Approach to-a-patient-with-chronic-diarrhoea

1. 1
SPEAKER: Dr ASHOK KUMAR
CHAIRPERSON: Dr ARDAMAN SINGH

2.  DIARRHEA: is defined as passage of abnormally liquid or
unformed stool at an increased frequency. For adult on
typical western diet, stool wt>200g/d can be considered
diarrhea.
 PSEUDODIARRHEA: frequent passage of small vol. of
stool,is often asso. With rectal urgency and a/c IBS or
proctitis.
 FECAL INCONTINENCE: is involuntary passage of rectal
contents and is most often caused by neuromuscular
disorders or structural anorectal problems
 Pseudodiarrhea and fecal incontinence occur at prevalence
rate comparable to or higher than that of chr. Diarrhea and
should always be considered in pt. complaining of diarrhea.
2

3.  Acute diarrhea: <2 wk
 Chronic diarrhea: >4 wk
 Persistent diarrhea :2-4 wk
 4 weeks– cut off point
3

4. SECRETORY CAUSES
 Exogenous stimulant laxative
 Chronic ethanol ingestion
 Endogenous laxatives(dihydroxy bile
acids)
 Bactrial inf.
 Bowel resection,disease ,fistula
 Partial bowel obst.,fecal impaction
 Harmone producing
tumors(carcinoid,VIPoma,medullary
ca)
thyroid,mastocytosis,gastrinoma,col
orectal villus adenoma)
 Addison’s disease
 Congenital electrolyte abs. defect
 idiopathic
OSMOTIC CAUSES
 Osmotic laxative(MG++,PO4,SO4--)
 Lactase and other disaccharide
defeciency
 Nonabs. CHO (sorbitol,lactulose
polyethylene glycol)
INFLAMMATORY CAUSES
 Idiopathic inflm,bowel
disease(CD,UC)
 Lymphocytic and collagenous
colitis
 Immune-related mucosal
disease(1,2nd
immunodeficiences,food
allergy,eosinophilic
gastroenteritis,GVHD)
Infections(invasive
bacteria,viruses,and
parasites,Brainerd diarrhea)
 Radiation injury 4

5. STEATORRHEAL CAUSES
 Intraluminal
maldigestion(pancreatic
exocrine deficiency,bactrial
overgrowth,bariatric sx,liver
dis.)
 Mucosal malabsorbtion(celiac
sprue,whipple’s disease,inf,
abetalipoproteinemia ,
ischemia)
 Post mucosal obst (1, 2nd
lympathic obst.)
FACTITIAL CAUSES
 Munchausen
 Eating disorders
DYSMOTILE CAUSES
 Irritable bowel
syndrome(including post-
infectious IBS)
Visceral
neuromyopathies
 Hyperthyroidism
 Drugs(prokinetic
agents)
Postvagotomy
IATROGENIC CAUSES
 Cholecystectomy
 Ileal resection
 Bariatric surgery5

6.  Antibiotics
 Antiretroviral agents
 Antineoplastic agents
 Anti-inflammatory agents (NSAIDs, gold, 5-ASA)
 Antiarrhythmics (quinidine)
 Antihypertensives (β blockers)
 Oral hypoglycemics (metformin, acarbose)
 Antacids (magnesium-containing)
 Acid-reducing agents (H2 blockers, PPIs)
 Colchicine
 Prostaglandin analogs (misoprostol)
 Theophylline
 Vitamin and mineral supplements
 Herbal products
 Heavy metals
6

7.  Due to derangement in fluid and
electrolyte transport across the
enterocolonic mucosa.
 CLUE:Watery,Large volume ( >1
L/d),painless, little change with fasting;
normal stool osmotic gap
1.Medications
2. Bowel resection,mucosal
disease,enterocolic fistula).
3. Hormonally mediated (uncommon)
4.Congen.defect in ion absorption:
7

8.  When ingested,poorly
absorbable,osmotically active solute
draw enough fluid into lumen to exceed
the reabsorptive capacity of the colon.
 CLUES: Stool volume decreases with
fasting; increased stool osmotic
gap(>50mosmol/l).
1 magnesium (antacids, laxatives)
2. Medications
3 Disaccharidase deficiency
8

9.  As stool leaves the colon, fecal osmolality is equal to
the serum osmolality, ie, approximately 290
mosm/kg. Under normal circumstances, the major
osmoles are Na+, K+, Cl–, and HCO3–. The stool
osmolality may be estimated by multiplying the stool
(Na+ + K+) × 2 (multiplied by 2 to account for the
anions)
 The osmotic gap is the difference between the
measured osmolality of the stool (or serum) and the
estimated stool osmolality and is normally less than
50 mosm/kg
 An increased osmotic gap implies that the diarrhea is
caused by ingestion or malabsorption of an
osmotically active substance
9

10.  >7g/d fat in stool(Small intestine
disease15-25g/d,pancriatic exocrine
def.>32g/d).
 CLUE:greasy ,Foul smelling,difficult
to flush,as/o with wt. loss
,nutritional def.(amino a,vitamins).
 Intraluminal maldigestion
 Mucosal malabsorption
 Postmucosal lymphatic obstruction
10

11.  CLUE:Fever, hematochezia, abdominal
pain
 Mechanism depending on lesion site(fat
malabsorption,fluid/electrolyte,hyperm
otility from cytokinins)
1.Inflammatory bowel disease
2. Microscopic colitis
3.Immunodeficiency
4.Eosinophillic gastroenteritis
11

12.  Parasites: Giardia lamblia, Entamoeba
histolytica, Cyclospora
 AIDS-related:
 Viral: Cytomegalovirus, HIV infection
 Bacterial: Clostridium difficile,
Mycobacterium avium complex
 Protozoal: Microsporida, Cryptosporidium,
Isospora belli
12

13.  Abnormal intestinal motility secondary to systemic
disorders or surgery may result in diarrhea due to
rapid transit or to stasis of intestinal contents
with bacterial overgrowth resulting in
malabsorption
 Stool feature suggestive of secretory
diarrhea,mild steatorrhea may be there.
 Hyperthyroidism, diabetic diarrhea ,carcinoid
syndrome.
 medications(PGs ,prokinetic drugs).
 Irritable bowel syndrome.
13

14.  Approximately 15% of patients with
chronic diarrhea have factitial
diarrhea caused by surreptitious
laxative abuse or factitious dilution of
stool.
 Munchausen syndrome(self inj. For
secondary gain,women),eating
disorder.
 Hypotension,hypokalamia.
 Psy. conselling beneficial. 14

15. Osmotic
Secretory
15

16. 16

17.  Onset
 Congenital
 Abrupt
 Gradual
 Travel history
 Exposure to contaminated
water
 Weight loss
 Dietary history
 Chloridorrhea
 Infections, idiopathic secretory
diarrhea
 All other etiologies
 Infectious diarrhea
 Aeromonas, Plesiomonas
 Giardiasis, Cryptosporidiosis
 Brainerd diarrhea
 Malabsorption, pancreatic exocrine
insufficiency, neoplasm
 “Sugar-free” foods with sorbitol,
mannitol , lactase deficiency, fructose
intolerance
17

18.  Previous treatments
 Systemic illness
 Abdominal pain
 Excessive flatus/bloating
 IV drug use, sexual
promiscuity
 Secondary gain/Fixation
on body image
 Institutionalized patients
 Medications, radiation
enteropathy, surgery
(bowel, gallbladder),
pseudomembranous colitis
 Hyperthyroidism, IBD,
diabetes
 Mesenteric vascular
insufficiency, IBD, IBS
 Carbohydrate malabsorption,
small bowel bacterial
overgrowth
 HIV infection
 Laxative abuse
 Medication, C. difficile
colitis, tube feeding,
ischemia, fecal impaction
with overflow diarrhea
18
Epidemiological and historical features Implication

19.  Young patients
 Inflammatory Bowel Disease
 Tuberculosis
 Functional bowel disorder (Irritable bowel)
 Older patients
 Colon Cancer
 Diverticulitis
DiarrheaDiarrhea alternates withalternates with ConstipationConstipation
Colon Cancer
Laxative abuse
Diverticulitis
Functional bowel disorder (Irritable bowel)
19

20. 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
Intermittent Diarrhea
Diverticulitis
Functional bowel disorder (Irritable bowel)
Malabsorption
Persistent Diarrhea
Inflammatory Bowel Disease
Laxative abuse
20

21.  Despite normal appetite
Hyperthyroidism
Malabsorption
 Associated with fever
Inflammatory Bowel Disease
 Weight loss prior to Diarrhea onset
Pancreatic Cancer
Tuberculosis
Diabetes Mellitus
Hyperthyroidism
TRAVEL
 Traveler’s diarrhea
 Infectious diarrhea
21

22.  Water: Chronic Watery Diarrhea
 Blood, pus or mucus: Chronic
Inflammatory Diarrhea
 Foul, bulky, greasy stools: Chronic
Fatty Diarrhea
22

23.
SMALL BOWEL DIARRHEASMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEALARGE BOWEL DIARRHEA
Large stool volumeLarge stool volume Small amount of stoolSmall amount of stool
Increased frequency with largeIncreased frequency with large
volume stoolvolume stool
Increased frequency withIncreased frequency with
small volume stoolsmall volume stool
No urgencyNo urgency urgencyurgency
No tenesmusNo tenesmus Tenesmus presentTenesmus present
No mucusNo mucus Mucus in stoolMucus in stool
No bloodNo blood Blood may be presentBlood may be present
Central abdominal painCentral abdominal pain Pain in left iliac fossa relivedPain in left iliac fossa relived
by defecationby defecation
23

24.  drug induced diarrhea
 Food borne illness
 waterborne illness
 High fructose corn syrup
 Excessive sorbitol or mannitol
 Excessive coffee or other caffeine
24

25.  Childhood diarrhea-resolves-re-emergence in
adulthood– celiac disease
 Uncontrolled diabetes
 Pelvic radiotherapy
PAST SURGICAL HISTORY
 Jejunoileal bypass
 Gastrectomy with vagotomy
 Bowel resection
 Cholecystectomy
25

26.  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
26

27. 27

28.  Celiac sprue (dermatitis herpetiformis)
 Mastocytosis (urticaria pigmentosa)
 Amyloidosis (macroglossia, purpura)
 Addison’s disease (hyperpigmentation)
 Glucagonoma (migratory necrolytic
erythema)
 Carcinoid syndrome (flushing)
 Degos’ disease (malignant atrophic papulosis)
 IBD (erythema nodosum,pyoderma
gangrenosum)
28

29.  Peripheral neuropathy,
orthostatic
hypotension
 Thyroid nodule
 Right-sided cardiac
murmur, hepatomegaly
 Arthritis
 Lymphadenopathy
 Peripheral vascular
disease/abdominal
bruits
 Amyloidosis
 Medullary carcinoma
of the thyroid
 Carcinoid syndrome
 IBD, Whipple’s,
infections
 AIDS, lymphoma
 Mesenteric vascular
insufficiency
29

30.  General appearance and mental status
 Vital signs
 Body weight
 Exophthalmos (hyperthyroidism)
 Aphthous ulcers (IBD and celiac disease)
 Lymphadenopathy (malignancy, infection or Whipple's disease)
 Enlarged or tender thyroid (thyroiditis, medullary carcinoma
of thyroid)
 Clubbing (liver disease, IBD, laxative abuse, malignancy)
30

31.  Surgical scars
 abdominal tenderness
 Masses
 Hepatosplenomegaly
 Borborygmus on
auscultation
 malabsorption
 bacterial overgrowth
 obstruction, or rapid
intestinal transit.
31

32.  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,episodic flushing,dyspnea (carcinoid
syndrome)
 Arthritis,uveitis,polyarthralgia,cholestatic,liver disease(IBD, Whipple's
disease)
32

33. 33

34.  24-hour stool collection for weight and quantitative
fecal fat–A stool wt. of > 300 g/24 h confirms the
presence of diarrhea, justifying further workup. A
wt. >1000–1500 g suggests a secretory process. A
fecal fat > 10 g/24 h indicates a malabsorptive
process
 Categorize diarrhea into watery, inflammatory, fatty
 Timed collection is best, spot tests on random stool
sample more practical
- Occult blood
- White blood cells
- pH
- Sudan stain for fat
- Cultures
- Laxative screen
- Electrolytes, osmolality
34

35.  Occult blood and white blood cells:
- Primarily define inflammatory diarrhea
- Wright stain: Sensitivity 70%, specificity 50% for leukocytes
- Fecal calprotectin and lactoferrin less operator dependent
 pH:
- Low pH (< 6) generally indicative of carbohydrate malabsorption
 Sudan stain:
- Fatty diarrhea (steatorrhea)
- Gold standard: Quantitative estimation of stool fat on collected
specimen
- Qualitative estimation feasible on random sample,
- Semiquantitative methods (number and size of fat globules)
correlate well with quantitative collection
35

36.  Stool cultures:
- Infection: Usually inflammatory diarrhea
- Bacterial infection rarely cause of chronic diarrhea in
immunocompetent host - Routine cultures are low yield
- Special techniques for Aeromonas and Plesiomonas
- Ova and Parasites
- Always consider giardiasis (stool ELISA for Giardia
antigen)
Laxative screen:
- High index of suspicion
- Stool for bisacodyl and phenolphtalein, urine for
anthraquinones
- Confirm on another sample before confronting patient
36

37.  Stool electrolytes:
Stool osmotic gap: 290 – 2([Na+] + [K+])
- Gap < 50 mOsm/Kg: Pure secretory diarrhea
- Gap > 125 mOsm/Kg: Pure osmotic diarrhea
- Gap 50-125 mOsm/kg: Mixed or mild carbohydrate
malabsorption
 Measured stool osmolality:
- Not used to calculate gap
- Useful in cases of unexplained diarrhea
- Low measured stool osmolality (< 290 mOsm/Kg)
suggestive of contamination with water or dilute urine
37

38.  Fecal fat (abnormal if >10 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
38

39. 39Fig. 22.21 The “face” of a Giardia lamblia trophozoite.

40.  Routine laboratory tests–CBC, serum electrolytes,
liver function tests, ca++, phosphorus, albumin,
TSH, total T4, and prothrombin time should be
obtained.
 Anemia occurs in malabsorption syndromes (vitamin
B12, folate, iron) and inflammatory conditions.
 Hypoalbuminemia is present in malabsorption,
protein-losing enteropathies, and inflammatory
diseases.
 Hyponatremia and non–anion gap metabolic acidosis
may occur in profound secretory diarrheas.
Malabsorption of fat-soluble vitamins may result in
an abnormal prothrombin time, low serum calcium,
low carotene, or abnormal serum alkaline
phosphatase
40

41.  In patients with suspected
secretory diarrhea
 serum VIP (VIPoma)
 gastrin (Zollinger-Ellison syndrome)
 calcitonin (medullary thyroid carcinoma)
 cortisol (Addison's disease)
 urinary 5-HIAA (carcinoid syndrome)
41

42.  Calcification on a plain abdominal radiograph
confirms the diagnosis of chronic pancreatitis.
 An upper gastrointestinal series or enteroclysis
study is helpful in evaluating Crohn's disease,
lymphoma, or carcinoid syndrome.
 Colonoscopy is helpful in evaluating colonic
inflammation due to IBD.
 Upper endoscopy malabsorption due to mucosal
diseases. with a duodenal aspirate and small bowel
biopsy is also useful in patients with AIDS and to
document Cryptosporidium, Microsporida, and M
avium-intracellulare infection.
 Abdominal CT is helpful to detect chronic
pancreatitis or pancreatic endocrine tumors.
42

43. Chronic diarrhea
Blood
PR
Features
,stool,
Suggest
malabsorption
Pain aggravated
before BM,relieved
withBM ,sense
incomplete
evacuation
No blood
features of
malabsorpti
on
Colonoscopy
+Biopsy
Small
bowel:imagin
g,biopsy,
aspirate
Suspect IBS
Consider
Functional
diarrhea
Dietary
exclusion
eg.
Lactose
sorbitol
Limited screen for
organic disease
43

44. Low Hb,Alb,abnormal MCV,MCH; excess
fat in stool
Opioid Rx + follow up
Persistent chronic
diarrhea
Titrate Rx to speed of
transit
Colonoscopy +
Biopsy
Small bowel:X
ray,biopsy,aspir
ate;stool 48-h
fat
Stool
vol,OSM,PH;L
axative
screen;Hormo
nal screen
Stool fat >20g/d
Pancreatic
function
Normal and
stool fat
<14g/d Full gut transit
Chronic diarrhea
Screening test all
normal
Low
k+
44

45. 45

46.  Treatment depend upon specific etiology
 Curative ,suppressive or empirical.
 CURATIVE:recetion of colorectal ca.,antibiotic for
whipple dis.,drug discontinuation of a drug.
 SUPPRESSIVE:(supress the underlying mechanism)
 Lactose avoid in lactase def.
 Gluten diet for celiac sprue.
 Glucocorticoids and anti inflammatory for IBD
 PPI for gastrinoma
 Cholestyramine for ileal bile acid malabsorbtion
 Octreotide for malignent carcinoid syndrome
 Prostaglandin (-) indomethacin:medullary ca thyroid
 Pancreatic replacement:pancreatic insufficiency
46

47.  EMPERICAL:mild to mod. Watery
diarrhea(diphenoxylate,loperamide),se
vere(codeine,opium)
 Avoid in IBD as toxic megacolon ppt.
 Clonidine:diabetic diarrhea
 Fluid and electrolyte
 Fat soluble vitamin
47

48. Drug Class Agent Dose
Opiates Diphenoxylate
Loperamide
Codeine
Morphine
Tincture of opium
2.5-5 mg QID
2-4 mg QID
15-60 mg QID
2-20 mg QID
2-20 drops QID
Adrenergic agonist Clonidine 0.1-0.3 mg TID
Somatostatin analog Octreotide 50-250 µg SQ TID
Bile acid-binding resin Cholestyramine 4 g once daily to QID
Fiber supplements Psyllium
Calcium polycarbophil
10-20 g daily
5-10 g daily
Others Probiotics
Herbals (berberine,
arrowroot) 48

49. THANKS..
49