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■ Endoscopically treatable lesions include polyps, vascular ectasias, and varices.

■ Radionuclide scans can detect slow or intermittent bleeding if source cannot be found with endoscopy. Angiography can detect more rapid bleeding, and embolization, of bleeding vessels can be done with, f'his procedure.

3. Surgery is reserved for severe or resistant Needing and usually involves resection of affected bowel (usually colon).

Diwrticulosis is extremely common, and the incidence increases with age. Il is thought to be caused partially by a low-fiber, high-fat diet. Complications are lower GI bleeding (common cause) and diverticulitis (inflammation of a diverticula). Look for lower left, quadrant pain, and tenderness, fever, diarrhea or constipation, artel a white count.

Diarrhea has multiple etiologies and is best broken down into categories:

1. Systemic causes: any illness can cause diarrhea as a systemic symptom (e.g., hyperthyroidism, infection).

2. Osmotic diarrhea: nonabsorbable solutes remain in the bowel, where they retain water (e.g., lactose or oilier sugar intolerances, Olestra in potato chips). When the patient stops ingesting die substance (e.g., no more milk or a trial ofNPO), the diarrhea stops an easy diagnosis.

3. Secretory diarrhea: bowel secretes fluid. Causes include bacterial toxins (cholera, some strains of Escherichia coli), vasoactive intestinal peptide-secreting tumor (pancreatic islet cell tumor), or bile acids (after ileal resection). Diarrhea continues with NPO status.

4. Malabsorption: causes include celiac sprue (look for dermatitis herpetiformis, and, stop gluten in the diet), Crohn's disease, and gastroenteritis. Diarrhea stops with NPO status.

5. Infectious causes: look for fever, white blood cells in stool (not with, toxigenic bacteria; only with invasive bacteria such as Shigella, Salmonella, Yersinia, and Campylobacter spp.) and travel (Montezuma's revenge caused by E. coli). Hikers and stream drinkers may get Giardia sp., "which presents with steatorrhea (fatty, greasy, malodorous stools that float) due to small bowel involvement and unique protozoal cysts in the stool.Treat with, metronidazole.

6. Exudative diarrhea: inflammation in bowel mucosa causes seepage of fluid. Due to inflammatory bowel disease (Crohn's disease or ulcerative colitis) or cancer.

1. Altered intestinal transit: after bowel resections or medications that: interfere with bowel function.

Important points:

1. With all diarrhea, watch for dehydration and electrolyte disturbances (e.g., metabolic acidosis, hypokalemia), a common and preventable cause of death in underdeveloped areas.

2. Do a rectal exam, look for occult blood in stool, and examine stool tor ova or parasites, fat content (steatorrhea), and white blood cells.

3. If the patient has a history of antibiotic use, think of Clostridium difficile and test the stool for C. difficile toxin. If the test is positive, treat with metronidazole (if it fails or is not a choice, use vancomycin).

4. Do not forget about diabetic diarrhea, factitious diarrhea (surreptitious laxative abuse, usually by medical personnel), hyperthyroidism, and colorectal cancer as causes of diarrhea.

5. Irritable bowel syndrome (IBS) is a common cause of GI complaints. Patients are anxious or neurotic and have a history of diarrhea aggravated by stress; bloating; abdominal pain relieved by defecation; and/or mucus in the stool. Look for psychosocial stressors in the history and normal physical findings and diagnostic tests. This diagnosis of exclusion requires basic lab tests, rectal, and stool examination, and sigmoidoscopy, but because it is very common, it is the most l ikely diagnosis in the absence of positive findings, especially in young adults. IBS is three times more common in females than males.

6. After bacterial diarrhea (especially E. coli or Shigella sp.) in children, watch for hemolytic uremic syndrome: thrombocytopenia, hemolytic anemia (schistocytes, helmet cells, fragmented red blood cells), and acute renal failure.Treat supportively. Patients may need dialysis and/or transfusions.

Inflammatory bowel disease

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Both Crohn's disease and ulcerative colitis may involve uveitis, arthritis, ankylosing spondylitis, erythema nodosum/multiforme, primary sclerosing cholangitis, failure to thrive or grow in children, toxic megacolon (more common in ulcerative colitis; look for markedly distended colon on abdominal x-ray), anemia of chronic disease, and fever. Both are treated with 5-ASA with or without a sulfa drug (e.g., sulfasalazine); steroids are used for severe flare-tips.

Toxic megacolon is classically seen with inflammatory bowel disease and infectious colitis (especially C. difficile). It may be precipitated by the use of antidiarrhea medications. Symptoms include high fever, leukocytosis, abdominal pain, rebound tenderness, and a very dilated segment of colon on abdominal x-ray. Toxic megacolon is an emergency. Start treatment by discontinuing all antidiarrhea medications; then place the patient on NPO status, insert a nasogastric tube, and administer IV fluids, antibiotics to cover bowel flora (e.g., ampicillin or cefazolm), and steroids if the cause is inflammatory bowel disease. Go to surgery if perforation occurs (free air on abdominal x-ray).

Liver disease, acute: elevated liver function tests, jaundice, nausea/vomiting, right upper quadrant pain or tenderness, and/or hepatomegaly.

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