CURRENT Essentials of Critical Care.pdf

166 Current Essentials of Critical CareDiarrhea■ Essentials of Diagnosis• Increase in fluidity, frequency, or quantity (200 g/day) of stool,any loose stool, or 500 mL watery stool per day for two days• Stool studies: fecal leukocytes, C difficile toxin, stool electrolytesto determine stool osmolar gap, ova and parasites• Consider flexible sigmoidoscopy if ischemic colitis or inflammatorybowel disease suspected• Etiologies: medications (antacids, antibiotics, metoclopramide),enteral feedings, infections, cholestatic syndromes (hepatitis,bile duct obstruction, steatorrhea), malabsorption (short-bowelsyndrome, afferent loop syndrome), diabetic neuropathy, hyperthyroidism,immunodeficiency, inflammatory colitis• Complications: volume depletion, electrolyte losses, skin breakdownwith secondary infection.■ Differential Diagnosis• Celiac disease • Lactase deficiency• Pancreatic insufficiency • Hyperthyroidism• C difficile colitis • Drug-related diarrhea• Ischemic colitis■ Treatment• Replete fluid and electrolyte losses• Discontinue possible causative agents and medications• Use antidiarrheal agents with great caution• Metronidazole or vancomycin for suspected or confirmed C difficilecolitis; enteric precautions to prevent spread to other patients• Enteral feeding associated diarrhea: discontinuation only proveneffective therapy; other options include changing to peptidebasedformula, adding fiber, or changing rate, fat content, osmolality,or temperature of feeding solution• Consider parenteral nutrition if unable to tolerate enteral feedings• Disimpaction if related to constipation and fecal impaction• Specific treatment directed once etiology determined■ PearlC difficile colitis in the ICU can be acquired from environmental exposures,person-to-person contacts, and hand carriage from healthcare providers.ReferenceRingel AF et al: Diarrhea in the intensive care patient. Crit Care Clin1995;11:465. [PMID: 7788541]