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1. APPROACH
TO CHRONIC
DIARRHEA
Dr Toqeer Hussain
PGT MEDICINE
SKBZ CMH MEDICINE

2. CHRONIC DIARRHEA
🠶 Diarrhea is defined as passage of abnormally
liquid or unformed stools at an increased
frequency.
🠶 Chronic Diarrhea- lasting > 4 weeks .
🠶Most of the causes are Non infectious.
🠶Stool weight more than 200 g daily in western diet.

3. CLASSIFICATIO
N
🠶1.Secretory diarrhea.
🠶2.Osmotic diarrhea.
🠶3. Steatorrheal
diarrhea.
🠶4.Inflammatory
diarrhea.
🠶5. Dysmotility causes.
🠶6.Factitial diarrhea.
🠶7.Iatrogenic causes.

4. 🠶Also classified –
🠶1. Small bowel
diseases.
🠶2. Colonic diseases.
🠶3. Malabsorption.

5. SECRETORY DIARRHEA
🠶 Due to derangements in fluid and electrolyte
transport across the entero colnic mucosa.
🠶 Net secretion of anions ( chloride or
bicarbonate ), potassium or net inhibition of
sodium absorption .
🠶 Lack of sufficient absorptive surface area
limits electrolyte absorption ( sodium )
🠶 Characterized by – watery ,large volume fecal output ,
painless and persist with fasting

6. Secretory diarrhea
1. Exogenous stimulant laxative
2. Chronic ethanol ingestion
3. Other drugs and toxins
4. Endogenous laxatives ( Dihydroxy bile acids)
5. Idiopathic secretory diarrhea
6. Bowel resection or fistula or disease.
7. Partial bowel obstruction / impaction
8. Hormone producing tumors ( VIPoma, Carcinoid ,Gastrinoma, ,
somatostatinoma)
9. Addison ‘s disease
10. Congenital electrolyte absorption defects.
11. Certain bacterial infection.( cholera ,E.coli )

7. 12. Diverticulitis
13. Endocrinopathies – Hyperthyroidism, Mastocytosis,
Medullary Carcinoma thyroid , pheochromocytoma
14. Ileal bile acid malabsorption
15. IBD – Crohn ‘s disease, Microscopic colitis ,
colitis
16. Neoplasia – Colon cancer, lymphoma, Villous
adenoma in rectum
17.Vaculitis.

8. OSMOTIC DIARRHEA
🠶Osmotic diarrhea occurs when ingested poorly
absorbed osmotically active solutes draw
enough fluid into the lumen to exceed the
reabsorptive capacity of the colon.
🠶Fecal water output increases in proportion to
solute load.
🠶Characteristically ceases with fasting or
with discontinuation of the causative
agent.

9. 🠶Causes include :
🠶1. Osmotic laxatives
🠶2. Ions – Magnesium, sulphate, phosphate
🠶3. Lactase and disaccharide deficiencies
🠶4. Non absorbable carbohydrates – sorbitol, lactulose,
mannitol, polyethylene glycol .
🠶5. Foods – FODMAPs – Fermentable oligosaccharides,
disaccharides, monosaccharides, and polyols.

10. STEATORRHEAL CAUSES
🠶Fat malabsorption lead to greasy , foul smelling,
difficult flush diarrhea.
🠶Associated with weight loss and nutritional deficiencies
due mal absorption of amino acids and vitamins.
🠶Quantitatively steatorrhea is defined as stool fat
exceeding 7g/day.

11. 🠶Causes
–
🠶 1. Intraluminal mal digestion : Pancreatic exocrine
insufficiency Bacterial overgrowth
Bariatric surgery Liver disease.
Inadequate luminal bile acid sequestration

12. CAUSES
2. Mucosal malabsorption :
Celiac sprue
Whipple’s disease.
Infections – Giardia abeta lipoproteinemia
Mesenteric Ischemia.
Short bowel syndrome
Small intestinal bacterial over growth
3. Post mucosal obstruction – Primary or Secondary

13. INFLAMMATORY DIARRHEA
🠶 Accompanied by fever, pain, bleeding.
🠶 Mechanism – Exudation of fluid
Fat mal absorption
Disrupted fluid / electrolyte
absortption Hyper secretion or hyper
motility
Stool analysis – presence of leukocytes or leukocyte
derived proteins
– Calprotectin.

14. 1.Idiopathic inflammatory bowel disease -Crohn ‘s disease and Chronic
ulcerative colitis*
2. Lymphocytic and collagenous colitis
3. Immune related mucosal diseases – primary and secondary
immunodeficiency, food allergy , eosinophilic gastroenteritis
4. Infections – Tuberculosis, yersiniosis , Amebiasis, Strongyloidasis
Pseudomembranous colitis, Cytomegalovirus, HSV
5. Radiation colitis
6. Gastrointestinal malignancies – Colon cancer, lymphoma,
7.Diverticulitis
8. Ischemic colitis

15. DYSMOTOLITY CASUES
🠶 Rapid transit – mal digestion
🠶Hypermotility – intestinal hurry
🠶Irritable bowel syndrome
🠶Visceral neuromyopathies
🠶Drugs ( prokinetic agents )
🠶Post vagotomy and Post
sympathectomy
🠶Diabetic autonomic neuropathy
🠶Hyperthyroidism

16. IATROGENIC CAUSES
🠶Cholecystectom
y
🠶Ileal resection
🠶Bariatric surgery
🠶Vagotomy
🠶Fundoplicatio.

17. FACTITIAL CASUES
🠶Munchausen
syndrome
🠶Eating disorders

18. APPROACH
🠶 HISTORY :
1.Duration - > 4 weeks
2.Onset – congenital, abrupt, gradual
3. Pattern – Continuous , intermittent
4. Severity
5.Dry mouth , increased thirst, decreased urine out put ,
weakness
- Dehydration
6.Abdominal pain – location, relation to meal, relation to
bowel movements, aggravating or relieving factors
7. Fever
8.Weight loss

19. 9.
Flatulance
10.Bloating or gaseous distension
11.Abdominal cramps
12.Systemic diseases: endocrine, collagen
vascular , neoplastic , immunologic
13.Extra intestinal manifestations- skin
changes, arthralgia, oral apthous ulcer.
14.Fecal incontinence/ urgency- present or
absent , Relationship of defecation to meals /

20. 15. Aggravating factors – diet, stress
16.Alleviating factors –diet, drugs
17.Previous evaluation.
18.Family history – IBD or Sprue
19.Stool characteristics : watery, bloody,
oil/food particles, frequency, volume,
20.Epidemiology
21.Iatrogenic factors – drugs, laxative abuse,
radiation, previous abdominal surgery.
22. Diet history

21. PHYSICAL EXAMINATION
FINDINGS POTENTIAL IMPLICATION
Orthostasis, Hypotension Dehydration, Neuropathy
Muscle wasting , edema Malnutrition
Urticaria pigmentosa,
dermatographism
Mast cell disease
Pinch purpura, macroglossia Amyloidosis
Hyperpigmentation Addison’s disease
Migratory necrotizing erythema Glucagonoma

22. Flushing, wheezing, right sided heart
murmur
Carcinoid syndrome
Dermatitis herpetiformis Celiac disease
Thyroid nodule , lymphadenopathy Medullary carcinoma of thyroid
Tremor
, lid lag Hyperthyroidism
Hepatomegaly Endocrine tumor, Amyloidosis
Abdominal bruits Chronic mesenteric ischemia
Arthritis IBD, Whipple’s disease
Lymphadenopathy HIV infection, Lymphoma, cancer
Anal sphincter weakness Fecal incontinence

23. STOOL ANALYSIS
🠶Random sample / timed sample
🠶Daily stool weight
🠶1.Stool Na, K,
🠶2.Stool pH – acidic ( < 6 ) increased
carbohydrate fermentation in colon
🠶3.Occult blood
🠶4.White blood cells
🠶5. Stool water analyzed for Laxatives -Mg,
PO4, SO4,Bisacodyl

24. 🠶6. Osmotic gap –
< 50 Osm/ Kg – Secretory diarrhea
> 100 Osm/ Kg – Osmotic diarrhea
🠶7.Fat contents –
Steatorrhea – excessive loss of fat in stool
 7 gm or > 9 % of intake for 24 hours.
 > 14 gm /24 hr – fat mal absorption
8.Lactoferrin or Calprotectin
9.Chemical test – Carbohydrates -Anthrone reagent
Alpha 1 anti trypsin clearance to detect protein
losing
enteropathy.

25. DIAGNOSTIC APPROACH TO THE PATIENT WITH
CHRONIC SECRETORY DIARRHEA

26. DIAGNOSTIC APPROACH TO THE
PATIENT WITH OSMOTIC
DIARRHEA

27. DIAGNOSTIC APPROACH TO THE PATIENT
WITH CHRONIC INFLAMMATORY
DIARRHEA

28. DIAGNOSTIC APPROACH TO THE PATIENT
WITH CHRONIC FATTY DIARRHEA

29. TREATMENT
🠶Fluid and electrolyte replenishment- oral
rehydration therapy or intravenous fluid therapy.
🠶Empirical therapy :
🠶1.Therapuetic trials of pancreatic enzyme
replacement and conjugated bile acid
supplementation.
🠶2. Opiates – codeine, opium or morphine
🠶3. Octreotide – Carcinoid syndrome ,
endocrinopathies, dumping syndrome,
chemotherapy induced diarrhea and AIDS.

30. 🠶4. Clonidine – diabetic diarrhea
🠶5.Crofelemer – non infectious diarrhea in AIDS
patients on ART
🠶6. Probiotics by modifying the colonic flora
stimulate local immunity and speed resolution in
traveler ‘s diarrhea ,antibiotic associated
diarrhea.
🠶7. Other non specific agents :
Herbal remedies – golden seal,
barberry,arrowroot Stool modifying agents-
psyllium

32. THANK YOU