An approach to a patient with chronic diarrhea

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  • 1. AN APPROACH TO A PATIENT WITH CHRONIC DIARRHEA Dr Basharat Hussain HOUSE OFFICER Dated:20th SEPT’06
  • 2. CHRONIC DIARRHEA DIARRHEA: passage of abnormally liquid/ unformed stools at an increased frequency FOR ADULT Stool wt > 200g 1day ACUTE DIARRHEA: If duration is < 2 wk. PERSISTENT DIARRHEA: duration is < 2-4 wks.
  • 3.   CHRONIC DIARRHEA: diarrhea lasting > 4 wks. PSEUDO DIARRHEA: frequent passage of small volumes of stool and is often associated with urgency and accompanies irritable bowl syndrome/ proctitis.
  • 4. FECAL INCONTINANCE: It is involuntary discharge of rectal contents and most often caused by neuromuscular disorders or structural anorectal sphincter problem. 
  • 5. CLASSIFICATION OF CHRONIC DIARRHEA  1. 2. 3. 4. 5. 6. According to patho physiological mechanism. Secretory Diarrhea. Osmotic Diarrhea. Steatorrheal Diarrhea. Dysmotility Diarrhea. Inflammatory Diarrhea. Factitial Diarrhea.
  • 6. SECRETORY DIARRHEA It is due to derangement of fluid & electrolyte transport across mucosa. It is characterized by  Watery  Large volume fecal output > 1 Ltr per day.  Painless  Persists with fasting  No fecal osmotic gap
  • 7. CAUSES ARE:  Laxative abuse.  Chronic ethonol ingestion.  Drugs / toxins.  Idiopathic Secretory Diarrhea.  Bowl resection & Fistula.  Carcinoid, Vipoma.  Congenital electrolyte absorption defect.
  • 8. OSMOTIC DIARRHEA It occurs when ingested, poorly absorbable, osmotically active solutes draw enough fluid lumen wards.  It ceases with fasting. CAUSES ARE:  Osmotic laxatives.  Lactase deficiency 
  • 9. STEATORRHEAL DIARRHEA    Steatorrhea is define as stool fat exceeding > 7gm per day. Fat malabsorption may lead to greasy foul smelling, difficult to flush diarrhea. It is offten associated with weight loss & nutritional deficiency due to malabsorption of A.A & vitamins.
  • 10. CAUSES ARE:  Intraluminan maldigation.  Mucosal malabsorption like  Coelic Disease  Tropical Spru  Whipples Diseases  A beta lipoprotenemia
  • 11. DYSMOTILITY DIARRHEA Rapid transit may accompany diarrhea as a secondary phenomenon.  Primary dysmotility is unusual cause of true diarrhea. SECONDRY CAUSES ARE:  Visceral Neuromyopathies  Hyper Thyroidism  Prokinetic Drugs  Diabetic Diarrhea often accompanied by autonomic neuropathies  IBS 
  • 12. INFLAMMATORY DIARRHEA Diarrhea accompanying fever, pain and bleeding.  Stool analysis show leukocytosis. CAUSES ARE:  Ulcerative colitis.  Crohn disease.  Microscopic colitis.  Collagenous colitis.  Eosinophilic gastritis. 
  • 13. CLINICAL APPROACH   History, Physical Examination and routine blood studies should attempt to characterize the mechanism of diarrhea. Assess the patient fluid and electrolyte and nutritional status.
  • 14. HISTROY & EXAMINATION  Pt. should be questioned about on set duration, pattern, aggravating and relieving factors, stool characteristics and extra intestinal manifestation like skin changes, arthralgia. GENERAL & SYSTEMIC EXAMINATION TO DONE THOROUGLY.
  • 15. INVESTIGATIONS 1.  PERIPHERAL BLOOD COUNT Decreased Hb (blood loss).  Leukocytosis (infections).  Eosinophilia (parasitosis)  Raised ESR (inflammation, tumor).
  • 16. INVESTIGATIONS    2. 3.  Increased Urea (Dehydration) Hypokalemia (Vipoma). Raised ALP (Liver Mets). STOOL CULTURE AND MICROSCOPY FOR OVA AND CYST PROCTOSIGMOIDOSCOPY All pts shold have a sigmoidoscopy and rectalbiopsy. It may show a pigmented mucosa (Melanosis coli).Rectalbiopsy show pigment laden macrophag.
  • 17. INVESTIGATIONS 4.  5.    COLONOSCOPY All pts with chronic diarrhea and hematochezia should be evaluated stool microbiologic studies and colonoscopy & mucosal biopsy. SPECIFIC INVESTIGATONS TFT’s Serum Gastrin Serum Calcitonin
  • 18.     Serum Vasoactive Intestinal peptide Duodenal and jajunal biopsy Small bowl eneamia .
  • 19. CHRONIC DIARRHEA WITH BLOOD  Stool Culture Rectal Biopsy Ulcerative Colitis Crohn Disease Colorectal Carcinoma  Colonoscopy & Biopsy
  • 20. DIRRHEA WITHOUT BLOOD        f abnormal Do Colonoscopy Shows UCI PMC      Stool culture Rectal biopsy If Normal Barium eneama SBFT Serum VIP TFT’s 5 HIAA    If Melanosis coli Look for purgative abuse
  • 21.        DECREASED HB DO SBFT      DO BLOOD TEST IF NORMAL DO USG CT ERCP      INCREASED MCV LOW FOLATE DO JAJUNAL BIOPSY
  • 22. TREATMENT  TREATMENT OF UNDERLYING CAUSE
  • 23. ….THANKS!!