approach to a patient with Chronic diarrhoea

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approach to a patient with Chronic diarrhoea

  1. 1. APPROACH TO A PATIENT WITH CHRONIC DIARRHOEA
  2. 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. 3. CLASSIFICATION  Acute diarrhea  Chronic diarrhea 4 weeks– cut off point
  4. 4. CAUSES  Chronic Fatty Diarrhea – malabsorption syndromes  Chronic Inflammatory Diarrhea  Chronic Watery Diarrhea – – – Secretory Diarrhea Osmotic Diarrhea Drug-Induced Diarrhea
  5. 5.  Infectious Diarrhea  Endocrine diarrhea  Functional Diarrhea (diagnosis of exclusion) – Irritable Bowel Syndrome
  6. 6. HISTORY
  7. 7. AGE  Young patients – – –  Inflammatory Bowel Disease Tuberculosis Functional bowel disorder (Irritable bowel) Older patients – – Colon Cancer Diverticulitis
  8. 8. DIARRHEA PATTERN  Diarrhea alternates with Constipation – Colon Cancer – Laxative abuse – Diverticulitis – Functional bowel disorder (Irritable bowel)
  9. 9.  Intermittent Diarrhea – Diverticulitis – Functional bowel disorder (Irritable bowel) – Malabsorption
  10. 10.  Persistent Diarrhea – Inflammatory Bowel Disease – Laxative abuse
  11. 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. 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. 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. 14. STOOL CHARACTERISTICS  Water: Chronic Watery Diarrhea  Blood, pus or mucus: Chronic Inflammatory Diarrhea  Foul, bulky, greasy stools: Chronic Fatty Diarrhea
  15. 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. 16. TRAVEL  Traveler’s diarrhea  Infectious diarrhea
  17. 17. ASSOCIATED SYMPTOMS  Abdominal pain  Alternating constipation  Tenesmus  Unintentional  Fever wt. loss
  18. 18. PAST MEDICAL HISTORY  Childhood diarrhea-resolves-reemergence in adulthood– celiac disease  Uncontrolled  Pelvic diabetes radiotherapy
  19. 19. PAST SURGICAL HISTORY  Jejunoileal bypass  Gastrectomy  Bowel with vagotomy resection  Cholecystectomy
  20. 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. 21. PHYSICAL EXAMINATION
  22. 22. GPE  General  Vital appearance and mental status signs  Body weight  Orthostasis- dysfunction volume depletion,autonomic
  23. 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. 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. 25. ABDOMINAL EXAMINATION  Surgical scars  abdominal tenderness  Masses  Hepatosplenomegaly  Borborygmus on auscultation – malabsorption – bacterial overgrowth – obstruction, or rapid intestinal transit.
  26. 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. 27. SYSTEMIC EXAMINATION  wheezing and right-sided heart murmurs (carcinoid syndrome)  arthritis (IBD, Whipple's disease)
  28. 28. INVESTIGATIONS
  29. 29. BLOOD TESTS CBC  TSH  Serum electrolytes  Serum albumin 
  30. 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. 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. 32. ENDOSCOPY  PROCTOSIGMOIDOSCOPY
  33. 33. TREATMENT
  34. 34. NON-SPECIFIC THERAPIES  Dietary modifications – Smaller, more frequent meals – Dec. carbohydrates – Dec. fat intake – Avoidance of milk – Avoid sorbitol and mannitol
  35. 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. 36. SPECIFIC THERAPIES  Clonidine- – Diabetic diarrhea – moderate and severe diarrhea-predominant IBS  Somatostatin – refractory diarrhea • • • • AIDS, post chemotherapy, GVHD, and hormone secreting tumors.
  37. 37.  bile acid binders (ie, cholestyramine)  pancreatic enzyme supplementation  antimicrobials –empiric fluoroquinolones therapy
  38. 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. 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. 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. 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. 42. Initial empirical therapy of chronic diarrhea for this patient should include:  A- Psyllium  B-Bismuth subsalicylate  C-Loperamide  D-Codeine
  43. 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
  44. 44. THANX…

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