approach to diagnosis and management of chronic diarrhea

1. MANAGEMENT OF CHRONIC
DIARRHEA
SPEAKER: ANGAN KARMAKAR
CHAIRPERSON: DR. K D BISWAS
(DEPT. OF GASTROENTEROLOGY)

2. Definition
• Increased stool weight > 200 gm/d
• 3 or more bowel movements
• Increased fluidity of stool
• > 4 weeks
Among Indians
• Average stool weight 311 g/d
• Bowel movement >3/d (9% of population)

4. Initial Evaluation:
HISTORY
• Duration, pattern,
epidemiology
• Severity, dehydration
• Stool volume & frequency
• Stool characteristics
• Nocturnal symptoms
• Fecal urgency, incontinence
• Associated symptoms (abd
pain, cramps, bloating,
fever, weight loss, etc)
• Extra-intestinal symptoms
• Relationship to meals,
specific foods, fasting, &
stress
• Medical, surgical, travel,
water exposure history
• Recent hospitalizations,
antibiotics
• History of radiation
• Current/recent medications
• Diet (including excessive
fructose, sugar alcohols,
caffeine)
• Laxative abuse

5. Stool characteristics
• Blood in stool – IBD, malignancy
• Watery stool – osmotic,secretory
• Oily stool – malabsorption,maldigestion
• Relationship with fasting –secretory diarrhea
• Nocturnal diarrhoea – organic
• Excess flatus - malabsorption

6. Initial Evaluation:
PHYSICAL EXAMINATION
Fever
Bowel sounds
Anemia, edema
Abdominal distention, tenderness, masses
Hepatomegaly, lymphadenopathy
DRE
Skin, joints, thyroid, peripheral neuropathy,
murmur

8. • CBC (Hb%,Hct, MCV, WBC count),ESR
• electrolytes, BUN /Cr, glucose, LFTs, Ca, albumin
• HIV serology, CRP, INR/PTT, TSH, B12, folate, Vit D, iron
• anti-transglutaminase IgA Ab, anti-endomyseal IgA Ab
• Stool studies
– OPC: Giardia , Microsporidia, Cryptosporidiosis
– Fecal leukocytes
– occult blood: inflammatory, malignancy
Initial Evaluation:
TESTING

9. – Stool electrolytes for osmotic gap = 290 – 2[Na + K]
Small gap(<50)= secretory
Large gap(>100)= osmotic
Measured osmolality <290= addition of water, urine
– Stool pH (<6 suggests carbohydrate malabsorption)
– Fat content (48h or 72h quantitative or Sudan stain)
>7gm/9% of fat intake for 24 hrs= steatorrhoea

12. CHRONIC OSMOTIC DIARRHEA
• CLUES:
Osmotic gap >100
Stool volume: decreases with fasting
Bloating
Stool analysis: stool pH(low)
laxative screen(Mg)

13. • CARBOHYDRATE MALABSORPTION
Dietary review
Breath hydrogen test using lactose, mucosal
lactase assay
Therapeutic trial: elimination diet

14. CHRONIC SECRETORY DIARRHEA
• CLUES:
Large volume(>1 litre)
Little change with fasting
(except bile salt diarrhea)
Normal osmotic gap

15. Further approach
• stool culture
• Microscopy for OPC
• Antigen testing
• CT/MRI of abdomen,pelvis
• Sigmoidoscopy/colonoscopy + mucosal biopsy
• Enteroscopy + mucosal biopsy & aspirate
• Capsule enteroscopy

16. • Selective testing
plasma peptides- gastrin, VIP
Urine autacoids & metabolites
Others – TSH, cortisol, SPEP, Ig
• Therapeutic trial
Bile acid binding agent

17. • 25% of all cases: undiagnosed
• Idiopathic secretory diarrhea

18. CHRONIC INFLAMMATORY
DIARRHEA
• CLUES:
Fever
Hematochezia
Abdominal pain
Weight loss

19. Further approach
• Sigmoidoscopy or colonoscopy + mucosal
biopsy
• CT/MRI – abdomen, pelvis
• Enteroscopy + mucosal biopsy
• Exclude infection : biopsy, serology, culture
(TB, parasite, virus)

20. CHRONIC FATTY DIARRHEA
• CLUES:
Weight loss
Fecal fat >7-10gm/24 hr
Anemia
Hypoalbuminemia
Vitamin deficiency

21. Further approach
• Exclude structural disease
CT abdomen, enteroscopy + small intestinal
biopsy & aspirate
• Exclude bile acid deficiency
empiric trial of bile acid
duodenal aspirate for bile acid conc
• Exclude pancreatic exocrine deficiency

22. Pancreatic exocrine insufficiency
• Smaller stool volume, higher fat content
>9.5 gm fat/100 gm stool- pancreatic/biliary
dysfunction
• Oil in stool
• Less hypocalcemia( w.r.t mucosal disaease)
• TESTS: therapeutic trial: pancreatic enzymes
stool elastase/chymotrypsin conc
secretin test

24. FACTITIOUS DIARRHEA
• Laxative abuse
• Munchausen’s syndrome
• Polle’s syndrome
• Addition of water, urine
• Treatment
counseling

25. MICROSCOPIC COLITIS
• Elderly female
• Normal colonoscopy
• two types – collagenous colitis and lymphocytic
colitis
• Treatment:
Bismuth, mesalamine
Steroid, immunosuppressive
Anti TNF-α

26. BILE ACID INDUCED DIARRHEA
• Causes:
Chronic cholestatic liver disease
ileal resection
• Diagnosis:
1. Therapeutic trial
2. Measuring conjugated bile acid in
duodenal aspirate

27. Empiric therapy for chronic diarrhea
INDICATIONS:
• initial therapy prior to diagnostic testing
• diagnostic tests fail to confirm a diagnosis
• diagnosis established, but no specific
treatment available or it fails to provide any
benefit
American Gastroenterological Association (AGA)
guidelines

28. Empiric therapy for chronic diarrhea
• Antibiotics

29. TREATMENT OF IBS-D

30. MAS – Indian persrpective
• Tropical sprue: broad spectrum antibiotic
folate, vit B12
• Coeliac disease: Gluten free diet
• Giardia infection: antibiotic
• Intestinal tuberculosis: ATD (9-12 months)

31. MEDICAL MANAGEMENT OF IBD

32. DRUGS FOR CHRONIC DIARRHEA
IN AIDS
BOVINE COLOSTRUM
Cryptosporidium Nitazoxanide
Microsporidia Albendazole
Isospora TMP/SMX
CMV Ganciclovir/ Foscarnet
MAC Macrolide +
Ethambutol
AIDS enteropathy
GI lymphoma
ART induced Crofelemer

33. TAKE HOME MESSAGES
• History, examination and assesment of stool
characteristics : MOST IMPORTANT
• Stepwise approach for finding etiology
• Judicious application of empiric therapy

34. THANK YOU