1. APPROACH TO A PATIENT
WITH CHRONIC DIARRHOEA

2. DEFINITION
 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.

3. CLASSIFICATION
 Acute
diarrhea
 Chronic diarrhea
4
weeks– cut off point

4. CAUSES

Chronic Fatty Diarrhea – malabsorption
syndromes

Chronic Inflammatory Diarrhea

Chronic Watery Diarrhea
–
–
–
Secretory Diarrhea
Osmotic Diarrhea
Drug-Induced Diarrhea

5.  Infectious
Diarrhea
 Endocrine
diarrhea
 Functional
Diarrhea (diagnosis of
exclusion)
– Irritable Bowel Syndrome

6. HISTORY

7. AGE

Young patients
–
–
–

Inflammatory Bowel Disease
Tuberculosis
Functional bowel disorder (Irritable bowel)
Older patients
–
–
Colon Cancer
Diverticulitis

8. DIARRHEA PATTERN

Diarrhea alternates with Constipation
–
Colon Cancer
–
Laxative abuse
–
Diverticulitis
–
Functional bowel disorder (Irritable bowel)

9.  Intermittent
Diarrhea
– Diverticulitis
– Functional bowel disorder (Irritable
bowel)
– Malabsorption

10.  Persistent
Diarrhea
– Inflammatory Bowel Disease
– Laxative abuse

11. SMALL BOWEL/LARGE
BOWEL
 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

12. DIURNAL 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

13. WEIGHT 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

14. STOOL CHARACTERISTICS
 Water:
Chronic Watery Diarrhea
 Blood,
pus or mucus: Chronic
Inflammatory Diarrhea
 Foul,
bulky, greasy stools: Chronic
Fatty Diarrhea

15. MEDICATION AND DIETARY
INTAKE
 drug
induced diarrhea
 Food borne illness
 waterborne illness
 High fructose corn syrup
 Excessive sorbitol or mannitol
 Excessive coffee or other caffeine

16. TRAVEL
 Traveler’s
diarrhea
 Infectious
diarrhea

17. ASSOCIATED SYMPTOMS
 Abdominal
pain
 Alternating
constipation
 Tenesmus
 Unintentional
 Fever
wt. loss

18. PAST MEDICAL HISTORY
 Childhood
diarrhea-resolves-reemergence in adulthood– celiac
disease
 Uncontrolled
 Pelvic
diabetes
radiotherapy

19. PAST SURGICAL HISTORY
 Jejunoileal
bypass
 Gastrectomy
 Bowel
with vagotomy
resection
 Cholecystectomy

20. RED FLAGS-suggestive of organic
causes









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

21. PHYSICAL EXAMINATION

22. GPE
 General
 Vital
appearance and mental status
signs
 Body
weight
 Orthostasis-
dysfunction
volume depletion,autonomic

23.  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)

24. SKIN LESIONS
 dermatitis

herpetiformis (celiac disease)
erythema nodosum and pyoderma
gangrenosum (IBD)
 hyperpigmentation

(Addison's disease)
flushing (carcinoid syndrome)
 migratory
necrotizing erythema
(glucagonoma).

25. ABDOMINAL EXAMINATION

Surgical scars

abdominal tenderness

Masses

Hepatosplenomegaly

Borborygmus on auscultation
– malabsorption
– bacterial overgrowth
– obstruction, or rapid
intestinal transit.

26. PERINEAL AND RECTAL
EXAMINATION
 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.

27. SYSTEMIC EXAMINATION
 wheezing
and right-sided heart
murmurs (carcinoid syndrome)
 arthritis
(IBD, Whipple's disease)

28. INVESTIGATIONS

29. BLOOD TESTS
CBC
 TSH
 Serum electrolytes
 Serum albumin


30. STOOL 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

31.  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

32. ENDOSCOPY
 PROCTOSIGMOIDOSCOPY

33. TREATMENT

34. NON-SPECIFIC THERAPIES
 Dietary
modifications
– Smaller, more frequent meals
– Dec. carbohydrates
– Dec. fat intake
– Avoidance of milk
– Avoid sorbitol and mannitol

35.  No
good evidence to support use of
bulking agents
 Bismuth
Bismol )
 opioids
subsalicylate (i.e., Pepto-
and opioid agonists
– Loperamide- first line therapy
– diphenoxylate-atropine (Lomotil )
– Codeine and other narcotics – for
refractory cases

36. SPECIFIC THERAPIES
 Clonidine-
– Diabetic diarrhea
– moderate and severe diarrhea-predominant IBS
 Somatostatin
– refractory diarrhea
•
•
•
•
AIDS,
post chemotherapy,
GVHD,
and hormone secreting tumors.

37.  bile
acid binders (ie, cholestyramine)
 pancreatic
enzyme supplementation
 antimicrobials
–empiric
fluoroquinolones therapy

38. 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.

39. The most clinically useful definition of
diarrhea for this patient would rely on:
 A-
Symptom description
 B-An
increase in daily stool weight (> 200
g/day)
 C-Laboratory
 D-Report
tests
of loose or watery stools

40. How would you begin to diagnose
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

41. How would you assess illness
severity?
 A-Length
of time since symptoms first
appeared
 B-Impact
of diarrhea on daily function
 C-Physical
 D-
examination
Stool frequency

42. Initial empirical therapy of chronic
diarrhea for this patient should include:

A- Psyllium

B-Bismuth subsalicylate
 C-Loperamide

D-Codeine

43. ROME 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

45. THANX…