1. Viral gastroenteritis
- Thunderclap onset
- Upper tract sx before lower tract sx
- Treat with IV LR since he's probably losing a lot of electrolytes
- Overwhelming likely to be norovirus
- Any nausea- zofran, compazine, metaclopromide, can give as suppository
- Warn patients about transient lactose intolerance since these viruses will strip your brush border - then people will drink milk and get bloating and diarrhea and come back to you thinking its recurred
- Course: 24 hrs of sx, then 24 hours of feeling weak, better
- Antidiarrheal meds fine, except dystentery and suspicion for c.diff. If you suspect bacterial gastro (fever, look sick) maybe hold off in case it turns into dysentery
2. Diarrhea
- Noninfectious - no f, abd pain, constitutional sx (less severe, longer lasting)
- Gastroenteritits - n/v, watery diarrhea, entire bowel affected
- Dysentery: grossly bloody stool, colon inflammation, tenesmus. Has to be grossly bloody-- anyone with bad viral gasteroenteritis will have heme+ stool
3. Common causes of food poisoning: 

4. Bacterial gastroenteritis

- Campy

- Salomonella

- EPEC

- Shigella (more likely to cause gastroenteritis than dysentery; and even with d) 

- C.diff 

- More likely to be bacterial if its slightly longer (3-6 days), while <24-48 hours you think viral, toxin. 

5. When to culture

- People you think it'll make a difference in treatment, 

- Public health move - outbreak tracking. 

- <10% of all stool cx are +, <1% of stool O+P are positive 

6. Prevention of traveler's diarrhea  

- Pepto bismol before meals decreases risk of traveler's diarrhea 30% 

- Prophylactic antibiotics - immunocompromised, IBD (gastroenteritis can cause IBD flare), high-stakes trip or high-risk area 

- Stop PPIs 

- Cipro or azithro +/- flagyl. Rifamaxin (not absorbed systemically) 

- Ice, mixed drinks, refilled bottled water

- "the only way to clean lettuce is with a blowtorch"

- Any food heated for a prolonged time (unless fried before you) 

- Fruit

- Table top sauces - Annals of internal medicine cultured tabletop sauces (guadelajara - 2/3 of table sauces grew out enteropathogenic organisms, 15% in houston) 

7. Antibiotics for cholera

- doxy, cipro, azithro. {source}

8. Diarrhea course: 

- 2 weeks acute, 6 weeks subacute, >6 weeks chronic

9. Differential Non-infectious diarrhea (no fever, chills, abd pain)

Medications and other ingestible substances (some with osmotic effect)

- Sorbitol (gum, mints, pill fillers- this is a big one for people taking mega-vitamins) 

- Mannitol

- Fructose (fruits, soft drinks)

- Fiber (bran, fruits, vegetables)

- Lactulose

- Magnesium-containing medications

Nutritional supplements

- Antacids

- Laxatives

Malabsorption

- Lactose intolerance (skim milk worst-- fat makes it better) 

- Pancreatitis (often chronic- look for people with alcohol hx, calcified pancreas)

Medications causing diarrhea through nonosmotic means

- Metformin

- Antibiotics

- Colchicine

- Digoxin

- Selective serotonin reuptake inhibitor antidepressants

IBS

10. IBS treatment

- High fiber diets

- Finding + avoiding trigger foods

- If people are constipation vs diarrhea predominant, you treat accordingly