Approach to a patient with chronic diarrhea,diagnosis and managment. different causes are also discussed in this presentation and respective treatment is stated.

1. APPROACH TO A PATIENT
WITH CHRONIC DIARRHOEA
Ahsan Sajjad
RMU-43

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 wt. loss
 Fever

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

19. PAST SURGICAL HISTORY
 Jejunoileal bypass
 Gastrectomy with vagotomy
 Bowel 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 appearance and mental status
 Vital signs
 Body weight
 Orthostasis- volume depletion,autonomic
dysfunction

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. PERINEALAND 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 subsalicylate (i.e., Pepto-
Bismol )
 opioids 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 tests
 D-Report 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 examination
 D- 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…