Diagnostic Algorithm for Chronic Diarrhea

Patient Presentation
CHRONIC DIARRHEA
History
Physical Examination

1 FREQUENT SMALL VOLUME STOOLS 2 PRIMARY FECAL INCONTINENCE + Evaluate and Treat

Rome II Criteria + Red Flags: Treat:

for IBS Reassurance
Hematochezia Patient Education
Weight Loss Empiric Therapy
Nocturnal Symptoms
Age >45 Interval Follow-up + Improvement
Positive Family History
+ Persistent or
Progressive Symptoms

Gross Appearance of Stool

Bloody Diarrhea Watery Appearing Diarrhea Fatty Appearing Diarrhea

R/O Primary Hemorrhoid

Blood Tests Blood Tests

R/O Primary Fissure Stool Tests Stool Tests

Blood Tests

INFLAMMATORY DIARRHEA WATERY DIARRHEA STEATORRHEA

Pathogen Screen R/O Celiac Disease

Celiac Serologies (EMA or tTG)
Pathogen Screen

Responsive to fasting Unresponsive to fasting + EGD

Colonoscopy With Biopsy High osmotic gap Low Osmotic Gap

OSMOTIC DIARRHEA SECRETORY DIARRHEA

Assess for Small Bowel
Malabsorption
Lactose Breath Test Laxative Screen Giardia ELISA

Stool Mg2+/PO42 Endoscopy Breath Test for

(for osmotic laxatives) <45 yrs old and HIV SBBO
Flexible Sigmoidoscopy
>45 yrs old or HIV+ Other
Colonoscopy With Assess for Pancreatic Disease
Blood Tests: Pathogen Screen: Random Biopsies
CBC, Chemistry, LFTs Bacteria CT Scan
Albumin, Coagulation Campylobacter, Yersina CT Scan
Profile, ESR/CRP, HIV (if risk), Aeromonas, Pleisomonas
C. Difficle
ERCP
TSH (if watery diarrhea) Hospitalization
(if Hx of ABx within 3 mos) Stool Analysis
Stool Tests: Pancreatic Function Test
Ova and Parasites Response to fasting
Fecal Electrolytes
Microscopy (normal risk: 1x; Blood tests for hormone-
Fecal Leukocytes
high risk: 2x) secreting tumors
Fecal Occult Blood Testing
Fecal Fat ELISA (if high risk)