[BCH] SGD 1: DIARRHEA

CASE: Hazel, a 25-year-old ballet dancer came into your clinic due to more than 10 episodes of
watery stools. Her condition started 2 weeks prior when she started to drink “slimming tea” for
her to lose weight. She denies any comorbidities and intake of any medications. On physical
examination, she looks weak with slightly sunken eyeballs and dry lips. Her CBC is normal. Her
routine stool examination is normal. Her stool sodium level of 50mmol/L, her stool potassium
level of 20mmol/L and stool pH of 5.

FACILITATOR: El

GUIDE QUESTIONS:

1. Identify the type of diarrhea Hazel is suffering from. Explain the basis of your diagnosis.
(Chen, Shein, Chad)

● CHAD JEREMY TUAZON

Osmotic. Due to slimming tea she drank 2 weeks prior and her CBC is normal. Her routine
stool examination is normal. Her stool sodium level of 50mmol/L, her stool potassium level
of 20mmol/L and stool pH of 5.

Normal stool has an alkaline pH

Osmotic diarrhea is characterized by an osmolar gap of >100 mOsm, stool sodium of <60 meq/L and
pH <5.3. Common causes include an increased osmolar load due to polyethylene glycol (PEG), Mg
salts, Na phosphate, sorbitol, mannitol, lactulose, xylitol. It can also be associated with
malabsorption due to infections, sprue, disaccharidase deficiency, Olestra, bacterial overgrowth,
pancreatic insufficiency, short bowel, and inflammatory bowel disease.

The small bowel mucosa is a porous epithelium; water and salts move across it rapidly to
maintain osmotic balance between the bowel contents and the blood. Under these
conditions, diarrhea can occur when a poorly absorbed, osmotically active substance is
ingested. If the substance is taken as an isotonic solution, the water and solute will simply
pass through the gut unabsorbed, causing diarrhea. Purgatives, such as magnesium sulfate,
work by this principle. The same process may occur when the solute is lactose (in children
with lactase deficiency) or glucose (in children with glucose malabsorption); both conditions
are occasional complications of enteric infections. If the poorly absorbed substance is taken
as a hypertonic solution, water (and some electrolytes) will move from the ECF into the gut
lumen, until the osmolality of the intestinal contents equals that of ECF and blood. This
increases the volume of the stool and, more importantly, causes dehydration owing to the
loss of body water. Because the loss of body water is greater than the loss of sodium
chloride, hypernatraemia also develops.

REF:
https://www.clinlabnavigator.com/stool-electrolytes-and-ph.html#:~:text=A%20fecal%20sodium%20c
oncentration%20of,with%20hypoosmotic%20urine%20or%20water
https://rehydrate.org/diarrhoea/tmsdd/2med.htm

2. Explain the pathophysiology of Hazel’s diarrhea. (Younes, Pat, Vince)

 3. Enumerate other conditions that may bring about similar manifestations. (Margareth, Alica)
- Viral gastroenteritis
– Viral gastroenteritis is an intestinal infection that includes signs and symptoms such as watery
diarrhea, stomach cramps, nausea or vomiting, and sometimes fever. The most common way to
develop viral gastroenteritis — often called stomach flu — is through contact with an infected
person or by consuming contaminated food or water. If you're otherwise healthy, you'll likely
recover without complications
Symptoms:
- Watery, usually nonbloody diarrhea — bloody diarrhea usually means you have a
different, more severe infection
- Nausea, vomiting or both
- Stomach cramps and pain
- Occasional muscle aches or headache
- Low-grade fever
- Note! Induced vomiting and diarrhea causes = DEHYDRATION (slightly sunken eyeballs and dry lips)
- difference: not normal CBC = HIGH WBC
https://www.mayoclinic.org/diseases-conditions/viral-gastroenteritis/symptoms-causes/syc-2037
8847

4. Differentiate the types of diarrhea. (El, Marj, Raine)

● Secretory
○ Increased secretion and decreased absorption of ions like chloride or
bicarbonate
○ Causes water to build up; can be caused by a number of factors such as:
■ Bacterial infection (e.g., salmonella, E. coli)
■ Parasites such as cryptosporidium and Giardia
■ Viral infection (e.g., norovirus, viral hepatitis)
■ Drugs (e.g., misoprostol)
■ Digestive disorders (e.g., celiac disease and ulcerative colitis)
 ■ Genetic disorders (e.g., congenital chloride diarrhea)
● Osmotic
● Dysmotility
● Malabsorptive
○ It is a type of diarrhea that is caused by malabsorption of amino acids and
vitamins.
○ This can lead to steatorrhea, which is a condition characterized by oily and
foul-smelling stools
○ It is also caused by intraluminal maldigestion such as:
■ Pancreatic exocrine insufficiency
■ Mucosal malabsorption such as Celiac disease
● Inflammatory
○ It is a type of diarrhea that is characterized by inflammation of the
gastrointestinal tract.
○
5. Create a management plan for Hazel’s condition. (Varona , Tribo)

Vincent Joshua Tribo & Ju Ma Ray Varona (Management Plan for Osmotic Diarrhea)

Managing osmotic diarrhea involves addressing the underlying cause and making dietary and
lifestyle adjustments to alleviate symptoms. Here's a general management plan:

1. Identify the Underlying Cause:

- Consult a healthcare professional to determine the specific cause of osmotic diarrhea, as
treatment may vary based on the cause.

2. Remove the Trigger:

- If the diarrhea is triggered by certain medications (e.g., laxatives) or dietary components (e.g.,
sugar alcohols like sorbitol), discontinue or reduce their consumption under medical guidance.

3. Rehydration:
- Osmotic diarrhea can lead to dehydration, so it's crucial to replace lost fluids and electrolytes.
- Drink oral rehydration solutions (ORS) or clear fluids like water, diluted fruit juices, or clear
broths.
- Avoid beverages that can worsen diarrhea, such as caffeine and alcohol.

4. Diet Modifications:
- Identify and eliminate foods or substances that may be causing osmotic diarrhea. Common
triggers include:
- Lactose-containing products (if lactose intolerance is the cause).
- Foods high in sugar alcohols (e.g., sorbitol, mannitol).
- Artificial sweeteners like sorbitol and xylitol.
- High-fructose foods and drinks.
- Certain fiber supplements or excessive fiber intake.

5. Low-Osmolality Diet:
 - Consume foods that are low in osmolality, such as rice, bananas, applesauce, and toast (BRAT
diet), as they are less likely to aggravate osmotic diarrhea.

6. Probiotics:
- Some individuals find relief from osmotic diarrhea by taking probiotics to restore gut flora
balance. Consult your healthcare provider before using them.

7. Medications:
- In some cases, medications may be prescribed to manage symptoms or address underlying
conditions.
- Loperamide (Imodium) may help reduce diarrhea by slowing down bowel movements. Consult
your healthcare provider before using it.

8. Monitoring:
- Keep an eye on your symptoms and report any worsening or new symptoms to your healthcare
provider.

9. Prevent Spread:
- If the diarrhea is infectious, practice good hygiene to prevent spreading it to others. Wash your
hands frequently and avoid close contact.

10. Follow Medical Advice:

- Always follow your healthcare provider's recommendations, as treatment may vary based on
the cause of osmotic diarrhea.

REFERENCES
https://www.healthline.com/health/osmotic-diarrhea#treatment