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DEFINITIONDEFINITION
Traditionally, diarrhea has been defined as an increase in daily stool weight (> 200 g/day). --- impractical
Diarrhea can be considered an increase in stool frequency (3 or more stools/day) and/or the presence of loose or liquid stools.
CAUSESCAUSES Chronic Fatty Diarrhea – malabsorption
syndromes
Chronic Inflammatory Diarrhea
Chronic Watery Diarrhea – Secretory Diarrhea – Osmotic Diarrhea – Drug-Induced Diarrhea
Infectious Diarrhea
Endocrine diarrhea
Functional Diarrhea (diagnosis of exclusion) – Irritable Bowel Syndrome
AGEAGE
Young patients Young patients – Inflammatory Bowel Disease – Tuberculosis – Functional bowel disorder (Irritable bowel)
Older patientsOlder patients – Colon Cancer – Diverticulitis
DIARRHEA PATTERNDIARRHEA PATTERN
Diarrhea alternates with alternates with Constipation
– Colon Cancer
– Laxative abuse
– Diverticulitis
– Functional bowel disorder (Irritable bowel)
Intermittent Intermittent Diarrhea
– Diverticulitis
– Functional bowel disorder (Irritable bowel)
– Malabsorption
SMALL BOWEL/LARGE SMALL BOWEL/LARGE BOWELBOWEL
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 VARIATIONDIURNAL 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 LOSSWEIGHT LOSS Despite normal appetite
– Hyperthyroidism – Malabsorption
Associated with fever – Inflammatory Bowel Disease
Weight loss prior to Diarrhea onset – Pancreatic Cancer – Tuberculosis – Diabetes Mellitus – Hyperthyroidism – Malabsorption
STOOL CHARACTERISTICSSTOOL CHARACTERISTICS
Water: Chronic Watery Diarrhea
Blood, pus or mucus: Chronic
Inflammatory Diarrhea
Foul, bulky, greasy stools: Chronic Fatty Diarrhea
MEDICATION AND DIETARY MEDICATION AND DIETARY INTAKEINTAKEdrug induced diarrheaFood borne illness waterborne illness High fructose corn syrup Excessive sorbitol or mannitol Excessive coffee or other caffeine
ASSOCIATED SYMPTOMSASSOCIATED SYMPTOMS
Abdominal pain
Alternating constipation
Tenesmus
Unintentional wt. loss
Fever
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
Childhood diarrhea-resolves-re-emergence in adulthood– celiac disease
Uncontrolled diabetes
Pelvic radiotherapy
PAST SURGICAL HISTORYPAST SURGICAL HISTORY
Jejunoileal bypass
Gastrectomy with vagotomy
Bowel resection
Cholecystectomy
RED FLAGS-suggestive of organic RED FLAGS-suggestive of organic causescauses 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
GPEGPE
General appearance and mental status
Vital signs
Body weight
Orthostasis- volume depletion,autonomic dysfunction
exophthalmos (hyperthyroidism)
aphthous ulcers (IBD and celiac disease)
lymphadenopathy (malignancy, infection or Whipple's disease)
enlarged or tender thyroid (thyroiditis, medullary carcinoma of the thyroid)
clubbing (liver disease, IBD, laxative abuse, malignancy)
SKIN LESIONSSKIN LESIONS
dermatitis herpetiformis (celiac disease)
erythema nodosum and pyoderma gangrenosum (IBD)
hyperpigmentation (Addison's disease)
flushing (carcinoid syndrome)
migratory necrotizing erythema (glucagonoma).
ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION
Surgical scars
abdominal tenderness
Masses
Hepatosplenomegaly
Borborygmus on auscultation– malabsorption – bacterial overgrowth– obstruction, or rapid
intestinal transit.
PERINEAL AND RECTAL PERINEAL AND RECTAL EXAMINATIONEXAMINATION
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 EXAMINATIONSYSTEMIC EXAMINATION
wheezing and right-sided heart murmurs (carcinoid syndrome)
arthritis (IBD, Whipple's disease)
STOOL EVALUATIONSTOOL 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)
Giardia lamblia antigen – Indicated for diarrhea >7 days and >10 stools/day
Clostridium difficle toxin – Indicated if recent antibiotics or hospitalization
Consider testing stools for laxative abuse
NON-SPECIFIC THERAPIESNON-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 subsalicylate (i.e., Pepto-Bismol )
opioids and opioid agonists – Loperamide- first line therapy– diphenoxylate-atropine (Lomotil )– Codeine and other narcotics – for
refractory cases
SPECIFIC THERAPIESSPECIFIC 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)
pancreatic enzyme supplementation
antimicrobials –empiric fluoroquinolones therapy
Case Presentation: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 The most clinically useful definition of diarrhea for this patient would rely on:diarrhea for this patient would rely on:
A- Symptom description
B-An increase in daily stool weight (> 200 g/day)
C-Laboratory tests
D-Report of loose or watery stools
How would you begin to diagnose How would you begin to diagnose this patient's complaint?this patient's complaint?
A-History and physical examination
B-History, physical examination, and laboratory studies
C-History, physical examination, laboratory studies, and colonoscopy with biopsy
D-History, physical examination, laboratory studies, and sigmoidoscopy with biopsy
How would you assess illness How would you assess illness severity?severity? A-Length of time since symptoms first
appeared
B-Impact of diarrhea on daily function
C-Physical examination
D- Stool frequency
Initial empirical therapy of chronic Initial empirical therapy of chronic diarrhea for this patient should include:diarrhea for this patient should include:
A- Psyllium
B-Bismuth subsalicylate
C-Loperamide
D-Codeine
ROME II CRITERIA FOR IBSROME 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