•21 year old female patient named Maria, hailing from Hyderabad presented with complain of →Loose motion since 1.5 years →Recurrent abdominal pain since 1 year →low grade fever and weight loss since 1 year •She passes loose motion 5-6 times a day, Moderate in amount, not mixed with blood •Pain is colicky and around umbilicus and right side of abdomen, Not related to food but relieves on defecation •Fever is low grade and continuous GENERAL PHYSICAL EXAMINATION The patient is ill-looking and emaciated (also looks depressed) • BP: 120/65 mm Hg • Pulse 96 beats/min • Temperature: 101ºF • Respiratory rate: 18/min. • Moderately anemic • Bilateral pitting edema +ve • No jaundice, cyanosis, clubbing, koilonychia, leukonichia SYSTEMIC EXAMINATION Gastrointestinal system →Lips, gums, teeth, and oral cavity—normal. → Tongue—pale. • Abdomen • Inspection: No abnormality detected • Palpation: →Tenderness in lower abdomen, more in right iliac fossa. →There is a small mass in the right iliac fossa, 2X2 cm in size, firm, non-tender →No visceromegaly •No abnormality detected on Percussion and auscultation APPROACH TO CHRONIC DIARRHEA DIARRHEA MUST BE DISTINGUISHED FROM FECAL INCONTINENCE!! Fecal Incontinence: ◦involuntary discharge of rectal contents ◦most often caused by neuromuscular disorder/structural/anorectal problems ACUTE: less than 2 weeks duration • PERSISTANT: 2-4 WEEKS DURATION • CHRONIC: GREATER THAN 4 WEEKS • CARBOHYDRATE MALABSORPTION •PROTEIN MALABSORPTION →Generalized weakness →Loss of visceral and somatic protein →Bloating →Flatulance →Abdominal discomfort •FATS MALABSORPTION →Loss of body fat →Steatorrhea • Nutrition and hydration • Skin, mucosa, conjunctiva →Flushing, dermatographism →Aphthous ulcer, glossitis →Koilonychia, clubbing, leukonychia →Edema →Hyperpigmentation → Erythema nodosum → Xerosis, keratomalacia •Thyroid mass •Heart murmur •Abdomen- Hepatomegaly, mass, ascites, tenderness

1. CASE PRESENTATION
BY DR. ALJI DANDHAL
HOUSE OFFICER
DEPARTMENT OF MEDICINE UNIT-II
LUH JAMSHORO

2. 2
•21 year old female patient named Maria, hailing from Hyderabad presented with
complain of
→Loose motion since 1.5 years
→Recurrent abdominal pain since 1 year
→low grade fever and weight loss since 1 year
•She passes loose motion 5-6 times a day, Moderate in amount, not mixed with blood
•Pain is colicky and around umbilicus and right side of abdomen, Not related to food but
relieves on defecation
•Fever is low grade and continuous
HISTORY

3. 3
The patient is ill-looking and emaciated (also looks depressed)
• BP: 120/65 mm Hg
• Pulse 96 beats/min
• Temperature: 101ºF
• Respiratory rate: 18/min.
• Moderately anemic
• Bilateral pitting edema +ve
• No jaundice, cyanosis, clubbing, koilonychia, leukonychia
• No lymphadenopathy or no thyromegaly
GENERAL PHYSICAL EXAMINATION

4. 4
• Gastrointestinal system
→Lips, gums, teeth, and oral cavity—normal.
→ Tongue—pale.
• Abdomen
• Inspection: No abnormality detected
• Palpation:
→Tenderness in lower abdomen, more in right iliac fossa.
→There is a small mass in the right iliac fossa, 2X2 cm in size, firm, non-tender
→No visceromegaly
•No abnormality detected on Percussion and auscultation
SYSTEMIC EXAMINATION

5. 5
• PATHOLOGICAL DIAGNOSIS….?
• DIFFERNTIALS….?
DIFFERNTIAL DIAGNOSIS…?

6. APPROACH TO CHRONIC DIARRHEA

7. 7
• IS THE DIARRHEA ….
→Acute or chronic? →Stool characterstics?
→Functional or organic? →Type of diarrhea?
→Relation to food? →Features of malabsorption?
→Which part of intestine is involved; Large bowel or small bowel?
EVALUTION OF CHRONIC DIARRHEA

8. 8
DIARRHEA MUST BE DISTINGUISHED FROM
FECAL INCONTINENCE!!
Fecal Incontinence:
◦involuntary discharge of rectal contents
◦most often caused by neuromuscular
disorder/structural/anorectal problems
EVALUTION OF CHRONIC DIARRHEA

9. 9
• ACUTE: less than 2 weeks duration
• PERSISTANT: 2-4 WEEKS DURATION
• CHRONIC: GREATER THAN 4 WEEKS
ACUTE OR CHRONIC DIARRHEA…?

10. 10
FUNCTIONAL OR ORGANIC DIARRHEA…?
FEATURES FUNCTIONAL ORGANIC
Duration Long short
Constitutional symptoms Less marked Marked
Weight loss No Yes
Appetite Normal Decrease
Nocturnal diarrhea No Yes
Gastro-colic reflex Yes No
Anxiety symptoms Yes No

11. 11
TYPE OF DIARRHEA MECHANISM OF CAUSATION TYPICAL CAUSES
Watery Intestinal secretion Pancreatic tumour
Large volume, pale, frothy Malabsorption Tropical sprue
Celiac disease
Parasitic infection
Drugs
Blood or pus Inflammatory Ulcerative colitis
Crohn’s disease
Tuberculosis
IDENTIFY TYPE OF ORGANIC DIARRHEA…

12. 12
FEATURES SMALL BOWEL LARGE BOWEL
Stool volume Large Small
Rectal symptoms Absent Frequent
Steatorrhea Can be present Absent
Excessive flatulance Can be present Absent
Protein malabsorption Can be present Absent
Pain abdomen Central, not improving with
defecation
Hypogastric, improve with
defecation
Vitamin deficiency Frequent Infrequent
LARGE BOWEL OR SMALL BOWEL…?

13. 13
• Watery stools → Osmotic and Secretory
• Greasy and Malodours → Fat malabsorption
• Visible blood → Inflammatory
STOOL CHARACTERSTICS…

14. 14
• PAINLESS DIARRHEA •PAINFUL DIARRHEA
→Tropical sprue →T.B
→Celiac disease →Crohn’s disease
→Giardiasis →Whipple disease
→Chronic pancreatitis
ASSOCIATED WITH ABDOMINAL PAIN AND BLEEDING…?

15. 15
• After meals → IBS
• Stop with fasting → Osmotic diarrhea
• Occur Inspite of fasting and during sleep → Secretory
RELATION TO FOOD…

16. 16
FEATURES OF MALABSORPTION

17. 17
• CARBOHYDRATE MALABSORPTION •PROTEIN MALABSORPTION
→Generalized weakness →Loss of visceral and somatic protein
→Bloating
→Flatulance
→Abdominal discomfort
•FATS MALABSORPTION
→Loss of body fat
→Steatorrhea
FEATURES OF MALABSORPTION…?

18. 18
• Nutrition and hydration
• Skin, mucosa, conjunctiva
→Flushing, dermatographism
→Aphthous ulcer, glossitis
→Koilonychia, clubbing, leukonychia
→Edema
→Hyperpigmentation
→ Erythema nodosum
→ Xerosis, keratomalacia
•Thyroid mass •Heart murmur
•Abdomen- Hepatomegaly, mass, ascites, tenderness
PHYSICAL EXAMINATION

19. 19
INVESTIGATIONS…

20. 20
• CBC
• ESR, CRP
• Total protein and albumin
• UCE & Thyroid profile
• Iron/TIBC
• HIV Serology
• Anti-tissue transglutaminase
• Stool examination and fecal occult blood
INVESTIGATIONS…

21. 21
• SERUM ELECTROLYTES
→Serum Na……………….130mEq/L ↓
→Serum Potassium…….3.0mEq/L ↓
→Serum Chloride………100mEq/L -
→Serum Bicarbonate…. 24mEq/L ↓
INVESTIGATIONS…

22. 22
• Serum Calcium…………….7.0mg/dl ↓
• Vitamin D3 Level………….<3.5ng/dl ↓
INVESTIGATIONS…

23. 23
FINDING ON STOOL
EXAM
DISEASE
Occult blood , Pus cells IBD,TB, Neoplasm
WBCs increased IBD
Sudan stain shows
increased fat
Small bowel disease
Pancreatic insufficiency
ROUTINE STOOL STUDIES…

24. 24
• In patients with suspected secretory diarrhea
→Serum VIP (VIPoma)
→gastrin ( Zollinger-Ellison syndrome)
→Calcitonin(Medullary thyroid cancer)
→Cortisol( Addison’s disease)
→Urinary 5-HIAA ( Carcinoid syndrome)
OTHER LABORTORY TESTS

25. 25
• CARBOHYDRATE MALABSORPTION
→D-Xylose absorption test
→Breath H2 Test
→Stool for reducing substances
• FAT MALABSORPTION
→ Breath Triolein test
→24 hours fecal fat
LABS TO CHECK FOR MALABORPTION

26. 26
• X-ray abdomen
• US Abdomen
• CT-Scan Abdomen
• MRI abdomen
IMAGING STUDIES

27. 27
CT-SCAN

28. 28
ENDOSCOPIC EXAMINATION AND MUCOSAL BIOPSY
• Colonoscopy to exclude Intestinal TB, IBDs, microscopic colitis
and colonic Neoplasia.
• Upper GI Endoscopy performed when Celiac
and Whipple disease is suspected.

29. 29
• Acute or Chronic diarrhea
• Organic or functional
• Watery, frothy or associated with pus
• Large or small bowel or both
• Painful or painless
• Not related to food
• No symptom of extra intestinal manifestation
• Colonoscopy shoes Koch’s lesion and biopsy confirmed ‘’ILEOCECAL TB’’
CASE SUMMARY

30. 30
• Treat the underlying cause…
• Loperamide: 4mg initially then 2mg after each loose stool
• Diphenoxylate with Atropine :One tab three times a day
• Clonidine: Alpha-2 adrengic agonist inhibit intestinal electrolyte secretion
• Octreotide: Somatostatin analogue stimulate intestinal fluid and electrolyte absorption
• Bile salt binders: Helpful in bile salt induced diarrhea
TREATMENT…

31. THANK YOU…!