I like your pathway Eric. I kind of teach it as "Are there red flags for a bacterial (non-CDiff) cause," and use that to determine testing and/or empiric Abx in the ED. The only other red flags I tend to add is >12 poops per day or fecal urgency, as those have a high PPV for invasive bacterial diarrhea IMO. 1) You can achieve about a 40% reduction in incidence Traveller's Diarrhea with Pepto 2 tablets TID + QHS! 2) I find imaging to be helpful when I suspect ischemic colitis or there's diagnostic uncertainty (usually in an older person) to potentially save the patient a bunch of antibiotics. 3) Reminder that this pathway is for adults, in kids you should consider HUS as well. Great video!
Great job as always. My only slight suggestion is I think you aren't negative enough regarding fecal occult blood testing (FOBT). FOBT is really only useful for colon cancer screening, with very poor sensitivity and specificity for acute diarrhea (or for suspected acute GI bleeding) such that it is probably more likely to confuse the picture than to improve diagnostic accuracy. I've seen many patients who had an indication for endoscopy fail to get one because of false negative FOBT and many others without a good reason for endoscopy get one because of positive FOBT. I've even had GI fellows decline to see patients because of (false) negative FOBT. Unfortunately the consultants aren't always aware of the limited test characteristics in this situation, so we generalists are forced to fill in the gaps. In the case of acute diarrhea, the major problem would be a false negative leading one to incorrectly exclude inflammatory causes. I suspect you know all of this but were being diplomatic in the video. Use of Fecal Occult Blood Testing as a Diagnostic Tool for Clinical Indications: A Systematic Review and Meta-Analysis: DOI: 10.14309/ajg.0000000000000495 A Case for Abandoning Inpatient Fecal Occult Blood Testing: doi: 10.7759/cureus.8807 TWDFNR: Fecal Occult Blood Testing in Hospitalized Patients with Upper Gastrointestinal Bleeding: doi.org/10.12788/jhm.2773
I’m in uk 🇬🇧 at my wits end ! Had explosive uncontrolled loose stools for a year now! With episodes of incontinence! It’s horrific it’s like a complete blow out! Seems mucus to me is present. I just have lost about 2 litres in volume over 1.5 hours on my last attack. I was shaking and cold. It’s horrific I’m worried about going out or doing anything I’m 34 and brought nappies ! The healthier I eat the worse it seems to be! I’m not lactose intolerant- had tests. Not under any more stress than usual! I’ve been more stressed and had no symptoms. It is utterly miserable 😭
Do you have an opinion regarding whether/ when loperamide or similar anti-diarrheal agents should be used/ not used? I remember something like if a toxin-associated diarrhea is suspected, then it should not be used. Not sure about whether there is any data for/ against this though or merely medical myth.
Anti-diarrheal agents may be used in patients with mild to moderate diarrhea to improve patient comfort. However they should not be used in patients with bloody diarrhea, high fever, or systemic toxicity for fear of worsening the disease. Loperamide (Cap. Imodium 2mg) is preferred in dosage of 4mg initially, followed by 2mg after each loose stool (maximum 16mg/24
Eric, can i get an opinion from you about this quote from a famous canadian physician named William Osler: "The good physician treats the disease; the great physician treats the patient who has the disease." What is your understanding of this quote?
How do you factor in particularly foul-smelling stools (or any change in smell for that matter)? I’ve read that can be suggestive of certain pathologies.
This is a common belief among nurses, and is repeated in layperson-targeted health websites. However, it is a myth. There were a few small studies that claimed to show it was possible specifically to identify the presence of C.diff. However, in those studies, the participants (i.e. the patients' nurses) were not blinded to the clinical characteristics of the patient. When a similar study was repeated with the participants blinded, it was shown that humans are not able to do this (www.ncbi.nlm.nih.gov/pmc/articles/PMC3571629/). Having said that, there are unique volatile compounds present in the stool of patients with C.diff; it's just that the concentration is too low for humans to detect. I can easily imagine an animal like a dog being trained to do this successfully, but it would be far too impractical to deploy in real life when C.diff assays are readily available in most places throughout the world.
I've heard about a case of a patient that was refered for ID for "diarrhea", that happened to have several apricot pits in his rectum that kept the anus open and it constantly leaked out.
I have been suffering for over 2 years with diarrhea, pain, weight loss, no appetite and low grade fever. I have had all the tests and they can't tell me why. I hardly leave the house any longer for fear of an accident. I am at my wits end.
I'm sorry to hear about this. You may find my video on "An Approach to Chronic Diarrhea" more relevant. I'm usually very hesitant to offer specific, individualized medical opinions on here, and this should not be taken as medical advice, but your mention of the low grade fever stands out to me. Most causes of chronic diarrhea are not associated with fever. Without knowing where in the world you are (e.g. if tuberculosis is endemic in your country) or your other medical history (e.g. immunosuppression), one diagnosis that I would wonder about is called Whipple'e disease; this would be particularly true if you also had a history of unusually severe pain in your large joints. It's a rare diagnosis and you probably don't have this, but for someone who has diarrhea + fever and has had "all the tests", I'd wonder about it. (Because it's so rare, it's usually not tested for...)
Hello- I’m in desperate need to find a doctor who can help my mom. She is proving to be a medical mystery- going on almost 8 years. These are just a few things that relate to her: lap band surgery, scar tissue, gut motility, stomach paralysis, 10 years of diarrhea, had stomach nerves burned to try to relieve daily pain, NUMEROUS exploratory surgeries, weight is lower than 100lbs, has to go to hospital at least 4 times a week to get fluids, screams and cries for hours because of pain. 6 different hospitals and still no answers. PLEASE CAN SOMEONE OFFER ANY HELP OR POINT ME IN DIRECTION OF ANYONE ELSE THAT CAN HELP. WE ARE LOSING HOPE.
Has anyone replied to you yet? Your comment is from 2 months ago ! Have you tried GI motility centers? I'm sorry I'm not from the US but I do hope you find what you need
I like your pathway Eric. I kind of teach it as "Are there red flags for a bacterial (non-CDiff) cause," and use that to determine testing and/or empiric Abx in the ED. The only other red flags I tend to add is >12 poops per day or fecal urgency, as those have a high PPV for invasive bacterial diarrhea IMO.
1) You can achieve about a 40% reduction in incidence Traveller's Diarrhea with Pepto 2 tablets TID + QHS!
2) I find imaging to be helpful when I suspect ischemic colitis or there's diagnostic uncertainty (usually in an older person) to potentially save the patient a bunch of antibiotics.
3) Reminder that this pathway is for adults, in kids you should consider HUS as well.
Great video!
OH MY GOD!!! THE MASTER IS BACK AGAIN 🎉🎉🎉🎉
I missed your videos doc!
Great job as always. My only slight suggestion is I think you aren't negative enough regarding fecal occult blood testing (FOBT). FOBT is really only useful for colon cancer screening, with very poor sensitivity and specificity for acute diarrhea (or for suspected acute GI bleeding) such that it is probably more likely to confuse the picture than to improve diagnostic accuracy. I've seen many patients who had an indication for endoscopy fail to get one because of false negative FOBT and many others without a good reason for endoscopy get one because of positive FOBT. I've even had GI fellows decline to see patients because of (false) negative FOBT. Unfortunately the consultants aren't always aware of the limited test characteristics in this situation, so we generalists are forced to fill in the gaps. In the case of acute diarrhea, the major problem would be a false negative leading one to incorrectly exclude inflammatory causes. I suspect you know all of this but were being diplomatic in the video.
Use of Fecal Occult Blood Testing as a Diagnostic Tool for Clinical Indications: A Systematic Review and Meta-Analysis: DOI: 10.14309/ajg.0000000000000495
A Case for Abandoning Inpatient Fecal Occult Blood Testing: doi: 10.7759/cureus.8807
TWDFNR: Fecal Occult Blood Testing in Hospitalized Patients with Upper Gastrointestinal Bleeding: doi.org/10.12788/jhm.2773
Great.. thanks a lot 🌺✨
I’m in uk 🇬🇧 at my wits end !
Had explosive uncontrolled loose stools for a year now! With episodes of incontinence! It’s horrific it’s like a complete blow out! Seems mucus to me is present. I just have lost about 2 litres in volume over 1.5 hours on my last attack. I was shaking and cold. It’s horrific I’m worried about going out or doing anything I’m 34 and brought nappies ! The healthier I eat the worse it seems to be! I’m not lactose intolerant- had tests. Not under any more stress than usual! I’ve been more stressed and had no symptoms. It is utterly miserable 😭
Thanks
Do you have an opinion regarding whether/ when loperamide or similar anti-diarrheal agents should be used/ not used? I remember something like if a toxin-associated diarrhea is suspected, then it should not be used. Not sure about whether there is any data for/ against this though or merely medical myth.
Anti-diarrheal agents may be used in patients with mild to moderate diarrhea to improve patient comfort. However they should not be used in patients with bloody diarrhea, high fever, or systemic toxicity for fear of worsening the disease. Loperamide (Cap. Imodium 2mg) is preferred in dosage of 4mg initially, followed by 2mg after each loose stool (maximum 16mg/24
Eric, can i get an opinion from you about this quote from a famous canadian physician named William Osler:
"The good physician treats the disease; the great physician treats the patient who has the disease."
What is your understanding of this quote?
How do you factor in particularly foul-smelling stools (or any change in smell for that matter)? I’ve read that can be suggestive of certain pathologies.
This is a common belief among nurses, and is repeated in layperson-targeted health websites. However, it is a myth.
There were a few small studies that claimed to show it was possible specifically to identify the presence of C.diff. However, in those studies, the participants (i.e. the patients' nurses) were not blinded to the clinical characteristics of the patient. When a similar study was repeated with the participants blinded, it was shown that humans are not able to do this (www.ncbi.nlm.nih.gov/pmc/articles/PMC3571629/).
Having said that, there are unique volatile compounds present in the stool of patients with C.diff; it's just that the concentration is too low for humans to detect. I can easily imagine an animal like a dog being trained to do this successfully, but it would be far too impractical to deploy in real life when C.diff assays are readily available in most places throughout the world.
@@StrongMed Appreciate the reply! Very interesting, it's funny how these sorts of myths propagated over time.
I've heard about a case of a patient that was refered for ID for "diarrhea", that happened to have several apricot pits in his rectum that kept the anus open and it constantly leaked out.
A good example of why it's important to distinguish diarrhea from fecal incontinence!
I have been suffering for over 2 years with diarrhea, pain, weight loss, no appetite and low grade fever. I have had all the tests and they can't tell me why. I hardly leave the house any longer for fear of an accident. I am at my wits end.
I'm sorry to hear about this. You may find my video on "An Approach to Chronic Diarrhea" more relevant.
I'm usually very hesitant to offer specific, individualized medical opinions on here, and this should not be taken as medical advice, but your mention of the low grade fever stands out to me. Most causes of chronic diarrhea are not associated with fever. Without knowing where in the world you are (e.g. if tuberculosis is endemic in your country) or your other medical history (e.g. immunosuppression), one diagnosis that I would wonder about is called Whipple'e disease; this would be particularly true if you also had a history of unusually severe pain in your large joints. It's a rare diagnosis and you probably don't have this, but for someone who has diarrhea + fever and has had "all the tests", I'd wonder about it. (Because it's so rare, it's usually not tested for...)
Hello- I’m in desperate need to find a doctor who can help my mom. She is proving to be a medical mystery- going on almost 8 years. These are just a few things that relate to her: lap band surgery, scar tissue, gut motility, stomach paralysis, 10 years of diarrhea, had stomach nerves burned to try to relieve daily pain, NUMEROUS exploratory surgeries, weight is lower than 100lbs, has to go to hospital at least 4 times a week to get fluids, screams and cries for hours because of pain. 6 different hospitals and still no answers. PLEASE CAN SOMEONE OFFER ANY HELP OR POINT ME IN DIRECTION OF ANYONE ELSE THAT CAN HELP. WE ARE LOSING HOPE.
Has anyone replied to you yet? Your comment is from 2 months ago ! Have you tried GI motility centers? I'm sorry I'm not from the US but I do hope you find what you need
You are a very good CZcamsr, can I get a comment heart?
❤
Isme Kia hai