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Dr. HSAR Lelosutan, Sp.PD-KGEH, MARS

Sub SMF Gastroentero-Hepatologi Dep Peny Dalam RSPAD Gatot Soebroto Ditkesad Jakarta, 2010

Complications Etiology : 1. Osmotic load 2. Increased secretions 3. Reduced contact time/surface area Evaluation : 1. History 2. Physical examination 3. Red flags 4. Interpretation of findings 5. Testing Treatment Key Points

Approach of Diarrhea
Malabsorption Syndromes Inflammatory Bowel Disease (IBD). Stool is 60 to 90% water. Stool amount is 100 to 200 g/day in healthy depending on the amount of unabsorbable dietary material (mainly carbohydrates). Diarrhea is defined as stool weight > 200 g/day. However, many people consider any increased stool fluidity to be diarrhea. Alternatively, many people who ingest fiber have bulkier but formed stools but do not consider themselves to have diarrhea.

Complications may result from diarrhea of any etiology. Fluid loss : dehydration, electrolyte loss (Na, K, Mg, Cl), Vascular collapse : develop rapidly in patients who have : 1. severe diarrhea (eg, patients with cholera) or 2. very young, very old, or debilitated.

. HCO loss can cause metabolic acidosis.


Hypokalemia can occur in severe or chronic diarrhea or if the stool contains excess mucus. Hypomagnesemia after prolonged diarrhea can cause tetany.

Normally, the small intestine and colon absorb 99% of fluid resulting from oral intake and GI tract secretionsa total fluid load of about 9 of 10 L daily. Thus, even small reductions (ie, 1%) in intestinal water absorption or increases in secretion can increase water content enough to cause diarrhea. There are a number of causes of diarrhea (see Table : Approach to the Patient With Lower GI Complaints: Some Causes of Diarrhea*).

Several basic mechanisms for most significant diarrheas: 1. increased osmotic load, 2. increased secretions, and 3. decreased contact time/surface area.
ex. Diarrhea in inflammatory bowel disease (IBD): mucosal destruction, exudation into the lumen, and from multiple secretagogues and bacterial toxins that affect enterocyte function

Some Causes of Diarrhea*

1. Viral infection 2. Bacterial infection 3. Parasitic infection 4. Food poisoning 5. Drugs : : : : : ex. Norovirus, rotavirus ex. Salmonella, Campylobacter, Shigella, Escherichia coli, Clostridium difficile ex. Giardia, Entamoeba histolytica, Cryptosporidia ex. Staphylococcus, Bacillus cereus, Clostridium perfringens ex. Laxatives, Mg-containing antacids, caffeine, antineoplastic drugs, many antibiotics, colchicine, quinine / quinidine, prostaglandin analogues, excipients (eg, lactose) in elixirs See Acute ex. Irritable bowel syndrome ex. Carbohydrate intolerance ex. Ulcerative colitis, Crohn's disease ex. Intestinal or gastric bypass or resection ex. Celiac sprue, Whipple's disease, pancreatic insufficiency ex. Colon carcinoma, lymphoma, villous adenoma of the colon ex. Vipoma, gastrinoma, carcinoid, mastocytosis, medullary carcinoma of the thyroid ex. Hyperthyroidism

1. Drugs : 2. Functional : 3. Diet : 4. Infl. bowel disease : 5. Surgery : 6. Malabsorption syndr. : 7. Tumors : 8. Endocrine tumors : 9. Endocrine :

Numerous causes exist. Some not mentioned may be likely causes in particular subgroups

Dietary Factors That May Worsen Diarrhea

Dietary Factor
1. Caffeine 2. Fructose (in quantities surpassing the gut's absorptive capacity)

Coffee, tea, cola, OTC headache remedies Apple juice, pear juice, grapes, honey, dates, nuts, figs, soft drinks (especially fruit flavored), prunes Sugar-free gum, mints, sweet cherries, prunes Milk, ice cream, frozen yogurt, yogurt, soft cheeses Mg-containing antacids

3. Hexitols, sorbitol, and mannitol 4. Lactose 5. Mg

Adapted from Bayless T: Chronic diarrhea. Hospital Practice Jan. 15, 1989, p 131; used with permission.

Osmotic load:
Diarrhea occurs when unabsorbable, water-soluble solutes remain in the bowel and retain water. Such solutes include polyethylene glycol, Mg salts (hydroxide and sulfate), and Na phosphate, which are used as laxatives. Osmotic diarrhea occurs with sugar intolerance (eg, lactose intolerance caused by lactase deficiency). Ingesting large amounts of hexitols (eg, sorbitol, mannitol, xylitol) or high fructose corn syrups, which are used as sugar substitutes in candy, gum, and fruit juices, causes osmotic diarrhea because hexitols are poorly absorbed. Lactulose, which is used as a laxative, causes diarrhea by a similar mechanism. Overingesting certain foodstuffs can produce osmotic diarrhea

Increased secretions:
Diarrhea occurs when the bowels secrete more electrolytes and water than they absorb. Causes of increased secretions include infections, unabsorbed fats, certain drugs, and various
intrinsic and extrinsic secretagogues.

Infections (eg, gastroenteritis, discussed in Gastroenteritis) are the most common causes of

secretory diarrhea. Infections combined with food poisoning are the most common causes of acute diarrhea (< 4 days in duration). Most enterotoxins block Na+-H+ exchange, which is an important driving force for fluid absorption in the small bowel and colon.

Unabsorbed dietary fat and bile acids (as in malabsorption syndromes and after ileal
resection) can stimulate colonic secretion and cause diarrhea.

Drugs may stimulate intestinal secretions directly (eg, quinidine, quinine, colchicine,

anthraquinone cathartics, castor oil, prostaglandins) or indirectly by impairing fat absorption (eg, orlistat :XENICAL). intestinal peptide), gastrinomas (gastrin), mastocytosis (histamine), medullary carcinoma of the thyroid ( calcitonin and prostaglandins), and carcinoid tumors (histamine, serotonin, and polypeptides). accelerate intestinal transit, colonic transit, or both.

Various endocrine tumors produce secretagogues, including vipomas (vasoactive

Some of these mediators (eg, prostaglandins, serotonin, related compounds) also

Reduced contact time/surface area:

Rapid intestinal transit and diminished surface area impair fluid absorption and cause diarrhea. Common causes include small-bowel or large-bowel resection or bypass, gastric resection, and inflammatory bowel disease. Other causes include microscopic colitis (collagenous or lymphocytic colitis) and celiac sprue. Stimulation of intestinal smooth muscle by drugs (eg, Mg-containing antacids, laxatives, cholinesterase inhibitors, SSRIs) or humoral agents (eg, prostaglandins, serotonin) also can speed transit

History: Duration and severity of diarrhea, circumstances of onset (including recent travel,
food ingested, source of water), drug use (including any antibiotics within the previous 3 mo), abdominal pain or vomiting, frequency and timing of bowel movements, changes in stool characteristics (eg, presence of blood, pus, or mucus; changes in color or consistency; evidence of steatorrhea), associated changes in weight or appetite, and rectal urgency or tenesmus should be noted. Simultaneous occurrence of diarrhea in close contacts should be ascertained.
examination with attention to the abdomen and a digital rectal examination for sphincter competence and occult blood testing are important. diarrhea.

Physical examination: Fluid and hydration status should be evaluated. A full Red flags: Certain findings raise suspicion of an organic or more serious etiology of
Blood or pus Fever Signs of dehydration Chronic diarrhea Weight loss

Interpretation of findings:
watery diarrhea in an otherwise healthy person is likely to be of infectious etiology, particularly when travel,
possibly tainted food, or an outbreak with a point-source is involved. Acute bloody diarrhea with or without hemodynamic instability in an otherwise healthy person suggests an enteroinvasive infection. Diverticular bleeding and ischemic colitis also present with acute bloody diarrhea. Recurrent bouts of bloody diarrhea in a younger person suggest inflammatory bowel disease. In the absence of laxative use, large-volume diarrhea (eg, daily stool volume > 1 liter/day) strongly suggests an endocrine cause in patients with normal GI anatomy. A history of oil droplets in stool, particularly if associated with weight loss, suggests malabsorption. Diarrhea that consistently follows ingestion of certain foods (eg, fats) suggests food intolerance. Recent antibiotic use should raise suspicion for antibiotic-associated diarrhea, including Clostridium difficile colitis. The symptoms can help identify the affected part of the bowel. Generally, in small-bowel diseases, stools are voluminous and watery or fatty. In colonic diseases, stools are frequent, sometimes small in volume, and possibly accompanied by blood, mucus, pus, and abdominal discomfort. In irritable bowel syndrome (IBS), abdominal discomfort is relieved by defecation, associated with more loose or frequent stools, or both. However, these symptoms alone do not discriminate IBS from other diseases, eg, inflammatory bowel disease. Patients with IBS or rectal mucosal involvement often have marked urgency, tenesmus, and small, frequent stools (see Irritable Bowel Syndrome (IBS): Symptoms and Signs). Extra-abdominal findings that suggest an etiology include skin lesions or flushing (mastocytosis), thyroid nodules (medullary carcinoma of the thyroid), right-sided heart murmur (carcinoid), lymphadenopathy (lymphoma, AIDS), and arthritis (inflammatory bowel disease, celiac disease).

Acute diarrhea
(< 4 days)

CBC ,electrolytes, BUN, and creatinine. Stool samples C. difficile toxin assay.
(> 4 wk)

Chronic diarrhea

stool testing should include culture, fecal leukocytes (detected by smear or measurement of fecal lactoferrin), microscopic examination for ova and parasites, pH (bacterial fermentation of unabsorbed carbohydrate lowers stool pH < 6.0), fat (by Sudan stain), and electrolytes (Na and K). Specific tests for Giardia antigen and Aeromonas, Plesiomonas, coccidia, and microsporidia Sigmoidoscopy or colonoscopy with biopsies should follow to look for inflammatory causes. small-bowel enteroclysis or CT enterography (structural disease) and endoscopic small-bowel biopsy (mucosal disease). Assessment of pancreatic structure and function Capsule endoscopy may uncover lesions, predominantly Crohn's disease or NSAID enteropathy, not identified by other modalities. Stool osmotic gap, which is calculated 290 2 (stool Na + stool K), indicates whether diarrhea is secretory or osmotic.
An osmotic gap < 50 mEq/L indicates secretory diarrhea; a larger gap suggests osmotic diarrhea. Patients with osmotic diarrhea may have covert Mg laxative ingestion (detectable by stool Mg levels) or carbohydrate malabsorption (diagnosed by hydrogen breath test, lactase assay, and dietary review).

Undiagnosed secretory diarrhea requires testing (eg, plasma gastrin, calcitonin, vasoactive intestinal peptide levels,
histamine, urinary 5-hydroxyindole acetic acid [5-HIAA]) for endocrine-related causes.

A review for symptoms and signs of thyroid disease and adrenal insufficiency should be done. Surreptitious laxative abuse must be considered; it can be ruled out by a fecal laxative assay

Fluid and electrolytes for dehydration Possibly antidiarrheals for nonbloody diarrhea in patients without systemic toxicity
Severe diarrhea

to correct dehydration, electrolyte imbalance, and acidosis.

Parenteral fluids containing NaCl, KCl, and glucose are generally required. Salts to counteract acidosis (Na lactate, acetate, HCO 3) may be indicated if serum HCO3 is < 15 mEq/L. An oral glucose-electrolyte solution can be given if diarrhea is not severe and nausea and vomiting are minimal (see Dehydration and Fluid Therapy: Solutions). Oral and parenteral fluids are sometimes given simultaneously when water and electrolytes must be replaced in massive amounts (eg, in cholera).

Diarrhea is a symptom. When possible, the underlying disorder should be treated, but symptomatic

treatment is often necessary. Diarrhea may be decreased by oral loperamide 2 to 4 mg tid or qid (preferably given 30 min before meals), diphenoxylate 2.5 to 5 mg (tablets or liquid) tid or qid, codeine phosphate 15 to 30 mg bid or tid, or paregoric (camphorated opium tincture) 5 to 10 mL once/day to qid.
Psyllium or methylcellulose compounds provide bulk. Although usually prescribed for constipation, bulking agents given in small doses decrease the fluidity of liquid stools. Kaolin, pectin, and activated attapulgite adsorb fluid. Osmotically active dietary substances (see Table : Approach to the Patient With Lower GI Complaints: Dietary Factors That May Worsen Diarrhea) and stimulatory drugs should be avoided.

Key Points
In patients with acute diarrhea,
stool examination (cultures, ova and parasites, C. difficile cytotoxin) is only necessary for patients who have prolonged symptoms (ie, more than 1 wk), or red flag symptoms.

Beware using antidiarrheals

if there is a possibility of C. difficile, Salmonella, or shigellosis.
Last full review/revision October 2007 by Adil E. Bharucha, MBBS, MD Content last modified October 2007