Diarrhea: The Basics

What is diarrhea?

Stools that are loose and watery, usually occuring more frequently than the usual bowel movements.

What causes diarrhea?
Most cases of diarrhea are caused by an infection of the gastrointestinal pathway, either viral, bacterial or parasitic. Other less common causes are as follows:

• Eating foods that upset the digestive system
• Allergies to certain foods
• Medications
• Radiation therapy
• Diseases of the intestines (Crohn’s disease, ulcerative colitis)
• Malabsorption (where the body is unable to adequately absorb certain nutrients from the diet)
• Hyperthyroidism
• Some cancers
• Laxative abuse
• Alcohol abuse
• Digestive tract surgery
• Diabetes

What needs to be done?
The mainstay of treatment is the prevention of dehydration and electrolyte losses. Make sure the patient is given adequate fluids. The best choice would be ORS (oral rehydrating solution), which contains adequate concentrations of electrolytes.

In mild cases of dehydration, water, soups, juices, sports drinks and other fluids may be used in the meantime if ORS is not immediately available.

If the patient has difficulty drinking fluids, intravenous fluids may be given instead.

Moderate dehydration requires ORS to be given more frequently.

Severe dehydration requires hospitalization for IV rehydration and observation.

Some cases of diarrhea may require antibiotic treatment. The majority of cases are, however, viral and do not require antibiotic therapy.

What should we watch out for in diarrhea?

We have to watch out for dehydration. The signs of dehydration may include the following:

• Dark urine
• Small amount of urine (less number of diaper changes in small children)
• Rapid heart rate
• Headaches
• Dry skin
• Irritability
• Confusion
• Dry mouth and tongue
• Sunken eyes or cheeks
• No or decreased tear production
• Irritability or listlessness
• Skin that stays pinched instead of flattening out after being pinched

Other signs to watch out for are: fever, blood, undigested food or mucus in the stool and weight loss.

All the above conditions require medical attention.

We must especially be wary of diarrhea in very young or very old patients, or if the diarrhea lasts for weeks.

How to prevent diarrhea?
Most gastrointestinal infections are transmitted via the fecal oral route. Handwashing with water and soap before eating, before and after food preparation and after defecating would prevent trasmission of the microbes that could cause diarrhea.

All water intended for drinking should be adequately disinfected. A simple and effective way is by boiling the water for at least 15 minutes.

Hygiene should always be observed during food preparation.

Source: WebMD

Blighted ovum

A blighted ovum, or anembryonic pregnancy occurs when a fertilized egg never develops an embryo after attaching itself to the uterine wall. The gestational sac, however, continues to develop until a spontaneous miscarriage occurs or a dilatation and curettage is done.

Signs and symptoms:

The usual signs of early pregnancy may be present (missed period, nausea, vomiting, etc.). A urine pregnancy test shows a positive result.

Diagnosis:

Transvaginal ultrasound (TVS) is usually requested to check for viability of an early pregnancy. There should be a gestational sac of adequate size (mean diameter of 13 mm and above) but with no visible yolk sac and embyonic pole on TVS in order to make a diagnosis of a blighted ovum.

It must be noted that a very early pregnancy with a small gestational sac (less than 13 mm diameter) may not show visible signs of either a yolk sac or embryonic pole yet, therefore a diagnosis of blighted ovum cannot be made yet. Repeat TVS should show an enlarging gestational sac and appearance of yolk sac and embryonic pole when the gestational sac is large enough in order to judge for viability of the pregnancy.

Causes:

Majority of blighted ova occur because of the presence of chromosomal abnormalities.

Treatment:

In some cases, the blighted ovum may spontaneously be aborted. However, some doctors and patients would prefer a D&C for physical and psychological closure.

Hydatidiform mole

Hydatidiform mole (H. mole) is one of a spectrum of diseases classified as a Gestational Trophoblastic Disease. Gestational trophoblastic disease encompasses several disease processes that originate in the placenta. These include complete and partial moles, invasive moles, placental site trophoblastic tumors, and choriocarcinomas.

Hydatidiform mole is a relatively complication of pregnancy. Incidence is about 1 in 1000 pregnancies in the United States and other western countries, but in the Philippines as well as other Asian countries, the incidence is much higher, closer to about 1 in 100 pregnancies.

Types:

Hydatidiform moles are usually classified as complete or partial moles. These are usually benign uterine masses, but they do have a slight chance of converting to malignancy.

In a complete mole, there is no identifiable fetal tissue, unlike in a partial mole, wherein there may be an abnomal fetus or other elements like placental tissue.

Other gestational trophoblastic diseases which must be differentiated are invasive moles and choriocarcinoma.

Etiology and Risk factors:

The etiology of this condition is not completely understood.

Potential risk factors may include the following:

- defects in the egg

- abnormalities within the uterus

- nutritional deficiencies: diets low in protein, folic acid and carotene

- age: Women under 20 or over 40 years of age have a higher risk.

Signs and Symptoms:

The most common complaint of patients with H. mole is painless vaginal bleeding. The patient may also experience nausea and vomiting, as well as other signs of pregnancy. The uterus may also be noted to enlarge, mimicking a normal pregnancy. There may also be symptoms of hyperthyroidism, since large amounts of Beta HCG in the blood may mimic thyroid stimulating hormones (TSH).

Diagnosis:

A urine pregnancy test may turn out to be positive because of the high levels of circulating human chorionic gonadotrophin (HCG) hormone, although there may also be cases wherein a false negative pregnancy test may also appear. A more accurate baseline would be a serum (blood) determination of the beta component of HCG (Beta HCG). Levels of Beta HCG are higher than what would be expected for a normal pregnancy of equal duration. This test, although highly suggestive of a gestational trophoblastic disease (GTD), is not definitive for any of GTDs.

A transvaginal ultrasound is usually ordered by the obstetrician gynecologist to check for the presence and characteristic of the uterine mass. The definitive diagnosis, however is via a biopsy.

Chest x-rays and abdominal ultrasounds are usually done to check for any metastasis of villous tissue, as this would affect both the diagnosis (H mole vs. invasive mole vs. choriocarcinoma) and the treatment. Blood exams are usually done prior to treatment to check for liver and kidney functions in preparation for possible chemotherapy treatment. A complete blood count, blood typing, and platelet count is usually done in preparation for blood transfusion.

Treatment:

Suction curettage is the treatment of choice to remove a hydatidiform mole. Since blood loss is expected during the surgery, compatible blood is usually prepared beforehand, typed and crossmatched, so that a transfusion may be done before, during or after surgery, as dictated by the findings.

Specimens obtained during the procedure are sent to the histopathology lab for a the definitive histopathologic diagnosis (Biopsy).

Depending on the associated finding, the gynecologist may also decide to give a course of chemotherapy with low dose Methotrexate (or other chemotherpeutic agents) as prophylaxis against malignant conversion or invasion.

It is important for the attending gynecologist to have a high index of suspicion regarding the mass. The levels of the serum beta HCG and the ultrasound findings would give a strong suggestion of the type of GTD, whether it is an H. mole, an invasive mole or a choriocarcinoma. This is because the treatment protocols of each disease in the spectrum is different.

Follow up:

Serum Beta HCG levels are monitored biweekly after suction curettage until the level reaches undetectable levels. If the beta HCG levels remain high or spikes after it has already decreased, additional therapy may be required.

Patient is advised not to get pregnant within 1 year because of the following reasons:

- Pregnancy increases HCG levels, which would make monitoring of any recurrence difficult.

- A new pregnancy episode may trigger a recurrence of H. mole.

Prognosis:

Prognosis for H mole is usually very good. 80% do not result in malignant conversion. Of the 20% who do develop malignancy, chemotherapy usually works in most cases.

Chance of recurrence is about 1%.

A previous H mole does not affect the chances for a future normal pregnancy. The normal risk factors still apply, though.

Disclaimer: Contents of this blog is only intended as a simplified guide. It is still best to consult an obstetrician-gynecologist if you suspect or are diagnosed with this problem.