Approach to the adult with chronic diarrhea

chronic diarrhea : a decrease in fecal consistency lasting for four or more weeks.
ETIOLOGY
o Osmotic diarrhea: Carbohydrate malabsorption
o Fatty diarrhea
Malabsorption syndromes :Short bowel syndrome ,Postresection diarrhea
,Small bowel bacterial overgrowth ,Mesenteric ischemia
Maldigestion :Pancreatic exocrine insufficiency ,Inadequate luminal bile acid
o Inflammatory diarrhea
IBD
Infectious diseases (TB, CMV, Amebiasis )
Ischemic colitis ,Radiation colitis
o Secretory diarrhea :
Laxative abuse
Post-cholecystectomy (from bile salts)
Microscopic (lymphocytic) colitis ,Collagenous colitis
Drugs
Disordered motility :Postvagotomy diarrhea ,Diabetic autonomic neuropathy
Hyperthyroidism ,IBS,
Neuroendocrine tumors: Gastrinoma ,VIPoma ,Carcinoid syndrome
Medullary carcinoma of thyroid
Neoplasia: Colon carcinoma, Lymphoma ,Villous adenoma
Addison's disease
Idiopathic secretory diarrhea

patients with IBS complain of mucus discharge with stools.

Large volume diarrhea, bloody stools, nocturnal diarrhea, and greasy stools are not
associated with IBS and suggest an organic disease.

Two different types of microscopic colitis have been generally recognized: Lymphocytic
colitis ,Collagenous colitis
The term microscopic colitis implies that the diagnosis is made by histology. Thus,
colonoscopy usually reveals macroscopically normal colonic mucosa although slight edema,
erythema, and friability may be seen.
Diarrhea following cholecystectomy is related to excessive bile acids entering the colon The
increased bile acids in the colon lead to diarrhea (cholerheic diarrhea). Patients often
respond to treatment with bile-acid binding resins such as cholestyramine ..
Secretory diarrhea Secretory diarrhea characteristically continues despite fasting, is
associated with stool volumes >1 liter/day, and occurs day and night in contrast to osmotic
diarrhea
The stool osmotic gap (290 - 2 ({Na+} + {K+}))
An osmotic gap of >125 mOsm/kg suggests an osmotic diarrhea while a gap of <50
mOsm/kg suggests a secretory diarrhea

Secretory diarrhea occurs in 80 percent of patients with carcinoid syndrome

o and is often the most debilitating component of the syndrome.
o Stools may vary from few to more than 30 per day, are typically watery and
nonbloody,
o and can be explosive and accompanied by abdominal cramping.
o The abdominal cramps may be a consequence of mesenteric fibrosis or intestinal
blockage by the primary tumor.
o The diarrhea is usually unrelated to flushing episodes.

empiric therapy may be warranted in certain situations, such as:

o When a diagnosis is strongly suspected. Giardiasis within the daycare,

Symptomatic therapy is indicated when

o the diagnosis has been made but definitive treatment is unavailable,
o when diagnosis has eluded diagnostic evaluation, and as a temporizing measure
during evaluation.
o loperamide , clays, activated charcoal , bismuth , fiber and bile acid binding resins

History
1. Introduce yourself
2. Personal history
3. Chief complaint
4. HOPI
a. Analysis of the complaint
1.
Onset, course, duration
2.
Stool characteristics
Blood >>>>>>
Oil/food particles>>>>>>
White/tan color >>>>
Nocturnal diarrhea >>>

3.
4.

Malignancy, inflammatory bowel disease

Malabsorption, maldigestion
Celiac disease, absence of bile
Organic etiology

Associated symptoms
Symptoms of the same system:
Mesenteric vascular insufficiency,
Abdominal pain >>
obstruction, irritable bowel syndrome
Excessive flatus >>>
Carbohydrate malabsorption

Leakage of stool >>>

Fecal incontinence

Vomiting , dysphagia, dyspepsia

b. Ask specific questions about D.D :

Exposure to potentially impure water Chronic bacterial infections (eg, Aeromonas), giardiasis,
source
cryptosporidiosis, Brainerd diarrhea
Travel history
Infectious diarrhea, chronic idiopathic secretory diarrhea
Malabsorption, pancreatic exocrine insufficiency, neoplasm,
Weight loss
anorexia
Previous therapeutic interventions
(drugs, radiation, surgery,
antibiotics)
Secondary gain from illness
Systemic illness symptoms
Intravenous drug abuse, sexual
promiscuity
Immune problems as
recurrent bacterial infections (eg,
sinusitis, pneumonia)

Family
history

Drug side effects, radiation enteritis, postsurgical status,

pseudomembranous colitis, post-cholecystectomy diarrhea
Laxative abuse
Hyperthyroidism, diabetes, vasculitis tumors, Whipple's
disease, inflammatory bowel syndrome, tuberculosis,
mastocytosis
AIDS

AIDS, immunoglobulin deficiencies

Congenital absorptive defects, IBD, celiac disease,

multiple endocrine neoplasia

5. Past history:
a. Past Hx of the same coplaint with detail if present
b. DM, HTN ,heart dz, asthma
c. Previous hospital admission
d. Previous surgeries
e. Blood transfusion
6. Drug history:
a. Medication( name ,duration)
b. Drugs and food allergy
c. Herbal medicine
7. Family history:
a. Hx of the same complaint
b. Hx of chronic medical disease
c. Cause of death of first degree relatives if present
8. Systemic review
9. Social history:
a. Marital state
b. House

c. Medical insurance
d. Smoking, alcohol

physical examination

findings suggestive of IBD

(eg, mouth ulcers, a skin rash, episcleritis, an anal fissure or fistula, the presence of
visible or occult blood on digital examination, abdominal masses or abdominal pain),
evidence of malabsorption
o (such as wasting, physical signs of anemia, scars indicating prior abdominal
surgery),
lymphadenopathy
o (possibly suggesting HIV infection),
and abnormal anal sphincter pressure or reflexes
o (possibly suggesting fecal incontinence).
Palpation of the thyroid and examination for exophthalmos and lid retraction may provide
support for a diagnosis of hyperthyroidism.

Specific testing .

The history and physical examination may point toward a specific diagnosis for which
testing may be indicated.
As an example, serologic testing for celiac disease
o would be appropriate in patients with risk factors (such as type 1 diabetes mellitus or
a family history of celiac disease) or those with unexplained iron deficiency anemia
or weight loss from fat malabsorption.
o Diarrhea in patients with diabetes may also be due to
visceral autonomic neuropathy, pancreatic exocrine insufficiency, bacterial
overgrowth, or fecal incontinence (which may be confused with diarrhea).
The minimum laboratory evaluation in most patients should include
o CBC and differential,
o erythrocyte sedimentation rate,
o thyroid function tests,
o serum electrolytes,
o total protein and albumin,
o and stool occult blood.
o most patients require some form of endoscopic evaluation and mucosal biopsy
(either sigmoidoscopy, colonoscopy, or sometimes upper endoscopy), depending
upon the clinical setting
o The stool osmotic gap
o stool cultures to exclude chronic infection,
o imaging of the small and large bowel,

o selective testing for secretagogues, such as gastrin or vasoactive intestinal

polypeptide
o Testing for bile-acid malabsorption or empiric treatment with a bile-acid binding
resin may also be helpful
o Temporary avoidance of lactose-containing foods can help establish the diagnosis of
lactose intolerance in patients who were unaware of the diagnosis.
o specific testing for lactose intolerance (such as hydrogen breath testing). ,Breath
testing can also identify specific forms of carbohydrate malabsorption (such as
fructose or sucrose)
o Testing the stool for laxatives may occasionally be required if laxative abuse is
suspected. Laxative abuse can be suggested by the presence of melanosis coli on
sigmoidoscopy or colonoscopy.
o Tests for bacterial overgrowth should be performed in patients with risk factors
o Fecal leukocytes are not a good test for inflammatory diarrhea.
o Fecal calprotectin useful for distinguishing inflammatory from noninflammatory
causes of chronic diarrhea
o Fecal lactoferrin Fecal lactoferrin (another marker of neutrophils) but its role in
the evaluation of patients with chronic diarrhea remains uncertain
o Currently, the gold standard for diagnosis of steatorrhea is quantitative estimation of
stool fat.
o An endoscopic evaluation should be considered if there are persistent symptoms,
inconclusive diagnosis, or failure to respond to therapy
o Complications associated with colonoscopy include perforation, hemorrhage,
respiratory depression due to sedation, arrhythmia, transient abdominal pain, ileus,
and nosocomial infection.