Chronic Diarrhea references include the American Academy of Family Physicians AAFP Special Thanks to my colleague Hadi Al Qurain for his participation in preparing this presentation

1. CHRONIC DIARRHEA
DAWOOD AL NASSER
Saudi Board of Family Medicine Trainee
May 2015

2. LEARNING OBJECTIVES
• Definition
• Categorization
• Medical history
• Physical examination
• Differential Diagnosis
• Common Causes of Chronic Diarrhea

3. DEFINITION
A decrease in stool consistency continuing for
more than four weeks..

4. This article focuses on a diagnostic approach that is
practical for the primary care physician.

5. • There is no firm rule as to what testing should be done.
• The history and physical examination may point toward a specific diagnosis for which testing may be
indicated.
• Not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories
overlap.
• Still, the most practical diagnostic approach is to attempt to categorize the diarrhea by type before
testing and treating.

6.  Try to explain the etiology and category of diarrhea in
the following patients:
?

7. CASE 1
30 year old obese female, presented with history of diarrhea for the
last 2 months , she is having fatty/oily stool, and occasional poor bowel
control ,her symptoms get worse whenever she eats more fat.
Physical Examination: WNL,BMI=36
She brought blue tablets that she is taking to look good at her wedding.
Fatty
Malabsorption

8. CASE 2
A 23 years old man presented to the PHC with 5 weeks history of diarrhea ,fatigue , Borborygmus,abd. Pain,
flatulence,wt.loss
On examination you noted:
Flesh-colored–to–erythematous excoriated papules or plaques with herpetiform (ie, small, clustered) vesicles
are symmetrically distributed over extensor surfaces, including the elbows, knees, buttocks, and shoulders.
You decided to refer him to a dermatologist who diagnosed his case as Dermatitis herpetiformis .
watery/fatty
malabsorption
celiac disease

9. 40 Years old farmer ,complains of abdominal fullness/bloating, nausea, abdominal pain, diarrhea, and
flatulence, that he used to have for years, he used to avoid milk which seemed to be “harmful” according
to him, but now his persistently having the symptoms even after eating bread and biscuits.
Fatty or watery
Malabsorption
Carbohydrate malabsorption (lactose intolerance)
Case 3

10. CASE 4
35 years old who spend a lot of time camping, backpacking, and hunting, presented with gradual onset
of diarrhea ,steatorrhea , and flatulence and cramping and weight loss of about 20% of his weight over
the last 5 weeks.
What is the most common cause of such presentation?
inflammatory
parasitic infection
Most common giardia

11. CASE 5
33 years old female ,presented with complaint of a chronic diarrhea ,fatigue and hair loss,during physical
examination she is noted to be nervous ,her hands are trembling ,moist and warm.
watery
endocrine disorder
 hyperthyroidism

12. Diarrhea
Watery
osmotic
secretory
functional
Fatty
Malabsorption
syndrome
Maldigestion
Inflammatory

13. Watery
Diarrhea
Secretory
Secretory (often nocturnal; unrelated to food intake; fecal
osmotic gap < 50 mOsm per kg*)
eg.alcoholism,cholera ,crohn
Osmotic
(fecal osmotic gap > 125 mOsm per kg*)
Eg.Carbohydrate malabsorption syndromes (e.g., lactose, fructose) ,Celiac
disease, Osmotic laxatives and antacids
Functional
(distinguished from secretory types by hypermotility,
smaller volumes, and improvement at night and with
fasting) eg.Irritable bowel syndrome

14. Fatty Diarrhea
(bloating and steatorrhea in
many, but not all cases)
Malabsorption syndrome
(damage to or loss of absorptive
ability)
Eg.Amyloidosis,gastric bypass,
medications
Maldigestion
(loss of digestive function)
Eg.Hepatobiliary disorders
Inadequate luminal bile acid

15. Inflammatory or exudative diarrhea :
(elevated white blood cell count, occult or frank blood or pus)
• Inflammatory bowel disease
• Crohn disease (ileal or early Crohn disease may be secretory)
• Diverticulitis
• Ulcerative colitis
• Ulcerative jejunoileitis
• Invasive infectious diseases

16. COMMON CAUSES OF CHRONIC DIARRHEA
 Celiac disease
 Clostridium difficile infection
 Drug-induced diarrhea
 Endocrine diarrhea
 Giardiasis
 Infectious enteritis or colitis
 Inflammatory bowel disease:
Crohn disease, ulcerative colitis
 Irritable bowel syndrome
 Ischemic colitis
 Microscopic colitis

17. MEDICAL HISTORY
• A history is the critical first step in diagnosis.
• It is important to understand exactly what patients mean when they say they have diarrhea.
• A patient may not actually have diarrhea, but incontinence occasioned by fecal impaction.

18. MEDICAL HISTORY
• Age
• Duration
• food,
• family history,
• pattern,
• timing,
• travel
• hospitalization
• Stool volume, frequency, and consistency can help categorize the diarrhea, as previously
mentioned.

19. PHYSICAL EXAMINATION
• General: wt.loss and lymphadenopathy  Ch. Infection or malignancy
• Eye : episcleritis  Inflammatory Bowel Disease ,
exophthalmia  hyperthyroidism
• Skin: Dermatitis herpetiformis, an itchy blistering rash, is found in celiac disease.

20. PHYSICAL EXAMINATION
• Abdomen:
scars  (surgical causes of diarrhea),
bowel sounds (hypermotility),
tenderness (infection and inflammation),
and masses  (neoplasia)
• Anorectal : Anal fistulae suggest Crohn disease

21. DIAGNOSIS
• History: age, duration, food, family history, pattern, timing, travel
• Physical examination: general, eye, skin, abdomen, anorectal
• Laboratory tests
• Blood (albumin and thyroid-stimulating hormone levels; complete blood count; erythrocyte
sedimentation rate; liver function testing)
• Stool (bacteria, blood, fat, leukocytes, ova and parasites, pH test, Giardia and Cryptosporidium
antigen tests)
• Celiac panel
• Clostridium difficile toxin, if indicated
• Laxative screen, if indicated
• Procedure: anoscopy

24. DIAGNOSIS AND
MANAGEMENT
OF
IBS IN ADULTS

25. LEARNING OBJECTIVES
• Definition
• Etiology and Pathophysiology
• Clinical Presentation
• Diagnosis
• Alarm features
• Rome III criteria
• Treatment

26. IBS IN SECONDARY SCHOOL MALE STUDENTS IN
ALJOUF PROVINCE, NORTH OF SAUDI ARABIA.
• METHODS:
 A cross sectional study was conducted in April 2009, AlJouf province of Saudi Arabia, involving a
self administered questionnaire (2025 students
• RESULTS:
 The prevalence of IBS was 8.9% and 9.2% according to Manning and Rome II criteria for diagnosis of
IBS respectively in the study subjects with mean age of 17.5 +/- 3 years and range of 15-23 years

27. • Irritable bowel syndrome (IBS) is defined as abdominal discomfort or pain associated with altered
bowel habits for at least three days per month in the previous three months, with the absence of organic
disease.
• Altered bowel habits include diarrhea-predominant, constipation-predominant, and mixed
presentation with alternating diarrhea and constipation.

28. ETIOLOGY AND PATHOPHYSIOLOGY
• One study showed a threefold increase in the risk of ibs in persons with an immediate family member
• Disturbances in gastrointestinal motility, mucosal barrier disruption, visceral hypersensitivity, dysfunction of the
gut-brain axis.
• There is an association between ibs and psychological disorders (e.g., Anxiety, depression, posttraumatic stress
disorder), with up to two-thirds of patients with IBS in tertiary care centers having a concurrent psychological
disorder.

29. CLINICAL PRESENTATION

31. ALARM FEATURES
Anemia
 Rectal bleeding
 Nocturnal symptoms
Weight loss
Recent antibiotic use
Onset after 50 years of age
Family history of colorectal cancer,
Inflammatory bowel disease, or celiac disease.

32. THE ROME III CRITERIA
• Commonly are used in research and less often in clinical practice.
Rome iii criteria:
• Symptoms of recurrent abdominal pain or discomfort and a
marked change in bowel habits for at least six months, with
symptoms experienced on at least three days per month for at
least three months. Two or more of the following must apply:
1. Pain is relieved by a bowel movement
2. Onset of pain is related to a change in frequency of stool
3. Onset of pain is related to a change in appearance of stool

33. MANNING CRITERIA
 Onset of pain linked to more frequent bowel movements
 Looser stools associated with onset of pain
 Pain relieved by passage of stool
 Noticeable abdominal bloating
 Sensation of incomplete evacuation more than 25 percent of the time
 Diarrhea with mucus more than 25 percent of the time

34. EVALUATION

35. EVALUATION OF
A SUSPECTED CASE OF
IBS
Classify into subtypes
Consistency and severity
assessment
IBS symptoms
Alarm features Room III

36. ALL TYPES OF IBS CAN BENEFIT FROM
• Exercise
• Fiber
• Probiotics
• Antispasmodic
• Antidepressants
• Complementary and alternative therapy

37. CONSTIPATION PREDOMINANT IBS
• Laxative
• Antibiotics
• 5 HT4 agonists
• Selective C-2 chloride channel activator

38. DIARRHEA PREDOMINANT
• Antidiarrheals
• Antibiotics
• 5HT3 antagonist (women only)