This document discusses the approach to chronic diarrhea. It defines diarrhea and describes the main types: osmotic, secretory, inflammatory, and abnormal motility. Chronic diarrhea is defined as lasting over 4 weeks and can be caused by diseases of the colon or small intestine, endocrinological issues, drugs like antibiotics, or miscellaneous conditions. Diagnosis involves a careful history, physical exam, stool tests, and other imaging exams. Treatment depends on the identified cause, including antibiotics for specific infections or loperamide for symptom relief.

1. APPROACH TO
Hamad Emad H. Dhuhayr

2. CONTENTS
• Introduction about diarrhea
• Chronic diarrhea
• Refferences

3. INRODUCTION
• Definition:
change of the normal bowel habits in the form of:
. Increase in frequency
. Increase in amount
. Fluid consistency
. Feces exceeding 200 gm/day when the dietary fiber content is low

4. PATHOGENESIS
• 1. OSMOTIC DIARRHEA:
Ø due to: presence of high concentration of non - absorbed hypertonic
Substances in intestine which will attract fluid from the blood to
Intestine à loose stools.
Ø examples: in disaccharidase deficiency: high concentration of lactose. In
Malabsorption syndrome: high concentration of solutes. Ingestion of non -
Absorbable substances, e.G. Lactulose.
Ø diarrhea stops when the patient is fasting

5. 2. Secretory diarrhea:
Ø due to: active intestinal secretions of fluid & electrolytes.
Ø examples: enterotoxins; cholera & e.Coli.
Ø diarrhea does not stop when the patient is fasting.
3. Inflammatory diarrhea: "mucosal destruction"
Ø due to: damage to the intestinal mucosa, causing loss of fluid & blood
Defective absorption.
Ø examples: bacillary dysentery. Ulcerative colitis.
Ø diarrhea partially improves when the patient is fasting.

6. • 4. Abnormal motility:
• Ø due to: hypermotility which causes defective absorption.
• Ø examples: thyrotoxicosis & post-vagotomy.
• Ø diarrhea partially improves when the patient is fasting

7. CHRONIC DIARRHEA
• Diarrhea persisting for more than four weeks.
• An estimated 5% of the U.S. Population suffers from chronic diarrhea, and about
40% of these individuals are older than 60 years of age. In 25 to 50% of cases,
expert history and physical examination may be sufficient to make a definitive
diagnosis

8. EATIOLOGY
A. Diseases of the colon:
1. Amoebic colitis.
2. AIDS: due to opportunistic infections .
3. Bilharzial colitis.
4. Cancer colon.
5. Crohn's disease of the colon OR ulcerative colitis.
6. Diverticulosis.

9. B. Diseases of the small intestine same causes of intestinal malabsorption.
C. Endocrinal causes:
1. Diabetic neuropathy.
2. Thyrotoxicosis.
3. Addison's disease.
4. Gastrinoma: "zollinger - ellison syndrome."
5. Verner - morrison syndrome: " pancreatic cholera“
D. DRUGS:
1. ANTIBIOTICS: ESPECIALLY CLINDAMYCIN WHICH CAUSES PSEUDOMEMBRANOUS
COLITIS
2. PURGATIVE ABUSE.
E. MISCELLANEOUS:
1. OBSTRUCTIVE JAUNDICE.
2. PELLAGRA.
3. VITAMIN B12 DEFICIENCY.

10. INVESTIGATION
1. Stool analysis and culture
2. Sigmoidoscopy: in bloody diarrhea not improving in 10 days
3. Barium enema
4. Malabsorption test

11. DIAGNOSIS
Careful History and physical examination
1. Watery stool: secretory diarrhea
2. Greasy stool: fatty diarrhea
3. Sensitivity to milk (lactose intolerance), or to wheat(celiac disease)
4. Neuropathy: DM
5. Arthritis: inflammatory bowel disease.

12. THERAPEUTIC TESTS
1. Diet free of milk products → improvement of diarrhea in lactose intolerance.
2. Diet free of wheat → improvement of diarrhea in caeliac disease.
3. Metronidazole for giardiasis.

13. TREATMENT
1- specific:
antibiotic or antiprotozoal> >> according to stool analysis
2- symptomatic:
Fluid & electrolyte replacement
Loperamide: 2mg after each loose stool- only in sever cases for short term
(impedes clearance of bowl of pathogen)

17. REFFERENCES
• KUMAR
• CECIEL
• WEBSITE