Friday, October 21, 2022: Gastroenterology: Diarrhea is an Increased Volume or Frequency of Stool, Generally of a more Liquid Consistency; Ax: 1) Idiopathic (Most Common Cause), 2) Viral Infection; Fluid Assessment is Most Important in the Management of this Disease Process (Hypotension, Orthostasis, Severe Pain, Fever, Abdominal Pain/Tenderness warrant Admission) and Normal Saline (NS) Bolus is Mandatory therein; Diarrhea can be classified as: 1) Acute (< 2 Weeks) and Infectious Aeitology must be Studied/Investigated (Bloody or Non; ); Antibiotic-Associated Diarrhea (Clostridioides Difficile) and Lactose Intolerance are the primary causative Factors herein; Stool Study is Important in Determining the Cause: Initial and Basic Work-up: 1) CBC, 2) BMP, and 3) Stool Culture; Other Investigations Possible and/or Relevant are 1) Stool Lactoferrin (WBC/RBS) Positive indicates a Bloody Diarrhea; 2) Ova And Parasites (O& P) or Giardia Antigen; 3) Culture of Stool (Delays Diagnosis by 2 Days); 4) Polymerase Chain Reaction (PCR) Stool Testing may assess Multiple and Variable Aetiologic Agents Possible; 5) C. Difficile Toxin; 6) Stool Osmotic Gap; 6) Fecal Fat Assessment; 7) Other Tests are Possible Depending on Symptoms and Manifestations; In Bloody Diarrhea and Positive Lactoferrin Test (Diagnostic Test for Bloody Diarrhea): 1) Salmonella spp (Salmonellosis) usually via Poultry, Eggs and Milk; 2) Campylobacter jejuni (Campylobacteriosis) via Poultry, Eggs and Milk (S/P Campylobacteriosis is Associated with Guillain-Barre Syndrome [GBS] and Reactive Arthritis [Reiter's Syndrome]). Salmonella and Campylobacter are the most common Causes of Bloody Diarrhea; 3) Shigella spp (Shigellosis); 4) YersInia enterocolitica (Yersiniosis); 5) Enterohemolytic Escherichia Coli (EHEC) causes Dysentery and Hemolytic Uremic Syndrome (HUS); 6) E. Coli O157:H7 (HUS via CBC with Thrombocytopenia, otherwise Thrombotic Thrombocytopenia Purpura [TTP-HUS]). Antibiotics and Platelets Transfusion is Contraindicated in this Diagnosis as a viable Treatment Modality; 7) Entamoeba Histolytica (Amoebiasis), An Anaerobic Parasite affecting Humans and other Primates also; 8) Vibrio parahemolyticus, a Gram-Negative Bacterium, is the causative agent of Acute Gastroenteritis via Raw/Undercooked Oysters and/Seafood; and 9) Vibrio vulnificus (Related to V. cholerae) and causative agent of Vibriosis, an Infection via Seafood ingestion. Liver Disease and a High Iron State is Associated with this Infection; Tx: If Subject is Stable: 1) Fluid Replacement and 2) Observation; In an Unstable Subject, 1) Antibiotics are Standard and 2) Culture (Do not await Culture): 1) PO Ciprofloxicin (or Other Flouroquinolone) and +/- Metronidazole; 2) If V. vulnificus is Suspected (History of Seafood Ingestion) Doxycycline is Indicated; It is useful to understand Most Cases are Self-Limited/Self-Resolving; 3) Ischemic Bowel Disease is a Possible complication in Older Subjects in a 1) Hypercoagulable State and 2) History of Atrial Fibrillation (A-Fib). Pain is a Prominent Sign and Leukocytosis. Dx: Abdominal X-Ray (Air Fluid Level, Bowel Hypertrophy, Thumbprint sign. Tx: Surgery). For Non-Bloody Diarrhea (Negative Lactoferrin Test): 1) Giardia lamblia/intestinalis/deudenalis (Giardiasis) and is Associated with Contaminated Water and Unprotected Sexual Intercourse (SSx: Watery diarrhea, and Flatulence, Foul Smelling Stool); Dx: Ova and Parasites (Positive O & P; Positive Giardia Antigen Test); 2) Bacillus Cereus, A Gram-Positive Bacterium acquired via Food (Foodborne Infection; Chinese Take-out food and Reheated Fried Rice; Emesis/Nausea); 3) Staphylococcus aureus, A Gram-Positive Bacteria (Associated with Coleslaw, Diary, Picnics; and Infection SSx are Emesis and Nausea; 4) Clostridium perfringens (Foodborne Infection due to Meat, otherwise Food Poisoning); 5) Listeria monocytogenes (Increased Incidence in Pregnancy); 6) Cryptosporidium hominis (Intestinal Cryptosporiosis) is a Parasite and is associated with Immunodeficiency of HIV Infection and is an AIDS-defining Infection (CD4 Cell Count < 100); Dx: CMP will show an Elevated Alkaline Phosphatase (High ALP); 7) Isospora belli (Cystoisosporiasis) is Parasitic Protozoan and is associated with Immunodeficiency of HIV-AIDS (Opportunistic Infection); Dx: CBC shows Eosinophilia; 8) Virus (Rotavirus MCC of Diarrhea and Norovirus is Typically has an Outbreak Epidemiology) are the Most Common Aetiologic Agents of Non-bloody Diarrhea/Dehydration; Tx: If Subject is Stable: 1) Fluid Replacement and 2) Observation; In an Unstable Subject, 1) Antibiotics are Standard and 2) Culture (Do not await Culture): 1) PO Ciprofloxicin (or Other Flouroquinolone) and +/- Metronidazole; 2) If the Subject is Gestating with Severe Symptoms, IV Ampicillin is Indicated; 3) For HIV-AIDS Subjects, HAART is Standard (Elevate CD4 Count). For Cystoisosporiasis (Isospora belli Infection), Trimethoprim-Sulfamethoxazole is Indicated; 4) Otherwise Gastrointestinal Infections are Self-Limiting. Mx: In an Outpatient Scenario, Hydration is the Paramount Treatment. Isotonic Drinks such as Gatorade, Pedialyte are preferable to Frank hydration due to Electrolyte Formulation (Potassium and Sodium). The Subject should be advised of 1) Basic Food Safety and 2) complications (Prolonged Diarrhea beyond 2 Weeks merits Further Medical Attention). In Antibiotic-associated Diarrhea (AAD), a common Nosocomial Infection, the Aetiologic Agent is Clostrioides difficile (C-Dif) and Intestinal overgrowth thereof due to Antimicrobials (particularly Clindamycin but any Antibiotic may Cause AAD). The Diagnosis can be Suspected in any Subject on Antibiotics and Presenting with Diarrhea. Dx: Positive C. difficile Toxin. Tx: 1) PO Metronidazole is SOC; 2) Retreatment with PO Metronidazole for Abated Symptoms and Recurrent Infection; 3) Refractory/Nonresponsive Subjects (> 2 Days) PO Vancomycin is Indicated. Complications possible are 1) Toxic Megacolon and 2) Perforation. In Lactose Intolerance (LI), a common Enzyme Deficiency Pathology, lactase is Absent or Deficient allowing Bacteria Metabolize Lactose to Glucose and Galactose effecting Flatulence and Diarrhea thereby. Dx: Elevated Stool Osmolar Gap on Stool Studies. Tx: 1) Avoidance of Dairy Products (with the Exception of Yogurt) will Treat the Problem and Diagnose the Pathology; 2) Lactase Supplementation; 3) Symptoms Abate within 1-2 Days. In 2) Persistent Diarrhea (> 2 Weeks) or 3) Chronic (=> 4 Weeks): 1) Irritable Bowel Syndrome (IBS) is a Painful Remitting (Night and with Bowel Movements) and Recurring Diarrhea of Chronic Presentation. 2) Inflammatory Bowel Disease (IBD) is a Systemic Pathology (Anemia [Anemia of Chronic Disease] on CBC and Dx via Colonoscopy) with Chronic Bloody Diarrhea (Positive Lactoferrin) and is characterized by Disease Processes like Ulcerative Colitis and Crohn's Disease (SSx: Diarrhea, Fever, Abdominal Pain, and Extraintestinal Manifestations). Arthritides and Dermatoses are Common IBD Pathology; 3) Lactose Intolerance (LI); 4) Malabsorption (MCC is Celiac Disease) manifests as Steatorrhea (Lipids in Feces) and a High Stool Osmotic Gap on Feces Investigations (Stool Study). Malnutrition (Due to Vitamin Deficiency) and Weight Loss are Possible Manifestations, Dx is via 1) Gluten-Free Diet Trial, 2) Anti-tissue Transglutaminase (Anti-tTG IgA) Antibodies or Anti-Gliadin (IgA/IgG Immunoglobulins) Antibodies, or 3) Small Bowel Biopsy via Endoscopy (Morphology of Inflammation/Infiltration [Intraepithelial Lymphocytes], Villi Atrophy, and Crypt Hyperplasia); 5) Carcinoid Syndrome (CS) has Chronic Diarrhea (CD) along with 1) Flushing, 2) Tachycardia (> 100 BPM), and 3) Hypotension (SBP < 90 mm/Hg or DBP < 60 mm/Hg where Normal Blood Pressure is 120/80) due to a Serotonin-Secreting Tumor commonly in the Appendix, Small Bowel and Bronchi (however any Tissue is Possible). The Diagnosis of CS is via the Urinary 5-Hydroxyindoleic Acid Test (5-HIAA), a Serotonin Metabolite. A High Level of 5-HIAA in the Serum is Excreted in the Urine and thereby indicating CS. The Tx is Octreotide Acetate (Sandostatin Tradename), a Short Bowel Syndrome (SBS) Agent/Somatostatic Agent, otherwise a Somatostatin Analog and the Mechanism of Action (MOA) is Serotonin Antagonism. Multiple Endocrine Neoplasia Type I (MEN-I; Pituitary Gland Tumor, Parathyroid Gland Tumor and Pancreatic Tumor Morphology) has a Positive Association with the Development of a Carcinoid Tumor in CS. It is useful to understand another possible Aetiologic Agent of Chronic Diarrhea is Hepatitis A Virus (HAV) Infection. Goodness, My first Dirrrhea Diagnosis on the Basis of Neoplasia. Just Kidding. The Subject simply went fishing too long and ate too many Crustacean Shrimps (Vibriosis due to Vibrio parahaemolyticus). MD Paul Bolin, Zu Essen gut ist aber zu Gesundheit Bauen, man muss essen mit der Macht (Macht geht vor Recht). Heil!
Friday, October 21, 2022: Gastroenterology: Diarrhea is an Increased Volume or Frequency of Stool, Generally of a more Liquid Consistency; Ax: 1) Idiopathic (Most Common Cause), 2) Viral Infection; Fluid Assessment is Most Important in the Management of this Disease Process (Hypotension, Orthostasis, Severe Pain, Fever, Abdominal Pain/Tenderness warrant Admission) and Normal Saline (NS) Bolus is Mandatory therein; Diarrhea can be classified as: 1) Acute (< 2 Weeks) and Infectious Aeitology must be Studied/Investigated (Bloody or Non; ); Antibiotic-Associated Diarrhea (Clostridioides Difficile) and Lactose Intolerance are the primary causative Factors herein; Stool Study is Important in Determining the Cause: Initial and Basic Work-up: 1) CBC, 2) BMP, and 3) Stool Culture; Other Investigations Possible and/or Relevant are 1) Stool Lactoferrin (WBC/RBS) Positive indicates a Bloody Diarrhea; 2) Ova And Parasites (O& P) or Giardia Antigen; 3) Culture of Stool (Delays Diagnosis by 2 Days); 4) Polymerase Chain Reaction (PCR) Stool Testing may assess Multiple and Variable Aetiologic Agents Possible; 5) C. Difficile Toxin; 6) Stool Osmotic Gap; 6) Fecal Fat Assessment; 7) Other Tests are Possible Depending on Symptoms and Manifestations; In Bloody Diarrhea and Positive Lactoferrin Test (Diagnostic Test for Bloody Diarrhea): 1) Salmonella spp (Salmonellosis) usually via Poultry, Eggs and Milk; 2) Campylobacter jejuni (Campylobacteriosis) via Poultry, Eggs and Milk (S/P Campylobacteriosis is Associated with Guillain-Barre Syndrome [GBS] and Reactive Arthritis [Reiter's Syndrome]). Salmonella and Campylobacter are the most common Causes of Bloody Diarrhea; 3) Shigella spp (Shigellosis); 4) YersInia enterocolitica (Yersiniosis); 5) Enterohemolytic Escherichia Coli (EHEC) causes Dysentery and Hemolytic Uremic Syndrome (HUS); 6) E. Coli O157:H7 (HUS via CBC with Thrombocytopenia, otherwise Thrombotic Thrombocytopenia Purpura [TTP-HUS]). Antibiotics and Platelets Transfusion is Contraindicated in this Diagnosis as a viable Treatment Modality; 7) Entamoeba Histolytica (Amoebiasis), An Anaerobic Parasite affecting Humans and other Primates also; 8) Vibrio parahemolyticus, a Gram-Negative Bacterium, is the causative agent of Acute Gastroenteritis via Raw/Undercooked Oysters and/Seafood; and 9) Vibrio vulnificus (Related to V. cholerae) and causative agent of Vibriosis, an Infection via Seafood ingestion. Liver Disease and a High Iron State is Associated with this Infection; Tx: If Subject is Stable: 1) Fluid Replacement and 2) Observation; In an Unstable Subject, 1) Antibiotics are Standard and 2) Culture (Do not await Culture): 1) PO Ciprofloxicin (or Other Flouroquinolone) and +/- Metronidazole; 2) If V. vulnificus is Suspected (History of Seafood Ingestion) Doxycycline is Indicated; It is useful to understand Most Cases are Self-Limited/Self-Resolving; 3) Ischemic Bowel Disease is a Possible complication in Older Subjects in a 1) Hypercoagulable State and 2) History of Atrial Fibrillation (A-Fib). Pain is a Prominent Sign and Leukocytosis. Dx: Abdominal X-Ray (Air Fluid Level, Bowel Hypertrophy, Thumbprint sign. Tx: Surgery). For Non-Bloody Diarrhea (Negative Lactoferrin Test): 1) Giardia lamblia/intestinalis/deudenalis (Giardiasis) and is Associated with Contaminated Water and Unprotected Sexual Intercourse (SSx: Watery diarrhea, and Flatulence, Foul Smelling Stool); Dx: Ova and Parasites (Positive O & P; Positive Giardia Antigen Test); 2) Bacillus Cereus, A Gram-Positive Bacterium acquired via Food (Foodborne Infection; Chinese Take-out food and Reheated Fried Rice; Emesis/Nausea); 3) Staphylococcus aureus, A Gram-Positive Bacteria (Associated with Coleslaw, Diary, Picnics; and Infection SSx are Emesis and Nausea; 4) Clostridium perfringens (Foodborne Infection due to Meat, otherwise Food Poisoning); 5) Listeria monocytogenes (Increased Incidence in Pregnancy); 6) Cryptosporidium hominis (Intestinal Cryptosporiosis) is a Parasite and is associated with Immunodeficiency of HIV Infection and is an AIDS-defining Infection (CD4 Cell Count < 100); Dx: CMP will show an Elevated Alkaline Phosphatase (High ALP); 7) Isospora belli (Cystoisosporiasis) is Parasitic Protozoan and is associated with Immunodeficiency of HIV-AIDS (Opportunistic Infection); Dx: CBC shows Eosinophilia; 8) Virus (Rotavirus MCC of Diarrhea and Norovirus is Typically has an Outbreak Epidemiology) are the Most Common Aetiologic Agents of Non-bloody Diarrhea/Dehydration; Tx: If Subject is Stable: 1) Fluid Replacement and 2) Observation; In an Unstable Subject, 1) Antibiotics are Standard and 2) Culture (Do not await Culture): 1) PO Ciprofloxicin (or Other Flouroquinolone) and +/- Metronidazole; 2) If the Subject is Gestating with Severe Symptoms, IV Ampicillin is Indicated; 3) For HIV-AIDS Subjects, HAART is Standard (Elevate CD4 Count). For Cystoisosporiasis (Isospora belli Infection), Trimethoprim-Sulfamethoxazole is Indicated; 4) Otherwise Gastrointestinal Infections are Self-Limiting. Mx: In an Outpatient Scenario, Hydration is the Paramount Treatment. Isotonic Drinks such as Gatorade, Pedialyte are preferable to Frank hydration due to Electrolyte Formulation (Potassium and Sodium). The Subject should be advised of 1) Basic Food Safety and 2) complications (Prolonged Diarrhea beyond 2 Weeks merits Further Medical Attention). In Antibiotic-associated Diarrhea (AAD), a common Nosocomial Infection, the Aetiologic Agent is Clostrioides difficile (C-Dif) and Intestinal overgrowth thereof due to Antimicrobials (particularly Clindamycin but any Antibiotic may Cause AAD). The Diagnosis can be Suspected in any Subject on Antibiotics and Presenting with Diarrhea. Dx: Positive C. difficile Toxin. Tx: 1) PO Metronidazole is SOC; 2) Retreatment with PO Metronidazole for Abated Symptoms and Recurrent Infection; 3) Refractory/Nonresponsive Subjects (> 2 Days) PO Vancomycin is Indicated. Complications possible are 1) Toxic Megacolon and 2) Perforation. In Lactose Intolerance (LI), a common Enzyme Deficiency Pathology, lactase is Absent or Deficient allowing Bacteria Metabolize Lactose to Glucose and Galactose effecting Flatulence and Diarrhea thereby. Dx: Elevated Stool Osmolar Gap on Stool Studies. Tx: 1) Avoidance of Dairy Products (with the Exception of Yogurt) will Treat the Problem and Diagnose the Pathology; 2) Lactase Supplementation; 3) Symptoms Abate within 1-2 Days. In 2) Persistent Diarrhea (> 2 Weeks) or 3) Chronic (=> 4 Weeks): 1) Irritable Bowel Syndrome (IBS) is a Painful Remitting (Night and with Bowel Movements) and Recurring Diarrhea of Chronic Presentation. 2) Inflammatory Bowel Disease (IBD) is a Systemic Pathology (Anemia [Anemia of Chronic Disease] on CBC and Dx via Colonoscopy) with Chronic Bloody Diarrhea (Positive Lactoferrin) and is characterized by Disease Processes like Ulcerative Colitis and Crohn's Disease (SSx: Diarrhea, Fever, Abdominal Pain, and Extraintestinal Manifestations). Arthritides and Dermatoses are Common IBD Pathology; 3) Lactose Intolerance (LI); 4) Malabsorption (MCC is Celiac Disease) manifests as Steatorrhea (Lipids in Feces) and a High Stool Osmotic Gap on Feces Investigations (Stool Study). Malnutrition (Due to Vitamin Deficiency) and Weight Loss are Possible Manifestations, Dx is via 1) Gluten-Free Diet Trial, 2) Anti-tissue Transglutaminase (Anti-tTG IgA) Antibodies or Anti-Gliadin (IgA/IgG Immunoglobulins) Antibodies, or 3) Small Bowel Biopsy via Endoscopy (Morphology of Inflammation/Infiltration [Intraepithelial Lymphocytes], Villi Atrophy, and Crypt Hyperplasia); 5) Carcinoid Syndrome (CS) has Chronic Diarrhea (CD) along with 1) Flushing, 2) Tachycardia (> 100 BPM), and 3) Hypotension (SBP < 90 mm/Hg or DBP < 60 mm/Hg where Normal Blood Pressure is 120/80) due to a Serotonin-Secreting Tumor commonly in the Appendix, Small Bowel and Bronchi (however any Tissue is Possible). The Diagnosis of CS is via the Urinary 5-Hydroxyindoleic Acid Test (5-HIAA), a Serotonin Metabolite. A High Level of 5-HIAA in the Serum is Excreted in the Urine and thereby indicating CS. The Tx is Octreotide Acetate (Sandostatin Tradename), a Short Bowel Syndrome (SBS) Agent/Somatostatic Agent, otherwise a Somatostatin Analog and the Mechanism of Action (MOA) is Serotonin Antagonism. Multiple Endocrine Neoplasia Type I (MEN-I; Pituitary Gland Tumor, Parathyroid Gland Tumor and Pancreatic Tumor Morphology) has a Positive Association with the Development of a Carcinoid Tumor in CS. It is useful to understand another possible Aetiologic Agent of Chronic Diarrhea is Hepatitis A Virus (HAV) Infection. Goodness, My first Dirrrhea Diagnosis on the Basis of Neoplasia. Just Kidding. The Subject simply went fishing too long and ate too many Crustacean Shrimps (Vibriosis due to Vibrio parahaemolyticus). MD Paul Bolin, Zu Essen gut ist aber zu Gesundheit Bauen, man muss essen mit der Macht (Macht geht vor Recht). Heil!
Sir any plans on making Dermatology playlist? It would be appreciated greatly by medical students. Thank you very much for everything!! :)
Thank you Dr. Bolin!
Haha i like your excitement at 18:57 it felt me like as if i am talking with gamer friends on discord
Thank you Dr. Bolin
Thank you so much sir😊..your videos are very helpful...
thanks for the update!
thank you Dr.
thank you so much
nice video, thank you
Dr. Paul, in reference to C. Difficile diarrhea, is it FIDAXOMYCIN used as Rx now or still Metronidazole? Just asking for exam purpose only.
First line Fidaxo, second line Vanco; in EU Metro is still considered to be an okay - good choice
Who have taken notes of what the dr said?
I have had every test in the world. Even breath testing. I have had Diarrhea for 2 years. Help!
♥️♥️♥️♥️♥️♥️♥️😍😍😍😍😍😍🤝🤝🤝🤝🤝