• Can be classified into 6 major categories:
• Characterized by ↑secretion of fluid &
• Associated with carcinoid syndrome &
disorders of intestinal inflammation e.g
• Neuroendocrine tumor arise from hormone –
producing cells of the GI tract, respiratory tract,
pancreas,& reproductive organs.
• These cells release bradykin ,serotonin ,
histamine , & prostaglandins.
• Excessive amounts of these hormones result in
the development if carcinoid syndrome.
• Symptoms include flushed face, neck and upper
chest, abdominal pain, &diarrhea.
• Characterized as a build- up of excess
blood, serum proteins , & mucus in the
• Associated with radiation colitis, infections,
& malignancies of the colon.
• Results from improper peristaltic
movement throughout the intestines.
• Occurs following surgical procedures e.g
gastrectomy, ileocecal valve resection.
• Results from ingestion of oral solutes that
fully absorbed & often follows the ingestion
Fruits, candies , dietetic foods, medications
sweetened with non-absorbed
& pancreatic resection.
• Results from malabsorption of solutes.
• Associated with lactase insufficiency,
celiac sprue, whipple’s disease, & short
• Diarrhea also can be classified according
to duration into:
Acute: symptoms that are<14 days in
Chronic: symptoms that persists beyond 1
• Majority of diarrhea is acute.
• Chemotherapy: damage intestinal mucosa
& increased fluid overwhelms large bowel
capacity.(irinotecan has cholinergic effect -
• Laxative therapy: atonic colon .
• Faecal impaction: associated with fluid
stool which leaks past a faecal plug or
• Radiotherapy: involve abdomen or pelvis
cause diarrhea in 2nd-3rd week of therapy.
• Malabsorption associated with:
• Carcinoma of head of pancreas:
insufficient pancreatic secretions &
consequent resultant steatorrhoea.
• Gastrectomy: resulting in poor mixing food
with pancreatic secretions →steatorrhoea.
• Vagotomy: ↑water secretion into the colon.
• Ileal resection : ↓the ability of small
intestines to reabsorb bile acids→ fluid in
the colon→osmotic effect.
• Colectomy: immediately post surgery-total
or near total, the water in the gut can’t be
adequately absorbed →ongoing daily loss
of extra water400-1000 ml of gut fluid
• Colonic or rectal tumors: causing partial
bowel obstruction or through ↑ mucus
• Diarrhea 2-3 times/day without warning
suggests anal incontinence.
• Profuse watery stools →colonic diarrhea.
• Sudden onset of diarrhea after a period of
constipation →suspicion of faecal impaction.
• Alternating diarrhea & constipation →poorly
regulated laxative Tx. or impending bowel
• Pale or fatty offensive stool →malabsorption due
to pancreatic or ileal disease.
• I s categorized by severity & classified on
• Look into table 2 (Grade 0 –Grade 4.
Grade 0 1 2 3 4
Patients None ↑of <4 stools ↑ of 4-6 stools ↑of ≥7 Physiologic
without /day over /day, or stools / day consequen
colostomy pretreatment nocturnal or ces
stools. incontinenc requiring
e; or need intensive
for care or
support for mic
Patients None mild ↑ in moderate ↑ in Severe ↑ in Physiologic
with a loose watery loose watery loose consequen
colostomy colostomy colostomy watery ces
output output colostomy requiring
compared to compared ć output intensive
pretreatment pretreatment compared ć care or
but not pretreatme heamodyna
interfering nt mic
• Mild Diarrhea: managed with diet
↑oral intake of fluids
Limit lactulose and fibers
Avoid gas forming foods
Attapulgite could be given(clay like powder
med can↓ absorption of benztropine,used
for short tx of diarrhea).
Bismuth salts can be given(chelating
agent used to mobilize toxic metals from
human tiisues-it’s main metabolite of
• These medications are categorized into :
• Mythyl cellulose;Citrucel:1-4 /day.
• Synthetic, PO, bulk forming laxatives.
• Mechanism: absorb liquid in GI to
• Advantages vs disadv.: not metabolized.
• Pt with PKU should avoid the sugar –free
preparation as it contains aspartame.
Preparations & dose:
Aspirin,300 mg 4 hourly,up to 4g/D
Bismuth subsalicylate,525 mg tab up to 5
Mechanism: antiinflammatory, antioxidant .
Advantage vs disadv.:
PO & PR available.
Careful monitoring for renal & liver impaired,
Risk for bleeding & bruising.
• Codeine:10-60mg4hourly,duration :4-6h.
• Loperamide:4mg initial,2mg after each
loose stool up to 16mg/D,duration:8-16h.
• Mechanism: opioid receptor agonist
• Act peripherally on µ-opioid receptors in
• Decrease activity of intestinal myenteric
plexus →↓gut motility→↑water absorption.
• Adv. Vs dis. : always R/O infectious
etiology pre use.
• Octreotide:300-600 mcg /24h by SC.
• Mechanism of action:
Somatostatin is produced in intestinal D cells.
Act on gut epithelial receptor s to inhibit
secretion & peristalsis.
It acts as inhibitor of growth hormone ,Glucagon
Treat refractory diarrhea & Carcinoid syndrome,
bowel obstruction, vasoactive intestinal peptide
Advantages vs Dis advantages:
Can be given once a month.
• Mild to moderate diarrhea: treated ć
• Grade ш and Grade 1V should be
hospitalized, treated with aggressive fluids
,electrolyte repletion plus medication.
• Refractory diarrhea should be treated with
continuous hydration plus medication.
• 1st line of TX: Loperamide ,initial 4mg
followed by 2mg q4h.
• Atropine –diphynoxylate 1-2 tab q6-8h
may be added to Loperamide for Grade 1
• Aggressive oral rehydration.
• Expectant management:
Loperamide4mg then 2mg q2h till diarrhea
free for 12 hr.
Octreotide for refractory diarrhea.
Admit for severe diarrhea ,nausea
,vomiting, fever, sepsis, or bleeding.
• Symptoms improved with addition of
Somatostatin analogs & Interferon.
• Short acting preparation should be used first like
Sandostatin(Octreotide),SC ,1*3/D .
• Opioids for mild cases & Cholestyramine(bile
• Long acting preparation can be given every 2-4
weeks depending on response &control of s&s
Octreotide LAR ,20 mg ,IMQ4 weeks.
Lanreotide LA 30 mg IM Q2weeks.
Lanreotide Autogel,60mgIM Q4weeks.
• Toxin mediated infection of colon.
• Etiology: Gram+ organism Clostridium
• Occur as a complication of antibiotic use