellaneous Dehydration , Wolfram syndrome , Sicca syndrome , Septo-optic dysplasia , Infiltrative lesions , Idiopathic , Hand-Schuller-Christian Syndrome , Familial CDI , Erdheim-Chester disease , DIDMOAD syndrome , Anophthalmia -- hypyothalamo-pituitary insufficiency , Anophthalmia -- hypothalamo-pituitary insufficiency , Amyloidosis

Table for HV

  • The table below summarizes the classification of the herpesviridae family
Classification Clinical manifestations
Subfamily

alphavirinae

Herpes simplex type 1
  • Perioral vesicular rash
  • Rarely encephalitis
  • Meningitis
Herpes simplex type 2

varicella-zoster virus

  • Disseminated vesicular rash at acquisition (chicken pox)
  • Localized vesicular rash with reactivation(zoster)
Subfamily betavirinae Cytomegalovirus
  • Mononucleosis like illness in healthy adults

Fever

  • Pneumonia
  • Hepatitis in immunocompromised adults
Human herpes virus 6 Acute febrile illness sometimes with rash (roseola infantum)
Human herpes virus 7 May cause febrile illness sometimes with rash ( roseola-like)
Subfamily

gammavirinae

Epstein-Bar virus mononucleosis, lymphoma, nasopahryngeal carcinoma and hodgkins disease.
Human herpes virus 8 Kaposi's sarcoma in immunocompromised.

Watery diarrhea

  • Osmotic diarrhea
    • Mg2+, PO43-, SO42- ingestion
    • Carbohydrate malabsorption
  • Secretory diarrhea
    • Laxative abuse (nonosmotic laxatives)
    • Congenital syndromes
    • Bacterial toxins
    • Ileal bile acid malabsorption
    • Inflammatory bowel disease
      • Ulcerative colitis
      • Crohn’s disease
      • Microscopic (lymphocytic and collagenous) colitis
      • Diverticulitis
    • Vasculitis
    • Drugs and poisons
    • Disordered motility
      • Postvagotomy diarrhea
      • Postsympathectomy diarrhea
      • Diabetic autonomic neuropathy
      • Hyperthyroidism
      • Irritable bowel syndrome
    • Neuroendocrine tumors
      • Gastrinoma
      • VIPoma
      • Somatostatinoma
      • Mastocytosis
      • Carcinoid syndrome
      • Medullary carcinoma of thyroid
    • Neoplasia
      • Colon carcinoma
      • Lymphoma
      • Villous adenoma
    • Addison’s disease
    • Epidemic secretory diarrhea
    • Idiopathic secretory diarrhea

Fatty diarrhea

  • Malabsorption syndromes
    • Mucosal diseases
    • Short-bowel syndrome
    • Postresection diarrhea
    • Mesenteric ischemia
  • Maldigestion
    • Pancreatic insufficiency
    • Bile acid deficiency

Inflammatory diarrhea

  • Inflammatory bowel disease
    • Ulcerative colitis
    • Crohn’s disease
    • Diverticulitis
    • Ulcerative jejunoileitis
  • Infectious diseases
    • Ulcerating viral infections
      • Cytomegalovirus
      • Herpes simplex
  • Ischemic colitis
  • Radiation colitis
  • Neoplasia
    • Colon cancer
    • Lymphoma
Cause Osmotic gap History Physical exam Labs Gold standard Treatment
Osmotic gap Other Labs
Watery Secretory Crohns
IBS
Osmotic
FunctionL

Watery

Table showing watery causes of chronic diarrhea (Table 1)

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50 mOsm per kg > 50 mOsm per kg*
Watery Secretory Crohns + -
Hyperthyroidism + -
  • TSH with T3 and T4
VIPoma + -
  • Elevated VIP levels
  • Followed by imaging
Osmotic Lactose intolerance - +
  • Avoidance of dietary lactose
  • Substitution to maintain nutrient intake
  • Regulation of calcium intake
  • Use of enzyme lactase
Celiac disease - +
  • IgA tissue transglutaminase Ab
Functional Irritable bowel syndrome - -

Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:

  • Onset associated with change in frequency of stool
  • Onset associated with change in appearance of stool
  • 25% of bowel movements are loose stools

History of straining is also common

  • Clinical diagnosis
    • ROME III criteria
    • Pharmacologic studies based criteria
Template:WikiDoc Sources

Fatty (bloating and steatorrhea in many, but not all cases)

Table showing fatty causes of chronic diarrhea ( Table 2)

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50

mOsm

per kg

> 50

mOsm

per kg*

lactose intolerance - +
  • Bloating,
  • Flatulence
  • Abdominal pain, and/or chronic diarrhea
  • after ingestion of lactose
 Lactose breath hydrogen test Restriction of lactose and maintain calcium and vitamin D intake.
Celiac sprue - +
  • Diarrhea with bulky, foul-smelling stools
  • Growth failure in children,
  • Weight loss,
  • Anemia,
  • Neurologic disorders
  • Osteopenia
  • Neuropsychiatric disease
  • Dermatitis herpetiformis
  • Arthritis
  • Iron deficiency
  • Metabolic bone disease
  • Hyposplenism
  • Kidney disease
  • Idiopathic pulmonary hemosiderosis
 Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper ebdoscopy with biopsy. Dietary counseling, elimination of gluten in the diet.
Whipple disease - +
  • Arthralgias
  • Weight loss
  • Diarrhea
  • Abdominal pain
  • Leukocytopenia
  • Thrombocytopenia
  • Skin hyperpigmentation
 Upper endoscopy with biopsies of the small intestine for T. whipplei testing (histology with PAS staining, polymerase chain reaction [PCR] testing, and immunohistochemistry) Doxycycline and hydroxychloroquine was bactericidal

Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)

Table showing inflammatory causes of chronic diarrhea ( Table 3)

Cause History Laboratory findings Diagnosis Treatment
Diverticulitis
  • Bloody diarrhea
  • Left lower quadrant abdominal pain
  • Abdominal tenderness on physical examination
  • Low grade fever
  • Leukocytosis
  • Elevated serum amylase and lipase
  • Sterile pyuria on urinalysis
 Abdominal CT scan with oral and intravenous (IV) contrast bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobic bacteria and gram-negative rods
Ulcerative colitis
  • Elvated ESR (>30mm/hr)
  • Low albumin
 Endoscopy Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease. See ...
Entamoeba histolytica cysts shed with the stool detects ameba DNA in feces Amebic dysentery ;
  • Metronidazole 500-750mg three times a day for 5-10 days
  • Tinidazole 2g once a day for 3 days is an alternative to metronidazole

Luminal amebicides for E. histolytica in the colon:

For amebic liver abscess:

  • Metronidazole 400mg three times a day for 10 days
  • Tinidazole 2g once a day for 6 days is an alternative to metronidazole
  • Diloxanide furoate 500mg three times a day for 10 days must always be given afterwards.

==Gestational Diabetes insipidus


Differentiating Diabetes insipidus based on the levels of ADH and the response of the body to the level of hyponatremia




Template:WikiDoc Sources

Question on Roseola

  • A woman brings her 14 month old baby to the physician for the evaluation of a rash. He was in a good state of health until about 3 days ago when he developed a very high fever. The mother says the temperature was as high as 40C (104F) when she measured it with her thermometer at home. She gave him some tylenol and the fever subsided after which the rash developed. It started as a non itchy pink rash with rose spots on the head and is now generalized all over the body. Today the boy's temperature measured in the clinic is 37 C( 98F), pulse 88/min and respirations are 16/min. His immunizations are up to date and the boy is in no apparent distress. What is the most likely diagnosis in this patient?
  • A. Scarlet Fever
  • B. Rubella(German measles
  • C. Roseola (sixth disease)
  • D. Rocky mountain spotted fever
  • E. Measles
  • F. Kawasaki disease
  • G. Erythema infectiosum (fifth disease)
  1. ↑ Müller O, Krawinkel M (2005). "Malnutrition and health in developing countries". CMAJ. 173 (3): 279–86. doi:10.1503/cmaj.050342. PMC 1180662. PMID 16076825.
  2. ↑ Danziger J, Zeidel ML (2015). "Osmotic homeostasis". Clin J Am Soc Nephrol. 10 (5): 852–62. doi:10.2215/CJN.10741013. PMC 4422250. PMID 25078421.
  3. ↑ Sterns RH (2015). "Disorders of plasma sodium--causes, consequences, and correction". N Engl J Med. 372 (1): 55–65. doi:10.1056/NEJMra1404489. PMID 25551526.
  4. ↑ Fenske WK, Christ-Crain M, Hörning A, Simet J, Szinnai G, Fassnacht M; et al. (2014). "A copeptin-based classification of the osmoregulatory defects in the syndrome of inappropriate antidiuresis". J Am Soc Nephrol. 25 (10): 2376–83. doi:10.1681/ASN.2013080895. PMC 4178436. PMID 24722436.
Retrieved from "https://www.wikidoc.org/index.php?title=Sandbox:DAMI&oldid=1399460"