APPROACH TO A PATIENT WITH CHRONIC DIARRHOEA

DEFINITION
Traditionally,

diarrhea has been defined as an increase in daily stool weight (> 200 g/day). --- impractical can be considered an increase in stool frequency (3 or more stools/day) and/or the presence of loose or liquid stools.

Diarrhea

CLASSIFICATION
Acute

diarrhea Chronic diarrhea

weeks cut off point

CAUSES

Chronic Fatty Diarrhea malabsorption syndromes

Chronic Inflammatory Diarrhea

Chronic Watery Diarrhea

Secretory Diarrhea Osmotic Diarrhea Drug-Induced Diarrhea

 Infectious Endocrine Functional

Diarrhea diarrhea Diarrhea (diagnosis of exclusion)

Irritable Bowel Syndrome

HISTORY

AGE

Young patients
Inflammatory Bowel Disease Tuberculosis Functional bowel disorder (Irritable bowel)

Older patients
Colon Cancer Diverticulitis

DIARRHEA PATTERN

Diarrhea alternates with Constipation

Colon Cancer

Laxative abuse
Diverticulitis Functional bowel disorder (Irritable bowel)

 Intermittent

Diarrhea

Diverticulitis Functional bowel disorder (Irritable bowel) Malabsorption

 Persistent

Diarrhea

Inflammatory Bowel Disease Laxative abuse

SMALL BOWEL/LARGE BOWEL

Small

intestine or proximal colon involved

Large stool Diarrhea Abdominal cramping persists after Defecation

Distal

colon involved

Small stool Diarrhea Abdominal cramping relieved by Defecation

DIURNAL VARIATION

No relationship to time of day: Infectious Diarrhea Morning Diarrhea and after meals
Gastric cause Functional bowel disorder (e.g. irritable bowel) Inflammatory Bowel Disease

Nocturnal Diarrhea (always organic)

Diabetic Neuropathy Inflammatory Bowel Disease

WEIGHT LOSS
Despite

Hyperthyroidism Malabsorption

normal appetite

Associated

Inflammatory Bowel Disease

with fever

Weight

Pancreatic Cancer Tuberculosis Diabetes Mellitus Hyperthyroidism Malabsorption

loss prior to Diarrhea onset

STOOL CHARACTERISTICS
Water: Blood,

Chronic Watery Diarrhea

pus or mucus: Chronic Inflammatory Diarrhea bulky, greasy stools: Chronic Fatty Diarrhea

Foul,

MEDICATION AND DIETARY INTAKE

drug

induced diarrhea Food borne illness waterborne illness High fructose corn syrup Excessive sorbitol or mannitol Excessive coffee or other caffeine

TRAVEL
Travelers Infectious

diarrhea diarrhea

ASSOCIATED SYMPTOMS
Abdominal Alternating

pain constipation

Tenesmus
Unintentional

wt. loss

Fever

PAST MEDICAL HISTORY

Childhood

diarrhea-resolves-re-emergence in adulthood celiac disease

Uncontrolled Pelvic

diabetes

radiotherapy

PAST SURGICAL HISTORY

Jejunoileal

bypass with vagotomy

Gastrectomy Bowel

resection

Cholecystectomy

RED FLAGS-suggestive of organic causes

Painless diarrhea Recent onset in an older patient Nocturnal diarrhea (especially if wakes patient) Weight loss Blood in stool Large stool volumes: >400 grams stool per day Anemia Hypoalbuminemia increased ESR

PHYSICAL EXAMINATION

GPE
General Vital Body

appearance and mental status

signs weight volume depletion,autonomic

Orthostasis-

dysfunction

 exophthalmos

(hyperthyroidism)

aphthous ulcers (IBD and celiac disease)

Whipple's disease) (malignancy, infection or

lymphadenopathy

enlarged

or tender thyroid (thyroiditis, medullary carcinoma of the thyroid) (liver disease, IBD, laxative abuse, malignancy)

clubbing

SKIN LESIONS
dermatitis

herpetiformis (celiac disease)

erythema nodosum and pyoderma gangrenosum (IBD)

hyperpigmentation

(Addison's disease)

flushing (carcinoid syndrome) necrotizing erythema (glucagonoma).

migratory

ABDOMINAL EXAMINATION

Surgical scars
abdominal tenderness Masses Hepatosplenomegaly Borborygmus on auscultation
malabsorption bacterial overgrowth obstruction, or rapid intestinal transit.

PERINEAL AND RECTAL EXAMINATION

Signs

of incontinence

skin changes from chronic irritation, gaping anus, weak sphincter tone.
Crohn's

disease

perianal skin tags Ulcers fissures abscesses Fistulas stenoses.

Fecal

impaction or masses might be noted.

SYSTEMIC EXAMINATION
wheezing

and right-sided heart murmurs (carcinoid syndrome)

arthritis

(IBD, Whipple's disease)

INVESTIGATIONS

BLOOD TESTS

CBC TSH Serum electrolytes Serum albumin

STOOL EVALUATION

Stool pH (<6 in carbohydrate malabsorption ) Fecal electrolytes (Fecal sodium and osmolar gap)
Differentiates chronic watery diarrhea category

Fecal occult blood test

Fecal leukocytes

 Fecal

fat (abnormal if >14 grams/24 hours)

Stool

ova and parasites (2-3 samples)

lamblia antigen

Giardia

Indicated for diarrhea >7 days and >10 stools/day

Clostridium

difficle toxin

Indicated if recent antibiotics or hospitalization

Consider

testing stools for laxative abuse

ENDOSCOPY
PROCTOSIGMOIDOSCOPY

TREATMENT

NON-SPECIFIC THERAPIES
Dietary

modifications

Smaller, more frequent meals Dec. carbohydrates Dec. fat intake Avoidance of milk Avoid sorbitol and mannitol

 No

good evidence to support use of bulking agents

Bismuth
opioids

subsalicylate (i.e., Pepto-Bismol )

and opioid agonists

Loperamide- first line therapy diphenoxylate-atropine (Lomotil ) Codeine and other narcotics for refractory cases

SPECIFIC THERAPIES
Clonidine-

Diabetic diarrhea moderate and severe diarrhea-predominant IBS

Somatostatin

refractory diarrhea
AIDS, post

chemotherapy, GVHD, and hormone secreting tumors.

 bile

acid binders (ie, cholestyramine)

enzyme supplementation empiric fluoroquinolones

pancreatic

antimicrobials

therapy

Case Presentation:

A 60-year-old woman
diarrhea for the past 3 months denies nausea, vomiting, or fever Her appetite is poor. She initially attributed the diarrhea to travel,

but her symptoms have not resolved over several weeks.

traveled to Singapore prior to the onset of symptoms.

The most clinically useful definition of diarrhea for this patient would rely on:
A-

Symptom description

B-An

increase in daily stool weight (> 200 g/day) tests

C-Laboratory
D-Report

of loose or watery stools

How would you begin to diagnose this patient's complaint?

A-History
B-History,

and physical examination

physical examination, and laboratory studies physical examination, laboratory studies, and colonoscopy with biopsy physical examination, laboratory studies, and sigmoidoscopy with biopsy

C-History,

D-History,

How would you assess illness severity?

A-Length B-Impact

of time since symptoms first appeared of diarrhea on daily function examination

C-Physical D-

Stool frequency

Initial empirical therapy of chronic diarrhea for this patient should include:

A- Psyllium B-Bismuth subsalicylate

C-Loperamide

D-Codeine

ROME II CRITERIA FOR IBS

At

least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:
Relieved with defecation; and/or Onset associated with a change in frequency of stool; and/or Onset associated with a change in form (appearance) of stool

Evaluation of Patient
There is a long list of investigations for the diagnostic of etiology of ch. diarrhea .
SMALL BOWEL DIARRHEA Large stool volume LARGE BOWEL DIARRHEA Small amount of stool

Increased frequency with large volume stool

No urgency

Increased frequency with small volume stool

urgency

No tenesmus
No mucus No blood Central abdominal pain

Tenesmus present
Mucus in stool Blood may be present Pain in left iliac fossa relived by defecation

THANX