Indications for evaluation include profuse diarrhea with dehydration, grossly bloody stools, fever ≥38.5° C, duration >48 h without improvement, new community outbreaks, associated severe abdominal pain in patients >50 years, and elderly (≥70 years) or immunocompromised patients.
In some cases of moderately severe febrile diarrhea associated with fecal leukocytes (or increased fecal levels of the leukocyte proteins) or with gross blood, a diagnostic evaluation might be avoided in favor of an empirical antibiotic trial.
Judicious use of antibiotics is appropriate in selected instances of acute diarrhea and may reduce its severity and duration.
Many physicians treat moderately to severely ill patients with febrile dysentery empirically without diagnostic evaluation using a quinolone, such as ciprofloxacin (500 mg bid for 3 to 5 d).
Empirical treatment can also be considered for suspected giardiasis with metronidazole (250 mg qid for 7 d).
Table 32-5. Signs Associated with Malabsorption Syndromes |
Gastrointestinal Signs |
Mass |
Crohn's disease, lymphoma, tuberculosis, glands |
Distention |
Intestinal obstruction, gas, ascites, pseudocyst (pancreatic), motility disorder |
Steatorrheic stool |
Mucosal disease, bacterial overgrowth, pancreatic insufficiency, infective/inflammatory, drug induced |
Extraintestinal Signs |
Skin |
Nonspecific |
Pigmentation, thinning, inelasticity, reduced subcutaneous fat |
Specific |
Blisters (dermatitis herpetiformis), erythema nodosum (Crohn's disease), petechiae (vitamin K deficiency), edema (hypoproteinemia) |
Hair |
Alopecia |
Gluten sensitivity |
Loss or thinning |
Generalized inanition, hypothyroidism, gluten sensitivity |
Eyes |
Conjunctivitis, episcleritis |
Crohn's disease, Behçet's syndrome |
Paleness |
Severe anemia |
Mouth |
Aphthous ulcers |
Crohn's disease, gluten sensitivity, Behçet's syndrome |
Glossitis |
Deficiencies of vitamin B12, iron, folate and niacin |
Angular cheilosis |
Deficiencies of vitamin B12, iron, folate, B complex |
Dental hypoplasia (pitting/dystrophy) |
Gluten sensitivity |
Hands |
Raynaud's phenomenon |
Scleroderma |
Finger clubbing |
Crohn's disease, lymphoma |
Koilonychia |
Iron deficiency |
Leukonychia |
Inanition |
Musculoskeletal |
Mono/polyarthropathy |
Crohn's disease, gluten sensitivity, Whipple's disease, Behçet's syndrome |
Back pain (osteomalacia/osteoporosis/sacroiliitis) |
Crohn's disease, malnutrition, gluten sensitivity |
Muscle weakness (low K, magnesium, vitamin D, generalized inanition) |
Diffuse mucosal disease, bacterial overgrowth, lymphoma |
Nervous system |
Peripheral neuropathy (weakness, paresthesias, numbness) |
Vitamin B12 deficiency |
Cerebral (seizures, dementia, intracerebral calcification, meningitis, pseudotumor, cranial nerve palsies) |
Whipple's disease, gluten sensitivity, diffuse lymphoma |
Blood assays of albumin, carotene, cholesterol, calcium, and folic acid and of the prothrombin time are useful screening studies for malabsorption. |
Table 32-6. Utility of Small Bowel Biopsy Specimens in Malabsorption |
Often Diagnostic |
Abnormal But Not Diagnostic |
Whipple's disease |
Celiac sprue |
Amyloidosis |
Systemic sclerosis |
Eosinophilic enteritis |
Radiation enteritis |
Lymphangiectasia |
Bacterial overgrowth syndrome |
Primary intestinal lymphoma |
Tropical sprue |
Giardiasis |
Crohn's disease |
Abetalipoproteinemia |
Agammaglobulinemia |
Mastocytosis |
اسپروها،اسکلروزسیستمیک،
کرون،رادیاسیون،BOS--› غیرتشخیصی (اسکراب - کرباس)
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