Diseases » Brainerd diarrhea » Diagnosis

Diagnosis of Brainerd diarrhea

Brainerd diarrhea Diagnosis: Book Excerpts

• Ask the following questions - DIARRHEA, ACUTE
• Ask the following questions - DIARRHEA, CHRONIC
• Differential Diagnosis - Diarrhea - Acute
• Differential Diagnosis - Diarrhea - Chronic
• Differential Diagnosis - Diarrhea – Chronic, No Blood or Weight Loss
• Differential Diagnosis - Diarrhea – Chronic, with Weight Loss
• Differential Diagnosis - Diarrhea – Acute
• Approach to the Diagnosis - DIARRHEA
• History and physical examination - Diarrhea
• History and physical examination - Fecal incontinence
• History and physical examination - Diarrhea
• History and physical examination - Fecal incontinence
• History - Diarrhea
• Differential Overview - Acute Diarrhea
• Differential Overview - Chronic Diarrhea
• History - Diarrhea
• History - Diarrhea
• Clinical Features and Diagnosis Acute Diarrhea - Diarrhea
• Clinical Features and Diagnosis - Fecal Incontinence
• History and physical examination - Diarrhea
• History and physical examination - Fecal incontinence

Tests and diagnosis discussion for Brainerd diarrhea:

Because the etiologic agent is unknown, there is no laboratory test that can confirm the diagnosis. Brainerd diarrhea should be suspected in any patient who presents with the acute onset of nonbloody diarrhea lasting for more than 4 weeks, and for whom stool cultures and examinations for ova and parasites have been negative. Care should be taken to exclude other causes of chronic diarrhea, both infectious and noninfectious (e.g., lymphocytic colitis, collagenous colitis, tumors, drug reactions). Brainerd diarrhea is not characterized by any specific laboratory abnormalities. On colonoscopy, petechiae, aphthous ulcers and erythema may be observed. Microscopic examination of colonic tissue biopsy specimens often reveals mild inflammation, with an increased number of lymphocytes, particularly in the ascending and transverse colon. The stomach and small intestine generally appear normal. (Source: excerpt from Brainerd Diarrhea General: DBMD)

Diagnostic Tests for Brainerd diarrhea: Online Medical Books

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DIARRHEA, ACUTE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there blood in the stool? From the algorithm, blood in the stool should indicate that there is Salmonella , Shigella , Campylobacter jejuni , ulcerative colitis, and amebic dysentery. Without blood in the stool, it is more likely that the acute diarrhea is due to a staphylococcal toxin, giardiasis, traveler's diarrhea, a virus, or contaminated food.
2. Is there a fever? Fever, especially with an elevated white count and blood in the stool, would suggest Salmonella , Shigella , Campylobacter jejuni , or ulcerative colitis in its acute stage. The absence of fever would suggest amebic dysentery or giardiasis, although there may be fever in amebic dysentery in the severe cases. Even traveler's diarrhea and toxic staphylococcal gastroenteritis do not usually give more than a low-grade temperature at best. Pseudomembranous colitis may result in a significant elevation of the temperature once the patient becomes severely dehydrated.
3. Is there severe vomiting? Severe vomiting is seen in toxic staphylococcal gastroenteritis! This follows 2 to 4 hr after eating food poisoned with the toxin. Traveler's diarrhea and viral gastroenteritis may also cause severe vomiting, as may food that is contaminated. On the other hand, there is little or no vomiting in giardiasis and pseudomembranous colitis.
4. Did several members of the family experience acute diarrhea also? This is a key question because it indicates whether there is a possibility of toxic staphylococcal gastroenteritis or the possibility of a contagious condition such as infection with Salmonella , Shigella , or Campylobacter . If only one member of the family was suffering from diarrhea and everyone is eating the same food, then it is less likely to be a contagious condition, and one must consider ulcerative colitis, pseudomembranous colitis, and conditions listed under chronic diarrhea.
5. Was there recent foreign travel? Recent foreign travel would suggest the possibility of traveler's diarrhea, cholera, shigellosis, salmonellosis, and giardiasis.
6. Is there neurologic symptomatology? This should point one in the direction of botulism, and generally a little epidemiologic research will disclose that other people in the community have been suffering from the same condition.

DIAGNOSTIC WORKUP

The first thing to do is a stool for occult blood. This will help distinguish those patients who are having obvious infectious disease of the large intestine or maybe even the small intestine. It will also make one suspicious of ulcerative colitis. All patients need a stool culture and stool for ova and parasites. A stool for Giardia antigen can also be done. Serologic studies will not be of much help in the acute condition, but they may help later on in cases of salmonellosis and amebiasis. The clinician himself should do a methylene blue smear for leukocytes and examine a wet saline preparation of the stool. If there is a history of antibiotic uses, a stool should be tested for Clostridium difficile toxin B. Leukocytes on a smear suggest bacterial cause and a culture should be done. The laboratory should be alerted if Campylobacter or Yersinia are suspected because special culture media are needed. If the diarrhea persists or if there is blood, sigmoidoscopy or colonoscopy should be performed. It is always important to examine the rectum for hemorrhoids and anal fissures that may be causing the positive stool for occult blood. When the diarrhea persists and becomes chronic, the diagnostic workup should include the studies that are listed under chronic diarrhea.

 

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

DIARRHEA, CHRONIC: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a positive drug or alcohol history? It is well known that alcohol can cause diarrhea, as do drugs in common use, such as digitalis, diuretics, beta-blockers, aspirin, colchicine, and other nonsteroidal anti-inflammatory drugs. Perhaps there is overuse of laxatives. Remember, patients may lie about the use of laxatives.
2. Is there blood in the stool? Blood in the stool certainly is significant for ulcerative colitis, carcinoma, and diverticulitis, but it is also found in amebiasis and the Zollinger-Ellison syndrome.
3. Is there a lot of mucus in the stool? Mucus is often found in ulcerative colitis, Crohn's disease, and irritable bowel syndrome.
4. Is there evidence of steatorrhea? Large volumes of stools that are partially formed or formed and float in the commode suggest steatorrhea. Stool analysis can be done, as is discussed later.
5. Is there an abdominal mass? A mass in the right lower quadrant would suggest carcinoma or diverticulitis. Tenderness in the left lower quadrant with or without a significant mass would be suggestive of ulcerative colitis, diverticulitis, and irritable bowel syndrome. A mass in the area of the ascending or descending colon or the transverse colon should be looked for also, as these would suggest carcinoma.
6. Are there signs of systemic disease? Many systemic diseases may cause diarrhea. Among them are thyrotoxicosis, in which case one would be looking for a thyroid tumor and a tremor and tachycardia; carcinoid syndrome, which would cause considerable flushing; Addison's disease, which would cause hyperpigmentation of the skin; and pellagra, which may cause dermatitis and dementia.
7. Does significant diarrhea persist on fasting? Diarrhea that persists after fasting suggests a secretory diarrhea from a polypeptide-secreting tumor, such as villous adenoma, a gastrinoma, or a carcinoid tumor.

DIAGNOSTIC WORKUP

Most patients will be diagnosed by a stool culture, stool for occult blood, and stool for ovum and parasites, along with a sigmoidoscopy and barium enema. Giardiasis may be best diagnosed by the finding of Giardia antigen in the stool. In patients who have been on antibiotics, the stool should be tested for C. difficile toxin B. If a systemic disease is suspected, CBC, sedimentation rate, chemistry panel, and thyroid profile should be done. An HIV antibody test may be indicated depending on the history. A urine test for 5-HIAA will uncover a carcinoid syndrome. A serum gastrin will usually reveal a gastrinoma. If these tests do not provide a diagnosis, the most cost-effective approach at this point is to refer the patient to a gastroenterologist, who will undoubtedly perform a colonoscopy as part of the workup. Small bowel aspiration and biopsy will be useful in diagnosing Giardia infection or celiac sprue; angiography will confirm mesenteric ischemia or infarcts.

If a gastroenterologist is not available, the clinician may proceed with a quantitative 24-hr stool analysis for fat. If there is 10 g or more of fat in the stool in a day, then steatorrhea can be diagnosed and one can proceed with the workup of steatorrhea. If there is less than 7 g of fat per day in the stool, the stool volume after fasting should be done. If it is large and we have ruled out surreptitious laxative abuse, a polypeptide-secreting tumor should be considered. Here again, it would be best to refer the patient to a gastroenterologist. If the volume after a fast is small, the problem is most likely lactose or other food intolerance or an irritable bowel syndrome. Occasionally, the problem is dysfunction of the anal sphincter. Once again, a GI specialist is probably best consulted for workup of a dysfunctional anal sphincter.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Diarrhea - Acute: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Infectious etiologies
  –Acute (viral) gastroenteritis
  –“Traveler's diarrhea”: Shigella, Salmonella, enterotoxigenic E. coli, Campylobacter
  –Rotavirus
  –Norwalk virus
  –Yersinia enterocolitica
  –Clostridium difficile (pseudomembranous enterocolitis): Follows antibiotic use
  –Giardiasis: Foul-smelling, explosive diarrhea
  –Enterovirus
• Lactose intolerance
• IBS: Alternating diarrhea and constipation
• Ischemic colitis: Associated with history of atherosclerotic disease (CAD, PVD, AAA)
• Inflammatory bowel disease (ulcerative colitis, Crohn's disease)
• Medications (e.g., laxatives, antibiotics, anticholinergics, chemotherapy, metformin)
• Malabsorption syndromes
• Vasculitis
• Neoplasia
• Appendicitis
• Adrenal insufficiency
• Hyperthyroidism
• HIV
• Less common etiologies include E. coli O157:H7 (commonly associated with raw meat; invasive, bloody diarrhea), Cryptosporidium, Cyclospora, Isospora belli, typhoid fever

Workup and Diagnosis

• History and physical examination
  –Proper history should include travel history, woodland exposure (Giardia), immune status, and sick contacts
  –Blood pressure and pulses, including orthostatics
  –Full abdominal examination
  –Back, genital, and rectal examinations
  –Skin examination (e.g., jaundice, turgor)
  –Signs of dehydration (e.g., loss of jugular pulsations, dry mucous membranes, skin tenting, orthostasis)

• Stool examination and culture are usually indicated
  –Fecal leukocytes suggest for infectious causes
  –Fecal lactoferrin suggests laxative abuse
  –Ova and parasites (for Giardia and Cryptosporidium) should be considered in at-risk patients with persistent diarrhea
  –Stool cultures may identify Salmonella, Shigella, Campylobacter, Yersinia, or E. Coli
  –Test stool for C. difficile toxin, if suspected
  –Stool osmolar gap is elevated in osmotic and malabsorptive diarrhea and decreased in infectious/secretory diarrhea

• Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, urinalysis, liver function tests, and hepatitis serologies
• Therapeutic trial of a lactose-free diet or lactose intolerance testing may be useful
• Barium enema, colonoscopy, and/or flexible sigmoidoscopy may be indicated
• Consider HIV testing

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Source: In a Page: Signs and Symptoms, 2004

Diarrhea - Chronic: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Diarrhea due to deranged motility presents with alternating diarrhea and constipation, bloating, mucus or blood in the stool, relief of abdominal pain upon defecation, worsening diarrhea with stress
  –IBS: Usually presents in the morning, seldom at night; more common in women; rectal urgency
  –Diabetic neuropathy: Uncontrolled, explosive, postprandial diarrhea; usually seen in patients with neurologic dysfunction and uncontrolled blood sugar
  –Hyperthyroidism
  –Postileal resection
  –Scleroderma
  –Carcinoid syndrome: Diaphoresis and diarrhea
• Secretory diarrhea will persist even after a 48–72 hour fast; stool osmotic gap <50
  –Bacterial gastroenteritis
  –Bile acid malabsorption
  –Colitis
  –Hyperthyroidism
  –Collagen vascular diseases (SLE, MCTD, scleroderma)
  –Neuroendocrine tumors (e.g., VIPoma, gastrinoma, carcinoid)
• Osmotic diarrhea will cease upon fasting; stool osmotic gap >100 mOsm/kg
  –Malabsorption (celiac sprue, nontropical sprue, Whipple's disease)
  –Nonabsorbable substances (e.g., laxatives, lactose, magnesium)

Inflammatory diarrhea presents with blood and mucus in the stools, urgency, fevers
–Inflammatory bowel disease
–Behçet syndrome
–Invasive bacterial disease (Campylobacter jejuni)
–Intestinal neoplasm

Workup and Diagnosis

• History should include appearance of bowel movements (e.g., bloody, mucusy, greasy, color, consistency), recent travel history, associated symptoms (e.g., abdominal pain), and timing
• Physical examination
  –Blood pressure and pulses, including orthostatics
  –Abdominal, back, genital, and rectal examinations
  –Skin examination (e.g., jaundice, turgor)
  –Signs of dehydration (e.g., loss of jugular pulsations, dry mucous membranes, tenting, orthostatics)
  • Stool examination
    –Blood suggests an inflammatory process
    –WBCs suggest an inflammatory or infectious process
    –72-hour stool collection for fecal fat with Sudan stain will diagnose malabsorption or oil-containing laxatives
    –Stool electrolytes should be measured to calculate stool osmolality [2(K⁺+Na⁺)] and osmotic gap [calculated stool osmolality – 300 ×(normal stool osmolality)]
    –Stool culture (including culture for parasites) is indicated if infectious causes are suspected
    –Stool pH
  • Initial lab tests may include CBC, electrolytes, LFTs, BUN/creatinine, calcium, glucose, urinalysis, and TSH
  • Endoscopy (flexible sigmoidoscopy, colonoscopy with biopsy, or EGD for small bowel biopsy)
  • Breath hydrogen test for lactose intolerance
  • Abdominal CT, small bowel series, and/or barium enema may be indicated
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Source: In a Page: Signs and Symptoms, 2004

Diarrhea – Chronic, No Blood or Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Osmotic: Presence of nonabsorbable solute, pH <5, volume <200 mL/day, normal electrolytes, stops with fasting
• Secretory: Mostly due to toxins, pH >6, volume >200 mL/day, no response to fasting, stool Na >70 mEq/L, negative reducing substances
• Toddler's diarrhea: Chronic nonspecific diarrhea, onset 3 months to 3 years of age, average 4–6 stools daily, due to excessive juice intake or low-fat diet
• Excessive intake of nonabsorbable solutes (lactulose, sorbitol, magnesium hydroxide)
• Congenital lactose deficiency: Very rare in infancy, but may occur in extremely premature infants; adult-onset type of hypolactasia may be seen in older children (over age 5), autosomal recessive, 15% white adults, 85% of black adults, 90% of Asian adults
• Secondary lactase deficiency: Follows a viral gastroenteritis, most commonly rotavirus, may persist for months
• Fructose intolerance
• Sucrase-isomaltase deficiency: Autosomal recessive, found in 0.2% of North Americans, symptoms commence on starting sucrose or glucose polymer-containing foods
• Glucose-galactose malabsorption: Rare, autosomal recessive disorder
• Infections
  –Giardiasis (most common infectious cause of chronic diarrhea in toddlers)
  –Cryptosporidium
  –Microsporidium
• Irritable bowel syndrome (IBS)
  –Abnormality of intestinal motility and pain perception with no organic basis
  –Abdominal pain associated with intermittent diarrhea or constipation
• Bacterial overgrowth: Enteric bacteria colonizes the upper small intestine
• Trehelase deficiency (trehelose is the sugar found in mushrooms)
• Zinc deficiency
  –Acrodermatitis enteropathica is typical rash
• Low-fat diet

Workup and Diagnosis

• History
  –Weight loss
  –Daycare setting, ill contacts
  –Diet history: Type and amount of fluids daily (intake of >150 mL/kg/day with normal weight and height suggests toddler's diarrhea)
  –Frequency of stool and consistency
  –Associated symptoms: Abdominal pain, bloating, flatulence, rash, fever, or vomiting
  –Onset of symptoms and relation to ingestion of milk, sucrose, or glucose
  –Worsening with stress (typical for IBS)
  –Exposure to lakes, well water (suggestive of parasite)
  –Travel history
  –Excessive “sugar free” gum chewing (sorbitol)

• Stool examination
  –Gross examination (blood, mucus, undigested food)
  –Color is not helpful
  –Occult blood test (not detected in IBS)
  –pH: Stool pH <5 indicates osmotic diarrhea from reducing sugars (sucrose and trehelose are nonreducing)
  –Stool cultures, O&P, Clostridium difficile toxin
• More studies only if all of above failed to reveal cause
• Hydrogen breath test
  –Detects carbohydrate malabsorption (lactose, sucrose, fructose, glucose) and bacterial overgrowth
• Stool electrolytes if secretory diarrhea is suspected

>>>

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Diarrhea – Chronic, with Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Allergic enteritis: Typically cow's milk or soy in infants
• Inflammatory bowel disease (IBD)
• Cystic fibrosis (CF)
  –Chronic diarrhea may be the only sign
  –90% have pancreatic insufficiency (PI)
• Celiac disease (CD): Gluten sensitivity, increased incidence in selective IgA deficiency, DM, and Down syndrome
• Immune deficiency (e.g., hypogammaglobulinemia)
• Sucrase-isomaltase deficiency: Autosomal recessive, symptoms with starting sucrose or glucose polymer-containing diet
• Microvillus inclusion disease: Most common cause of persistent diarrhea in the neonatal period
• Schwachman-Diamond syndrome
  –Pancreatic insufficiency, neutropenia, short stature, skeletal abnormalities
• Johannson-Blizzard syndrome
  –Pancreatic insufficiency, scalp defects, agenesis of nasal cartilage, deafness, imperforate anus
• Whipple disease:
  –Tropheryma whippelii (actinomycete)
  –Diagnosed mainly in adults
  –Weight loss, diarrhea, and arthropathy
• Tropical sprue: Common in developing countries; folate deficiency and diarrhea
• Neural crest tumors: Pheochromocytoma, VIPoma, Zollinger-Ellison syndrome, carcinoid tumors
• Mastocytoma
• Neuroblastoma
• Abetalipoproteinemia
• Giardiasis, Strongyloides, coccidia
• AIDS
• Acrodermatitis enteropathica: Zinc deficiency, acral perioral and perianal rashes, consider underlying cystic fibrosis
• Mutational defects in ion transport proteins
  –Chloride-losing diarrhea: Rare, ileal chloride transport defect, maternal polyhydramnios
  –Congenital sodium diarrhea
• Tufting enteropathy (epithelial dysplasia)
• Enterokinase deficiency

Workup and Diagnosis

• History and physical exam
  –Diet history and nutritional assessment, onset, frequency, and consistency, history of foreign travel
  –Associated symptoms: Vomiting, irritability, and rashes (dermatitis herpetiformis) with CD; frequent infections in CF and Schwachman-Diamond; digital clubbing in CF, CD, and IBD
  –Hypertension, tachycardia, anxiety, flushing, and sweating with pheochromocytoma; peptic ulcers with Zollinger-Ellison; wheezing, abdominal pain, flushing with carcinoid tumors; pruritus, flushing, and apnea with mastocytoma

• Stool examination: Oily, bulky, and foul-smelling with fat malabsorption; massive watery stools with secretory diarrhea; blood and mucus seen with colitis; stool for ova and parasites or antigen test for Giardia; WBC, eosinophils in allergic disease; occult blood test, stool pH, electrolytes, osmolarity, reducing substances
• PI proven by 72-hour fecal fat, stool elastase, secretin stimulation test, fat-soluble vitamin deficiency (ADEK)
• CBC, ESR, electrolytes, LFT, albumin (low in CD or IBD)
• Sucrose breath test for sucrase-isomaltase deficiency
• Sweat test to rule out CF
• Endoscopic biopsy: CD, IBD, Whipple diagnosis, microvillus inclusion (abetalipoproteinemia)
• Hormonal assay: Gastrin, vasocative intestinal peptide
• Anti-tissue transglutaminase IgA antibodies for CD

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Diarrhea – Acute: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Viral gastroenteritis
  –Rotavirus, most common (winter)
  –Norwalk-like virus
  –Calcivurus
  –Enteric adenovirus
  –Astrovirus
• Bacterial gastroenteritis
  –Campylobacter jejuni (associated with Guillain-Barré syndrome)
  –Salmonella
  –Shigella: May cause seizures (up to 30%), HUS
  –Escherichia coli (various types): Enteropathogenic, enterohemorrhagic (O157:H7) verotoxin can cause HUS (6–8% of cases), enterotoxigenic (traveler's diarrhea), enteroinvasive
  –Clostridium difficile (toxin A or B)
  –Yersinia enterocolitis (mimics acute appendicitis)
  –Vibrio cholerae
  –Aeromonas hydrophila
  –Toxin-mediated food poisoning: Bacillus cereus, Staphylococcus aureus, Clostridium perfringens
  • Parasitic infestations
    –Giardia lamblia
    –Cryptosporidium (severe in AIDS patients)
    –Entamoeba histolytica
  • Food allergies
    –Cow's milk and soy protein allergy are most common in infancy
  • Malbasorption (celiac disease, CF)
  • Lactose or fructose intolerance
  • Overfeeding (relative lactase deficiency)
  • Vitamin deficiency (e.g., niacin )
  • Zinc deficiency
  • Laxative abuse
  • Irritable bowel syndrome
  • Constipation with encopresis
  • Bacterial overgrowth
  • Antibiotics
  • Hirschsprung toxic colitis
  • Adrenogenital syndrome

  Workup and Diagnosis

  • History
    –Duration of diarrhea
    –Frequency and consistency of stool
    –Vomiting, weight loss
    –Diet history
    –History of sick contact
    –Fever and blood mixed in stool more common with invasive pathogens: Salmonella, Shigella, Campylobacter, Yersinia, E. coli O157:H7, and E. histolytica
  • Physical exam
    –Vital signs, look for signs of dehydration
    –Severe cases may present in hypovolemic shock
  • Labs
    –Urinalysis: Specific gravity and ketones
    –Serum electrolytes: Acidosis, hyper- or hyponatremia, hypoglycemia
    –Stool for Rotazyme
    –Stool culture: Salmonella, E. coli, Shigella, Campylobacter, and Yersinia
    –Stool ELISA for C. difficile toxin A and B
    –Stool for ova and parasites
    –Blood culture indicated in the presence of fever
    –CBC may reveal high bandemia with shigellosis
    –Stool for occult blood and WBC is of little value in differentiating viral from bacterial causes

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Source: In A Page: Pediatric Signs and Symptoms, 2007

DIARRHEA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Whichever method is applied (anatomic or physiologic), most causes of diarrhea can be recalled before interviewing the patient. Then one can proceed to ask the right questions to eliminate each suspected cause. Combinations of symptoms and signs will assist greatly in narrowing the differential diagnosis. For example, chronic diarrhea and copious mucous without blood suggests irritable bowel syndrome. Chronic diarrhea with mucous and blood suggests ulcerative colitis.

Physical examination is often unrewarding but it may disclose a hepatic, rectal, or pelvic source for the diarrhea; it may also indicate that the diarrhea is a sign of a systemic disease (e.g., scleroderma or hyperthyroidism). Rectal examination may reveal a fecal impaction. A warm stool examination for pus, pH (acid stool suggests lactase deficiency), fat and meat fibers, blood, ova, and parasites is most essential. A stool culture is done. Proctoscopy (immediately if there is blood) followed by colonoscopy, barium enema, and upper gastrointestinal (GI) series is usually necessary in all cases.

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Source: Differential Diagnosis in Primary Care, 2007

Diarrhea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn't in shock, proceed with a physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient's temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.

Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Last, find out if he's under unusual stress.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Fecal incontinence: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern — for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool sample. Focus your history taking on GI, neurologic, and psychological disorders.

Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See

Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Diarrhea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in shock, proceed with a brief physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient’s temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.

Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Lastly, find out if he’s under unusual stress.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Fecal incontinence: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, at night or with diarrhea. Note the frequency, consistency, and volume of stools passed within the last 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.

Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation, page 334.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Diarrhea: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. General. How long has the diarrhea been present? Most cases of acute diarrhea are secondary to infection (Table 9.1) (2). The overwhelming majority of cases of acute diarrhea are benign and self-limited. Diarrheal illnesses lasting longer than 3 weeks are classified as chronic and should be clinically investigated (Table 9.2) (3,4). Other symptoms to inquire about include associated nausea, vomiting, chills, fever, or abdominal pain. Bloody or melanotic stools and weight loss are red flags that should prompt further diagnostic testing (Chapters 2.13 and 9.11).

B. Acute diarrhea. Has the patient recently traveled, tried new foods, used any medications, or had recent illness? Traveler’s diarrhea commonly begins 3 to 7 days after arrival in a foreign location after exposure to foods or water contaminated with enterotoxigenic Escherichia coli, Salmonella spp., or Giardia spp. Diarrhea that develops within 12 hours of food ingestion is most likely caused by a bacterial preformed toxin. If diarrhea occurs in the setting of a recent course of antibiotic therapy, pseudomembranous colitis caused by Clostridium difficile toxin should be suspected. A thorough medication history includes all products, including over-the-counter agents, alcohol, and caffeine.

 C. Chronic diarrhea. In patients with chronic diarrhea, the history should focus on the characterization of the stools and the pattern of the diarrhea. Diarrhea at night favors an organic cause. Associated periods of constipation can be a clue to irritable bowel syndrome (Chapter 9.3). Is there a family history of diarrhea? Family history can provide clues to a diagnosis of irritable bowel syndrome, inflammatory bowel disease, or a multiple endocrine neoplastic disorder. Concurrent diarrheal illness among family members suggests the possibility of shared pathogens (e.g., Giardia) with a contaminated water source. The history should also detail other medical problems, prior surgeries, and allergies. A sexual history should be sought. Homosexual individuals are at higher risk for exposure to infectious agents, including amebiasis, giardiasis, and shigellosis. In patients with acquired immune deficiency syndrome, infectious agents may include Candida spp., cytomegalovirus, and Cryptosporidium spp. A careful medication history should also screen for laxative abuse.

Physical examination

 A. Focused physical examination. Obtain vital signs (notably temperature) and include orthostatic blood pressure measurements. Assess the patient’s weight and general nutritional status. The abdomen should be examined for bowel sounds, localized tenderness, and organomegaly. A rectal examination may demonstrate a fistula or abscess that can be a clue to Crohn’s disease. Occult or gross blood can indicate an invasive inflammatory diarrheal illness, diverticular disease, or an ischemic bowel.

B. Additional physical examination. The history may lead to a more specific examination (e.g., thyroid for thyrotoxicosis) or a search for lymphadenopathy in an immunocompromised patient.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Acute Diarrhea: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Viral gastroenteritis

❑ Staphylococcal enterotoxin

❑ E. coli

❑ Salmonella

❑ Campylobacter

❑ Drugs

❑ C. difficile colitis

❑ Giardia

❑ Shigella

❑ Yersinia

❑ Entamoeba histolytica

❑ Typhoid fever

❑ Vibrio parahaemolyticus

❑ Cryptosporidia

❑ Cholera

❑ Strongyloides

Diagnostic Approach

Most cases of acute diarrhea are self-limited. Red flags to prompt further evaluation include: profuse watery diarrhea with dehydration; passage of blood or mucous; temperature .38.5˚C, duration .48 hours; severe abdominal pain in a patient over 50; or an immunocompromised patient.

Symptoms that begin within 6 hours of eating suspect food suggest a preformed toxin of Staph aureus or Bacillus cereus, at 8 to 14 hours Clostridium perfringens, and over 14 hours from viral agents or bacterial contamination of food with E. coli.

Secretory diarrhea is characterized by the absence of fever and prominent nausea/vomiting with watery stools that persist when fasting. It is caused by a toxin (Staph, E. coli, Vibrio cholera), gastrin (pancreatic cancer), calcitonin (medullary carcinoma of the thyroid), or vasoactive intestinal peptide
(VIP). Invasive infection with exudative diarrhea is associated with systemic
symptoms, fever, chills, and blood, pus, and proteinaceous material in
the stools. It is most commonly found with infections such as Salmonella, Shigella, Campylobacter, or enterohemorrhagic E. coli. Bloody diarrhea usually indicates invasive infection, but the differential also includes superior mesenteric artery thrombosis, inflammatory bowel disease, and drug-induced or ischemic colitis.

Small bowel diarrhea is characterized by passage of large loose stools, and with periumbilical pain. Large bowel diarrhea has frequent passage of small stools, with tenesmus.

Common pathogens in HIV-associated diarrhea are cytomegalovirus, Cryptosporidia, Isospora, Salmonella, and Giardia.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Chronic Diarrhea: Differential Overview
(Field Guide to Bedside Diagnosis)

Altered Intestinal Motility

❑ Irritable bowel syndrome

❑ Diabetic enteropathy

Inflammatory

❑ Inflammatory bowel disease

❑ Giardiasis

❑ Cryptosporidiosis

Osmotic

❑ Lactase deficiency

❑ Drugs

❑ Pancreatic insufficiency

❑ Post-gastrectomy

❑ Celiac sprue

❑ Small bowel lymphoma

Secretory

❑ Villous adenoma

❑ Pancreatic cholera

❑ Carcinoid

❑ Zollinger-Ellison syndrome

❑ Medullary carcinoma of the thyroid

Diagnostic Approach

Symptoms of inflammatory diarrhea are fever, abdominal tenderness, blood in the stool, or extraintestinal manifestations such as arthritis, erythema nodosum, pyoderma gangrenosum, or iritis. Osmotic diarrhea is suggested by steatorrhea or carbohydrate malabsorption. It improves with fasting. Secretory diarrhea is evidenced by large volume and watery stools, which persist at night and with fasting. Voluminous watery diarrhea is more likely with small bowel disorders, while small-volume frequent diarrhea occurs with colon disorders.

Fat malabsorption is characterized by increased stool bulk with foul-smelling stools. Stools are difficult to flush and leave oil in the bowl. Weight loss occurs despite adequate appetite and intake. Increased flatulence occurs with carbohydrate malabsorption. Protein-losing enteropathy is associated with peripheral edema and ascites. Malabsorption of fat-soluble vitamins may cause specific deficiencies, such as vitamin A (night blindness and dry eyes), vitamin D (paresthesias and cramps), or vitamin K (easy bruising) deficiencies.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Diarrhea: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain the patient’s history. Does he have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Ask about his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Lastly, find out if he’s under unusual stress.

Physical examination

If the patient isn’t in shock, proceed with a brief physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient’s temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Diarrhea: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Lastly, find out if he’s under unusual stress.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Diarrhea: Clinical Features and Diagnosis: Acute Diarrhea
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infection

Gastroenteritis

Viral

Rotavirus

Most commoncause of viral gastroenteritis in North America.

Usually occurs between 3 mos and 3yrs of age.

Although most common during wintermonths, it may occur year round.

Diarrhea may be accompanied by feverand vomiting. Blood is not usually found in stools. Usually lastsfor few days and up to 1 wk.

Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic.

Other Viruses

Adenovirusesmay be associated with acute gastroenteritis, especially in children <2 yrsof age.

Illnessusually occurs during summer.

Stool viral culture is diagnostic.

Caliciviruses, which include Norwalkand Norwalk-like viruses, usually cause epidemics in school-agedchildren or adults.

Infection usually comes from contaminated wateror food.

Cramping abdominal pain, vomiting,and low-grade fever may be associated with diarrhea. Illness usuallylasts several days.

Diagnostic tests include enzyme immunoassayfor detection of viral antigen in stool or antibody in serum, reverse-transcriptasepolymerase chain reaction for detection of viral RNA in stool, and electronmicroscopy for detection of viral antigen in stool.

Astrovirus infection usually occursduring winter.

Vomitingand fever are variable findings.

Stool viral culture is diagnostic.

Role of enteroviruses in GI diseaseis still unsettled.

Although diarrhea may occur, incidence is probablyvery low.

Stool viral culture is diagnostic.

Bacterial

Most commoncauses of bacterial diarrhea include Salmonella species, Shigellaspecies, C. jejuni, and E. coli. Less common are Y. enterocolitica,A. hydrophila, C. difficile, V. parahaemolyticus, non-O1 Vibrioserogroups, S. aureus, and C. perfringens.

Positive bacterial stool culture isdiagnostic.

Salmonella

Most commoncause of bacterial diarrhea in children.

Presentation is variable.

Uncomplicatedacute gastroenteritis is associated with diarrhea, vomiting, cramping abdominalpain, and fever, with resolution usually within 1 wk. Blood in stoolis variable finding.

Salmonella food poisoning occurs 12–24hrs after ingestion of contaminated food or milk products. Vomiting,diarrhea, and abdominal cramping pain usually occur for 2–3days. History and positive culture of stool or contaminated foodproduct are diagnostic.

Enteric or typhoid fever causes abdominalpain and diarrhea. During second week of illness, fine pink macularor papular rash with typical rose spots occurs, and S. typhi maybe isolated from stool and blood.

Shigella

Usual clinicalpresentation of intestinal shigellosis is watery diarrhea and fever. Bloodin stool is variable finding. Occasionally, seizure occurs.

Another presentation is dysentery,which is characterized by severe diarrhea, tenesmus, and fever.Stools contain mixture of blood, mucus, and pus.

Campylobacter jejuni

Peak incidenceof illness due to C. jejuni is between 1 and 5 yrs of age.

Clinical findings include fever, vomiting,abdominal pain, and watery, foul-smelling diarrhea. Stools may containblood and mucus.

Escherichia coli

5 groupsof pathogenic E. coli are recognized: enteropathogenic, enterotoxigenic,enteroinvasive, enteroaggregative, and enterohemorrhagic. In theU.S., disease caused by first 4 groups is uncommon, whereas enterohemorrhagicform is often associated with diarrheal illness seen with hemolytic-uremicsyndrome (HUS).

Although stool culture can identifyE. coli, serotyping must be performed to identify specific strains.

Enteropathogenic strains cause diarrheaand low-grade fever, primarily in infants.

Enterotoxigenic strains produce toxinsthat cause watery diarrhea, vomiting, abdominal cramping pain, andlow-grade fever. Major cause of traveler's diarrhea, butdefinitive diagnosis requires enterotoxin identification, whichis not widely available.

Enteroinvasive strains produce illnesscharacterized by watery diarrhea, abdominal cramps, and high feverwith or without blood in stool. Outbreaks usually occur secondaryto food contamination.

Enteroaggregative strains usually producemild chronic diarrhea.

Enterohemorrhagic strains produce toxinsthat cause watery diarrhea mixed with streaks of blood, hemorrhagiccolitis, or HUS. Serotype 0157:H7 is most common strain associatedwith HUS.

Other Bacterial Pathogens

Infectionwith Y. enterocolitica is most common in children <5 yrsof age.

Clinical findings include fever, vomiting,diarrhea with occasional blood in stool, and right lower quadrantabdominal pain, which may mimic pain of acute appendicitis. Associatedreactive arthritis also may occur. Diarrhea usually lasts 1–2wks.

Usual presentation of A. hydrophilainfection is self-limited, watery diarrhea that usually occurs inchildren <3 yrs of age. Vomiting, fever, and occasionalblood in stools also may occur.

Transmission of V. cholerae, rare infectionin the U.S., occurs by contaminated food or water. Ingested bacteriarelease toxin in intestinal lumen that causes explosive diarrheawith rice water–like stools and massive fluid losses.

Parasitic

Giardia lamblia

G. lamblia,flagellate protozoan, is most common intestinal parasite in the U.S.

Can cause acute self-limited illnesswith diarrhea and crampy abdominal pain or chronic diarrhea withmalabsorption and poor weight gain. Fever is unusual, and bloodin stool is rare. Eosinophilia occurs in minority of cases.

Presence of either trophozoites orcysts in stool or detection of G. lamblia antigens in stool by enzymeimmunoassay is diagnostic.

Entamoeba histolytica

Althoughmany species of amebae exist, only E. histolytica is clearly pathogenic.

Transmission occurs by fecal contaminationof food or water.

Infection is endemic throughout theworld, especially where poor sanitation exists.

Clinical manifestations include diarrheaand abdominal pain or acute colitis with abdominal cramps, tenesmus,and diarrhea containing blood and mucus.

Diagnosis is usually made by identificationof cysts or trophozoites in stool. Serology also may be helpful,particularly with diagnosis of extraintestinal amebiasis and liverinvolvement.

Cryptosporidium parvum

Infectionhas been described in normal persons, individuals with drug-inducedimmunosuppression, and those with HIV.

Normal individuals usually have self-limitedillness, which consists of crampy epigastric pain, nausea, vomiting,and watery, nonbloody diarrhea.

Chronic diarrhea may occur with HIVinfection.

Identification of oocysts in stoolis diagnostic.

Strongyloides stercoralis

This roundworm,2.5 mm in length, is endemic in southern U.S. and common in tropicsand Asia.

Skin becomes red and pruritic afterpenetration by larvae, which usually occurs on feet. Diarrhea, vomiting,and abdominal pain may follow. Migration of larvae through lungscan cause cough and pneumonia. Peripheral eosinophilia also mayoccur.

Identification of larvae in stool isdiagnostic.

Ascaris lumbricoides

Infectioncan be asymptomatic or cause mild diarrhea, intermittent epigastricpain, anorexia, and vomiting.

Identifying whitish-brown Ascaris worm,20–40 cm in length, or finding Ascaris eggs on microscopicexam of stool is diagnostic.

Hookworm Infection

Adult hookwormsN. americanus and A. duodenale can cause red, pruritic lesions on feetor between toes where larvae penetrate. Other manifestations includediarrhea, vomiting, abdominal pain, anemia from GI blood loss, andperipheral eosinophilia.

Detecting hookworm eggs on stool smearis diagnostic.

Trichuris trichiura

T. trichiura,4-cm long whipworm, occurs most commonly in tropical areas but isalso found in subtropical areas (e.g., southern U.S.).

Most individuals are asymptomatic,but diarrhea, tenesmus, weight loss, anemia, and peripheral eosinophiliamay occur.

Seeing eggs on microscopic stool examis diagnostic.

Fungal

Candida Species

C. albicansis most common cause of Candida enteritis, which is characterizedby watery diarrhea and abdominal pain.

Predisposing factors include prolongedantibiotic or immunosuppressive therapy.

Because yeast forms are ubiquitousand occur in fecal flora of normal persons, their presence aloneis not diagnostic. Definitive diagnosis requires demonstration ofintestinal mucosal invasion by Candida on biopsy or isolation ofCandida from ulcerative lesions.

Other Infections

Diarrhea also may be associated with otitismedia, urinary tract infection, meningitis, and septicemia (seefurther discussion of these disorders in other chapters).

Food Poisoning

Occurs becauseof food contaminated with bacterial toxins. Most common bacteria areS. aureus, C. perfringens, and V. parahaemolyticus.

Children usually have acute onset ofcrampy abdominal pain, vomiting, and profuse watery diarrhea.

Resolution usually occurs in 2–3days.

Positive stool culture or culture ofsuspected contaminated food is confirmatory.

Antibiotic-Associated Diarrhea

Oral antibiotictherapy may produce mild, self-limited diarrhea, nausea, vomiting, andabdominal pain.

Frequently implicated antibiotics includeamoxicillin, erythromycin, and tetracycline. Discontinuing drugleads to resolution of diarrhea.

C. difficile–associated diseasepresumably occurs because of antibiotic alteration of colonic floraallowing spores to form vegetative forms that produce toxins. Almostany antibiotic can be implicated, but most frequent ones are amoxicillin,ampicillin, cephalosporins, and clindamycin. Spectrum of illnessvaries from self-limited diarrhea to severe colitis.

Confirm diagnosis with assay specificfor C. difficile toxin because nontoxigenic strains can be isolatedfrom anaerobic cultures. Sigmoidoscopy with biopsy can show typicalmultiple plaquelike lesions (pseudomembranes) in colon.

Allergic Disorders

Developmentof diarrhea after formula feeding may indicate cow milk proteinor soy protein sensitivity.

Clinical picture is variable, rangingfrom acute enterocolitis to chronic diarrhea with or without bloodin stools.

Cow Milk Protein Sensitivity

Although >25known proteins in cow milk are immunogenic, casein and beta-lactoglobulinare of most clinical importance.

Besides diarrhea, other manifestationsof cow milk protein sensitivity are urticaria and anaphylaxis.

Positive skin tests are useful butmay be negative in children <3 yrs. There also may be false-positiveresults with radioallergosorbent test to cow milk protein.

Elimination of cow milk with subsequentchallenge can confirm diagnosis, but if symptoms have been severe,most physicians would not rechallenge.

Soy Protein Sensitivity

Many infantswith cow milk protein sensitivity also have soy protein sensitivity.

Most common presentation is persistentdiarrhea.

History of soy protein formula intakefollowed by clearance of symptoms on hypoallergenic formula [Alimentum(Abbott Laboratories, Abbott Park, IL), Nutramigen (Mead JohnsonNutritionals, Evansville, IN), Neocate (SHS North America, Gaithersburg,MD)], and if necessary, rechallenge with soy formula confirmsdiagnosis.

Other Food Allergy

Common causesbesides milk and soy include eggs, chocolate, shellfish, citrusfruits, and nuts.

Clinical manifestations include diarrhea,urticaria, rhinitis, wheezing, eczema, and anaphylaxis.

History is often diagnostic. Double-blindfood challenges are also diagnostic but can be dangerous if severeallergic reactions have previously occurred.

Congenital Aganglionic Megacolon (Hirschsprung Disease)

Characterizedby absence of enteric ganglia along variable length of intestine.May present in many ways, including delayed passage of meconium;constipation; intestinal obstruction with vomiting and abdominaldistension; or enterocolitis with explosive diarrhea, abdominaldistension, vomiting, and fever.

Suction rectal biopsy with acetylcholinesterasestaining is usually diagnostic.

Hemolytic-Uremic Syndrome

E. coli0157:H7 is most common pathogen associated with HUS.

Onset often begins with fever, vomiting,abdominal pain, and diarrhea, which may contain blood, followedin 5–10 days by hemolytic anemia, hematuria, thrombocytopenia,and often oliguria or anuria.

Intussusception

Most commonage of presentation is 6–12 mos. Usual clinical manifestationsare crampy abdominal pain, vomiting, and blood in stool. Abdominalmass may be palpable, and diarrhea may occasionally occur.

Abdominal radiographs that show leadingedge of intussusceptum outlined by air are diagnostic. Otherwise,radiographs may be normal or show evidence of bowel obstruction.

If intussusception is suspected, air-contrastenema should be performed. If bowel obstruction is suspected, surgicalconsultation should be obtained before proceeding with air-contrastenema.

Diagnostic Approach: Acute Diarrhea

Most commoncause of acute diarrhea is infection with rotavirus. Common bacterial pathogensinclude Salmonella species, Shigella species, and C. jejuni.

Presence of fever and blood or pusin stool suggests bacterial infection, and bacterial stool cultureshould be performed.

Stool toxin assay for C. difficileshould be considered whenever diarrhea persists during or followingantibiotic therapy.

Cow milk or soy protein sensitivityis likely when diarrhea occurs after ingestion of these productsand no evidence of infection or antibiotic usage exists.

Intussusception and HUS also shouldbe considered in children with bloody diarrhea.

'>'>>>

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Fecal Incontinence: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Maturational Delay or Developmental Conflict

Some childrenexperience maturational delay in developing bowel control. Others havenever been toilet trained.

Sometimes developmental conflicts resultin fecal incontinence.

History and normal physical exam arediagnostic.

Stress-Related Factors

Stress iscommon cause of secondary fecal incontinence. Stress-related factorsinclude illness, separation, birth of sibling, attending new school,death of family member, parental divorce, or any other personalor family upset.

History and normal physical exam arediagnostic.

Constipation

Chronicconstipation from functional fecal retention is thought to be majorcause of encopresis, which is defined as fecal incontinence notresulting from illness or organic disorder.

Most cases of encopresis occur in school-agedchildren, who soil their underclothes.

See Chap.9, Constipation.

Neurologic Disorders

Childrenwith mild mental retardation may have delay in achieving bowel control, whilesome with severe retardation never achieve control.

Spinal dysraphism, spinal cord injury,or spinal cord tumor can be associated with fecal incontinence.

History andphysical exam, including rectal and neurologic exams, screen forthese disorders. Often there is history of lower extremity weakness,impaired sensation, and lack of bladder or bowel control. Strength,tone, sensation, and reflexes of lower extremities; back; anal sphinctertone; perianal sensation; and gait should be particularly examined.

Spine radiography, CT, and MRI locateand define extent of lesion.

Primary Psychologic Disturbance

Childrenwith severe behavioral disorders or psychosis may develop fecalincontinence.

History (including psychosocial historyof child and family), physical exam, clinical observation of child,and psychologic testing are diagnostic.

Diagnostic Approach

In childwith normal physical exam, most common causes of fecal incontinenceare maturational delay, developmental conflict, stress-related factors,and constipation. If primary psychologic disturbance exists, furtherevaluation should be performed by clinical psychologist or psychiatrist.

History and physical exam can screenfor a neurologic disorder. Relaxed anal sphincter tone, decreasedperianal sensation, lower extremity weakness, and urinary incontinencesuggest spinal cord lesion. Combination of spine radiography, CT,and MRI is usually diagnostic.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Diarrhea: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in shock, proceed with a physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient's temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.

Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Last, find out if he's under unusual stress.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Fecal incontinence: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient with fecal incontinence about its onset, duration, and severity and about any discernible pattern—for example, does it occur at night or only with episodes of diarrhea? Note the frequency, consistency, and volume of stools passed within the past 24 hours and obtain a stool specimen. Focus your history taking on GI, neurologic, and psychological disorders.

Let the history guide your physical examination. If you suspect a brain or spinal cord lesion, perform a complete neurologic examination. (See Neurologic control of defecation.) If a GI disturbance seems likely, inspect the abdomen for distention, auscultate for bowel sounds, and percuss and palpate for a mass. Inspect the anal area for signs of excoriation or infection. If not contraindicated, check for fecal impaction, which may be associated with incontinence.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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