Approach to Diarrhea

Abdulsemed M
Internist, Gastroenterologist & Hepatologist
Assistant professor of Medicine
Addis Ababa University
June 2018
Objectives
• Definition of diarrhea
• Approach to Acute Diarrhea
• Approach to Chronic Diarrhea
Epidemiology
• World wide > 1 billion ppl suffer one or more
episodes of acute diarrhea each year

• Acute infectious diarrhea remains one of the

most common causes of death in children in
developing countries
Diarrhea, definition
• Grossly defined as passage of abnormally liquid/unformed stools at increased
frequency

Technical Definition (Western diet)

>3 bowel mov’ts per day
>200g stool/day

Duration:
Acute - <2 weeks
Persistent – 2-4 weeks
Chronic - >4 weeks

• Everyone’s normal varies

• Distinguish from
• Pseudodiarrhea- frequent passage of small volume stool
• Incontinence- involuntary discharge of rectal contents
Physiology

10L of fluid exits the duodenum

Diet, Acid, Bile

8.5 L absorbed by small bowel

1.5L into colon

1.5 L into large bowel

0.1L out
Physiology
 Basically excess stool water

 Water passively moves across intestinal mucosa

following transport of electrolytes and nutrients

 Basic types of diarrhea

 Secretory: secondary to impaired electrolyte
transport
 Osmotic: water retained by osmotically active
substance (magnesium, lactulose)
Approach to Diarrhea
• Acute vs Chronic
• Large volume vs Small volume
• Osmotic vs Secretory
• Watery /Fatty / Inflammatory
Acute Diarrhea
• < 2-4 wks

Infection! (90%)
Vomiting, fever and abdominal pain
Food poisoning
Medication related
Ischemia
Early course of chronic diarrhea
Acute watery diarrhea
• Most common
• Usually self limiting
• Dehydration is main complication

Rotavirus, vibrio cholerae

Acute bloody Diarrhea
• Dysentry
• Mucosal damage by invasive organisms
• Complications- sepsis, HUS, dehydration
▫ Yersinia
▫ Shigella
▫ Salmonella
▫ Campylobacter
▫ C.Difficile
▫ Ecoli O157:H7
▫ E. histolytica
Acute Diarrhea: Protozoa
Many are non-pathogenic
• Entamoeba
▫ Histolytica requires treatment because can become
invasive
▫ E. dispar and E.moshkovskii difficult to differentiate
but nonpathogenic
▫ All other entamoeba’s are nonpathogenic
▫ Pathogenic will develop antibodies by 5-7 days
• Giardia lamblia
Acute Diarrhea: Protozoa
• Cyclospora cayetanensis:
▫ Food/water borne (guatemalan raspeberries)
▫ Diarrhea + flu + systemic—jejunal inflammation
▫ Self-limited to chronic

• Cryptosporidia
▫ Water related
▫ self-limited when immune competent
▫ Up to 30% of AIDS patients get biliary involvement

• Microsporidia: HIV with CD4 <100

Drugs that cause Diarrhea
• Osmotic drugs
▫ Oral magnesium, Lactulose
• Motility Agents
▫ Erythromycin
• Secretory agents
▫ Caffeine, theophylline
• Inflammation inducers
▫ Gold, MMF, ASA
• Enterocyte apoptosis
▫ Chemotherapy—eg. 5FU, irinotecan
Diagnosis and Treatment
• Assess severity:
▫ If short duration and no dehydration - oral rehydration,
no workup required
-NB- Most cases of acute diarrhea are mild and self-limited

▫ Indications for further evaluation,

 elderly or immunocompromised
 Hypovolemic
 Bloody stool, Fever, Severe abdominal pain
 Duration >48 hrs w/o improvement
 Recent antibiotic use
Clues
• Fever: invasive bacteria (salmonella, shigella,
campylobacter, Cdiff), virus, or entamoeba

• Diarrhea then becoming systemic—Listeria

• Food history

• Timing
▫ Within 6 hours: toxin mediated
Food History
Exposure Bug
Meat, eggs S. Aureus
Meat, home canning C. perfringens
Lizards, eggs, meat Salmonella
Undercooked poultry, raw milk, cheese Campylobacter
Shellfish, seafood from South America V. Cholerae
Shellfish from South Asia V. parahemolyticus
Meat, coleslaw, potato salad in pregnancy Listeria
and neonates
Work up
• Direct stool examination for ova/parasite, WBCs

• Stool culture for bacteria and virus

• Immunoassay for bacterial toxins (C.diff), antigens

• PCR
• Sigmoidoscopy and biopsy
• Duodenal aspirate
• Abdominal imaging
Therapy
• Oral rehydration (salt, sugar, water)

• Antibiotics only if severe, prolonged

▫ Emperic
▫ EHEC may increase risk of HUS
• Anti-motility agents
▫ Ok if non-bloody, no fever
▫ May increase risk of toxic megacolon, HUS in EHEC
▫ Peptobismol can also help and doesn’t carry these
risks
• Diet: low fat, +/- lactose free
 Chronic Diarrhea
• >4 wks duration

• Most causes are non infectious

• Classification by pathophysiologic mechanisms

facilitates rational approach to management
▫ Many diseases cause diarrhea by multiple
mechanisms
Evaluation
• History is key:
▫ Onset, pattern, duration
▫ Watery, bloody, fatty
▫ Small volume vs large volume –left colon vs right/SB
▫ Fecal incontinence?
▫ Tenesmus, urgency?
▫ Aggravating/Alleviating factors
▫ Iatrogenic factors: meds, herbals, radiation, chemo,
surgery
▫ Constitutional symptoms: weight loss, fevers, sweats
Chronic Diarrhea
• Physical exam:
▫ BMI
▫ Malnourishment/malabsorption
▫ Extraintestinal manifestations of IBD
▫ Signs immunocompromise: oral thrush
Clinical Signs of Malabsorption
• Subcutaneous fat wasting
• Protein malabsorption
▫ Edema, muscle atrophy
• Vitamin B deficiency
▫ B12: Loss of vibration and position sense (SCD)
▫ Glossitis, angular cheilitis
• Iron deficiency
▫ Angular cheilitis
• Vitamin A
▫ Hyperfollicular keratosis, night blindness
Initial investigations
• CBC
▫ Anemia: bleeding, iron or B12 malabsorption,
chronic inflammatory disease
▫ Eosinophilia: cancer, parasites, eosinophilic dz
• Lytes: potassium, bicarbonate
• Creatinine for prerenal azotemia
• ESR, CRP for inflammatory state
• Albumin: nutritional state
• AXR: if you suspect impaction and overflow
Initial Evaluation
• If true diarrhea, group into:
▫ Functional or Organic
 IBS: lower abdominal pain with altered stool habits,
mucus, etc (Rome IV criteria)
▫ If Organic:
 Watery : Secretory or osmotic
 Inflammatory
 Fatty
Inflammatory
• Bloody diarrhea, pain
• Small volume
• Tenesmus and urgency

• DDx: IBD, radiation enteritis, infectious

(bacteria, TB, Entamoeba, CMV)

• Need stool cultures, colonoscopy and biopsies,

small bowel follow through or CT enteroclysis
Fatty (Malabsorptive)
• Greasy, floating stools with oil droplets, difficult
to flush
Secondary to:
• Malabsorption: celiac, bacterial overgrowth,
short bowel syndrome
OR
• Maldigestion: inadequate bile acids (terminal
ileum resection, PBC), pancreatic insufficiency
(chronic pancreatitis)
Fatty (Malabsorptive)
• Work-up:
▫ Celiac: Anti-TTG, duodenal biopsies
▫ Bacterial overgrowth (in patients with dysmotility,
short gut, fistula, strictures, CF, cirrhosis)
 Gold standard is jejunal aspirate
 Realistically-right situation + 14C-d-xylose breath test,
lactulose or glucose hydrogen breath tests
▫ Pancreatitis: imaging of pancreas, sweat chloride test
▫ Exocrine pancreas analysis- trial of enzyme
supplementation, no good tests
Fatty (Malabsorptive)
• Stool analysis
▫ Volume: should be >200g per day
▫ Stool pH <5.6 suggests carbohydrate malabsorption
▫ Spot Sudan stain for fecal fat: qualitative
▫ 72hr Fecal fat:
 Normal person <6g per day but any type of diarrhea
increases the amount of fat, so up to 14g per day is
normal
 Need to consume >120g of fat per day to measure
accurately—excreting >9% of this is abnormal
Watery Diarrhea
• Usually large volume
• Secretory or Osmotic
▫ Stool osmotic gap: 290 – [2 x (fecal Na+K)]
▫ Gap <50 = secretory (the osmolality of the stool
water is mostly unabsorbed electrolytes)
▫ Gap >100 = osmotic (unmeasured osmoles)
▫ If 2 x Na+k is > than 290 then the diarrhea is from
ingestion of poorly absorbed anion (sulfate or
phosphate)
Osmotic Diarrhea
• One of three things:
• Magnesium
▫ Osmotic laxative
▫ Unknown from antacids or supplements
• Carbohydrate malabsorption
▫ Stool pH<5.6
• Excessive carbohydrate ingestion
▫ Sugar alcohols sorbitol/mannitol poorly absorbed
▫ High fructose corn syrup
Secretory Diarrhea
• First, rule out infection—multiple O&P, rule out
HIV, biopsy mucosa to look for pathogens

• Look for structural disease (small bowel bacterial

overgrowth, lymphoma, IBD, fistulae) with CT
enterography/enteroclysis and endoscopy with
random biopsies for microscopic colitis

• Endocrine: Hyperthyroidism, Addison’s disease

Secretory Diarrhea
• If other symptoms present, think of peptide secreting
tumours
▫ Flushing, diarrhea, large hard liver: carcinoid with
metastasis to liver causing carcinoid syndrome: urinary 5-
HIAA levels

▫ Diarrhea with dyspepsia, multiple gastric and duodenal

ulcers - Zollinger-Ellison: gastrin level

▫ Diarrhea + headache, flushing, urticaria pigmentosa:

histamine level (Mastocytosis)
Summary
• Diarrhea is a complicated topic
• Different approaches for acute vs chronic
• Acute = INFECTION, DRUGS
• Chronic: use volume, type (watery, bloody, fatty)
and patient’s other symptoms to guide you