Beruflich Dokumente
Kultur Dokumente
Diarrhea
Increased frequency of bowel movements and
reduced consistency/increased fluidity of stool
Number of bowel movements greater than 3/daily,
with stool weight > 200g/d
Duration:
Acute (< 2 weeks)
Persistent (> 2 and < 4 weeks)
Chronic (> 4 weeks)
Diarrhea - Issues
Second (?) cause of death worldwide
Leading cause of death in pediatric population worldwide
Developing vs developed countries
Contamination ( CDC-US ):
76.000.000 americans
325.000 admissions to hospital
5.000 deaths
Amebiasis
Giardiasis
Tuberculosis
Blastomycosis
Ulcerative colitis
Crohns disease
Collagenous colitis
Microscopic colitis
Malabsorption
Gastroenteric anastomosis
Pancreatic insufficiency
Hyperchlorydria
Celiac disease
Crohns disease
Tropical sprue
Abetalipoproteinemia
Intestinal lymphangiectasia
Whipples disease
Lactose, fructose
Sorbitol
Drugs
Antibiotics
Anti-hypertensives
Anti-arrhytmics
Diuretics
Chemotherapy
Antacids (Mg)
Ethanol
NSAIDs
Caffeine
Colchicine
Gastrectomy
Vagotomy
Cholecystectomy
Intestinal resection
Endocrine
Adrenal insufficiency
Hyperthyroidism
Hypothyroidism
Diabetes
Laxative abuse
Intestinal ischemia
Radiation colitis/proctitis
Diverticulitis
Functional diarrhea
Gastrinoma
VIPoma
Villous adenoma
Medullar thyroid carcinoma
Ganglioneuroma
Pheochromocytoma
Carcinoid tumor
Mastocytosis
Infiltrative/autoimmune
Scleroderma
Amyloidosis
Intestinal Lymphoma
Immunoproliferative disorders
Food allergy
Absorption of nutrients
Regulation of water, electrolyte absorption/secretion
Motility
Inflammation
Liver/pancreatic function
Surface area/mucosal integrity
Malabsorption - Algorithm
stool analysis
normal
altered
carbohydrates
fecal fat (timed collection)
leukocytes/eosinophils
Malabsorption
imaging
steatorrhea
Case 1
A.V.F., 52 years old, female
Referred for investigation of chronic diarrhea since Feb 1997
Otherwise well when change in bowel habits ~9 years ago,
characterized by 5-6 daily, explosive, watery BMs, LLQ pain,
flatulence, associated with perianal burning. Improvement
with fasting.
Significantly better with reduction in dairy intake.
All symptoms developed following acute, infectious
gastroenteritis in January 1997. No weight loss, no fever or
chills
Physical exam was unremarkable
CBC, lytes, fasting glucose, SPE were normal
Case 2
J.A.P., 34 years old male
Diagnosed with ileocolonic Crohns disease 8 years ago, with ileal
resection due to fibrostenotic disease. On maintenance 5-ASA at
1.2 g/d
Chronic Diarrhea
Osmotic/secretory
Abdominal distention and pain: intestinal gas
carbohydrate vs. fat malabsorption
MSK
Muscle spams, weakness, paresthesia: malabsorption
of vit D, Ca, Mg and PO4
Bone disease (osteoporosis, osteopenia,
osteomalacia) and fracture: fat malabsorption, Ca, vit
D, secondary hyperparathyroidism
Chronic Diarrhea
diagnosis
Nutrient Absorption
pre-epithelial
epithelial
post-epithelial
Chronic Diarrhea
Labs - Imaging
Function Tests
Lactose, lactulose, fructose tolerance test
D-Xylose
Schilling
Bacterial overgrowth (glucose, lactulose, D-xylose)
Pancreatic:
- secretin
- bentyromide
- pancreolauril
- fecal elastase
- 14C-trioleyn
Imaging
US (abdomen)
- pancreas, lymphadenopathy, thickening of bowel wall
Upper gastrointestinal endoscopy
- biopsies of second portion of duodenum
EUS
Colonoscopy and biopsies
SBFT / ACBE
CT
MRI
ERCP
Malabsorption - Algorythm
stool analysis
normal
altered
carbohydrates
fecal fat (timed collection)
leukocytes/eosinophils
Malabsorption
imaging
steatorrhea
Steatorrhea
Sudam III
++ / +++
Quantitative Fecal Fat
Steatorrhea excluded
Steatorrhea
Steatorrhea
Fecal Fat (quantitative)
No fat malabsorption
D-Xylose
Steatorrhea
US/CT abdomen
Assessment of Pancreatic Exocrine Function
D-Xylose
Steatorrhea
D-Xylose
Altered
Normal
Assessment of
Pancreatic Function
Duodenal biopsies
Steatorrhea
Pancreatic Function Test
Normal
Altered
Antibiotics
H2 expirado (ppm)
200
150
100
50
0
0
15
30
45
60
75
Tempo (min)
lactase
glucose
galactose
absorption
colon
H2
CO2
pH
SCFA
lungs
20 ppm
AUC0-4h 3000
diarrhea
H2 expirado (ppm)
20
10
0
0
15
30
45
60
75
90
Tempo (min)
H2 expirado (ppm)
200
Lactase (+)
Lactase (-)
150
100
50
0
0
15
30
45
60
75
90
Tempo (min)
Other Tests
HIV, CMV
EMA/IgA/TTG (celiac)
1-antitrypsin in stool (protein loosing enteropathy)
gastrin (Zollinger-Ellison), calcitonin (thyroid ca),
glucagon (glucagonoma), VIP (VIPoma), PTH
5-hydroxy-indol acetic acid (5-HIAA, carcinoid), metanephrines in
urine (pheo), hystamine (mastocytosis, carcinoid)
Immunoglobulins (nodular lymphoid hyperplasia, commom
variable immunodeficiency)
Small intestinal biopsy (celiac, Whipples)
Case 1
A.V.F., 52 years old, female
Referred for investigation of chronic diarrhea since Feb 1997
Otherwise well when change in bowel habits ~9 years ago,
characterized by 5-6 daily, explosive, watery BMs, LLQ pain,
flatulence, associated with perianal burning. Improvement with
fasting.
Significantly better with reduction in dairy intake.
All symptoms developed following acute, infectious gastroenteritis in
January 1997. No weight loss, no fever or chills
Physical exam was unremarkable
CBC, lytes, fasting glucose, SPE were normal
Case 1
Colonoscopy: normal
Lactose tolerance test: flat response, H2 breath test: AUC 6800
H2 expirado (ppm)
200
Lactase (+)
Lactase (-)
150
100
50
0
0
15
30
45
60
75
90
Tempo (min)
Case 1
Significant improvement on a lactose free diet
Other options: lactase supplements
Potential differential diagnosis to be considered:
Fructose intolerance
Celiac disease
IgA/EMA/Duodenal biopsies/Gluten-free diet
Microscopic colitis
Budesonide, bismuth, 5-ASA
IBS (post-infectious?)
Case 2
J.A.P., 34 years old male
Diagnosed with ileocolonic Crohns disease 8 years ago, with ileal
resection due to fibrostenotic disease. On maintenance 5-ASA at
1.2 g/d
Case 2
Fibrostenotic ileal Crohns disease/diabetes: small intestinal bacterial
overgrowth suspected
Case 2
Maintenance treatment of small intestinal Crohns disease:
Case 2