AN APPROACH TO THE

PATIENT WITH DIARRHEA

GUIDE: DR SEETARAM N.
STUDENT: DR SAMARTH V SHETTY
DEFINITION

• Diarrhea is loosely defined as passage of abnormally liquid or unformed

stools at an increased frequency.
• Frequently represents a protective response to a variety of intestinal insults
and assaults.
• stool weight greater than 400 g/24 h (cf. Western definition of 200 g/24 h)-
in hospital patient
• an increase in the frequency and liquidity of the stool compared to an
earlier time period- outpatient clinic
• three or more stools, taking the form of the container into which they are
passed, in a 24 h period- for field studies
CLASSIFICATION

1. Acute diarrhea : <2 weeks

2. Persistent diarrhea: 2-4 weeks
3. Chronic diarrhea: >4 weeks
• PSEUDODIARRHEA: or the frequent passage of small volumes of stool, is often
associated with rectal urgency and tenesmus .
seen In IBS or proctitis

• FEACAL INCONTINENCE: involuntary discharge of rectal contents and is most often

caused by neuromuscular disorders or structural anorectal problems

• OVERFLOW DIARRHEA: occur in nursing home patients due to fecal impaction

( readily detectable by rectal examination.)
• Increased stool weight due to fibre ingestion
FLUIDS IN INTESTINE

Every day 8-10 litres of fluids enters small intestine of which 2L is from
diet,rest from intestinal secretions

8-9 litres absorbed in small intestine rest 1.5 litres are presented to large
intestine.approximately 100ml is lost in stool.
Diarrhea can result from increased secretion by the small intestine or the colon if the maximal daily
absorptive capacity of the colon (4 L) is exceeded. Alternatively, if the colon is diseased so that it
cannot absorb even the 1.5 L normally presented to it by the small intestine, diarrhea results.
MECHANISMS/PATHOPHYSIOLOGY OF
DIARRHEA
• OSMOTIC DIARRHEA
• SECRETORYDIARRHEA
• ALTERED MOTILITY

Because many diarrheal diseases are due to more than one of these mechanisms, it is
clinically useful to categorize diarrhea as malabsorptive (fatty), watery, and inflammatory .
ACUTE DIARRHEA
DEFINITION

• Passage of 3 or more loose or liquid stools per day and lasting less than 14
days
• > 90% of acute diarrhea is caused by infection AND remaining 10% by
medications,toxic ingestions,ischemia,food indiscretions,Pelvic
inflammation,intestinal ischemia
• Clinical features: vomiting, fever , pain abdomen, loose stools
• Feco-oral transmission from water,food and person to person contact
• If vomit>diarrhea= consider viral gastroenteritis/food poisoning first
COMMON CAUSES OF ACUTE DIARRHEA
APPROACH

• DURATION: less than 14 days

• FREQUENCY OF DIARRHEA: more than 3 episodes of loose stools per
day
APPROACH

Associated symptoms:
Vomiting: if more predominant- consider viral gastroenteritis/food
poisoning first
Fever:invasive causes of diarrhea
Tenesmus: large bowel diarrhea
CONSISTENCY

Acute Diarrhea

watery Blood and mucous

• Excessive fluid secretion in SI/LI Invasive organisms

1. Vibrio cholerae 1.Shigella
2. Enteotoxigenic E.coli 2. Enteroinvasive Ecoli
3. Viral Gastroenteritis 3. Entamoeba histolytica
PESONAL HISTORY
• MEDICATION HISTORY
Antihypertensives,NSAIDS,
Antibiotics ( overgrowth of clostridium
difficle), antiarrythmics,bronchodilators
laxatives and antacids.
• TRAVEL HISTORY
Giardia,Enterotoxigenic Ecoli
APPROACH

• General physical examination

change in mental status: irritable in some dehydration,lethargic/comatose in severe dehydration

Eyes: sunken
Mucosa: dry
Radial pulse: low volume in some dehydration,absent in severe dehydration
tachycardia in moderate dehydration
Bp: orthostatic hypotension( if 10% of circulating blood volume is lost)
supine hypotension( if 20% of circulating blood volume is lost)
APPROACH TO THE PATIENT WITH ACUTE
DIARRHEA
• Infectious diarrhea, from clinicians’ point of view, comprises 2
pathophysiological syndromes mentioned as follows:
1. Inflammatory (loss of mucosal intergrity)
2. Non inflammatory(increased intestinal secretions)
SMALL VOUME VS LARGE VOLUME DIARRHEA

• Large Volume Diarrhea: If the source of diarrhea is upstream in the right

colon or small bowel and if the rectosigmoid reservoir is intact ,bowel
movements are fewer ,but larger.
• Small Volume Diarrhea: When the reservoir capacity is compromised by
inflammatory or motility disorders involving the left colon ,frequent small
volume bowel movements ensue
ASSESSMENT OF DEHYDRATION
 INVESTIGATIONS
• Most acute diarrheas are mild and self limited and don’t need diagnostic
and pharmacological intervention
• Indication for evaluation:
 Severe dehydration
 Grossly bloody stools
 Fever> 38.5 degree celcius
 Duration >48hr without improvement
 Recent antibiotic use
 Elderly(>70years) and immocompromised patients
• Blood investigations: CBC, serum electrolytes, kidney function test
• Leukocyte & lactoferrin testing in stool
• Occult blood
• Stool examination(ova, parasite, cyst)
• Radiographic investigations- Usg , CT abdomen
TREATMENT

• Rehydration Therapy:
- CORNER STONE of diarrhea management
- Currently reduced osmolality oral rehydration solution is used
- Recommended dose:
Adults with mild to moderate dehydration: 2-4L approx over 3-4 hours
- ORT contraindicated in

Severe dehydration
Paralytic ileus
Persistent vomiting (>4 episodes /hour)
Painful oral conditions (ulcers & candidiasis)
ANTIDIARRHEAL THERAPY

1. Antimotility agents

2. Antisecretory agents
ANTIBIOTICS
PREVENTION

• Good hygiene
• Hand washing
• Safe food preparation
• Access to clean water
COMPLICATIONS ASSOCIATED WITH DIARRHEA

• Persistent diarrhea
• Hypoglycemia
• Hypo- or hyper- natremia
• Acute renal failure
• Hemolytic Uremic Syndrome (sudden onset ,short - term renal failure )
• Heart failure due to severe electrolyte imbalances .
• Seizures (hypoglycemia, electrolyte derangement)
• Paralytic ileus
PERSISTENT
DIARRHEA
• Persistent over more than 2 weeks
• <3% individuals with acute diarrhea develops persistent diarrhea
• Common causes-
Giardia
Cryptosporidium
Bacterial infectios (enteroaggregative Ecoli )
• Evaluation
Bacterial – cultures
Viral – nucleic acid amplification test (NAAT’s)
Protozoal- microscopy

• Antimicrobial therapy- limited only to severe cases

CHRONIC DIARRHEA
DEFINITION

• Three or more bowel movements per day

• Stool weight more than 200 g daily in western diet
• Decrease in fecal consistency, lasting for FOUR OR MORE
WEEKS(abnormally liquid or unformed)
• Most of the causes of chronic diarrhea: NON INFECTIOUS
• CLASSIFICATION based on stool characteristics
INFLAMMATORY: non infectious,infectious
WATERY: osmotic,dysmotility,secretory
FATTY(Steatorrhea): Maldigestion,Malabsorption
 CLASSIFICATION OF
DIARRHEA

WATERY FATTY
INFLAMMATORY
(STEATORHHREA)

DYSMOTILIT
OSMOTIC SECRETORY
Y
OSMOTIC DIARRHEA

• Ingestion of poorly absorbed agents: Ions are transported actively by

mechanisms that are saturated at low intraluminal ion concentrations and
passively by mechanisms that are slow.
• Together ,these processes limit total absorption to a fraction of the amount
that can be ingested.
• The unabsorbed ions that remain in the intestinal lumen obligate retention
of water leading to diarrhea
• Sugars and sugar alcohols are other subcategory of substances that
cause osmotic diarrhea.
• Monosaccharides are absorbed intact across the apical membrane of
intestine
• Disaccharides require disaccharidase for absorption. Absence of
disaccharidases leads to osmotic diarrhea.
• Disaccharidase deficiency may be congenital or acquired.
ex: Congenital lactase deficiency,Congenital sucrase deficiency.
• Characteristics of osmotic diarrhea:
1)Disappears with fasting or cessation of ingestion of the offending
substance.
2)Electrolyte absorption is not impaired in
osmotic diarrhea ,and electrolyte concentrations in stool water are usually
low
SECRETORY DIARRHEA

• Exogenous secretagogues- Inhibit Na-H exchange in the small intestine and

colon there by blocking the most important driving forces for electrolytes and
fluid absorption.
ex:Enterotoxins, Laxatives

• Endogenous secretagouges: Interact with intracellular regulators or intracellular

messengers of enterocytes-stimulation of secretion by epithelial cells.
ex:Neuroendocrine tumors
Characteristics of secretory diarrhea:
• Doesn’t disappear with fasting.
• Electrolyte absorption is impaired and so electrolyte concentration in stool
water is high.
DYSMOTILE DIARRHEA

• Irritable bowel syndrome

• Visceral neuromyopathies
• Hyperthyroidism
• Drugs (prokinetic agents)
• Postvagotomy
FATTY DIARRHEA (STEATORRHEA)

• Greasy, foul smelling, difficult to flush diarrhea often associated with

weight loss and nutritional deficiencies.
• Increased fecal output caused by osmotic effects of fatty acids after
bacterial hydroxylation
• Quantitatively steatorrhea is defined as stool fat >7gm/day
INFLAMMATORY DIARRHEA

• Accompanied by pain, fever, bleeding.

• Disrupted fluid/ electrolyte absorption, hypersectretion, hypermotility
secondary to release of cytokines and other inflammatory mediators.
MISCELLANEOUS
Factitial diarrhea
• Munchausen
• Eating disorders
Iatrogenic diarrhea
• Cholecystectomy
• Ileal resection
• Bariatric surgery
• Vagotomy
CLINICAL APPROACH TO CHRONIC
DIARRHEA
HISTORY
AGE: old age suspect malignancy
GENDER: IBS and microscopic colitis are more common in females.
DURATION: More than 30 days
ONSET
• IBS-commonly occur in the third and fourth decade
• AIDS related diarrhoea is common in younger patients.
• Peak incidence of microscopic colitis is in the seventh and eighth decade of life.
• Colon cancer should be excluded in a patient with new onset of diarrhoea over
the age of 50 years.
• Whether the patient gets up from his sleep in the night to defecate -
secretary/inflammatory diarrhoea
• Is diarrhoea affected by fasting? - pointing towards food intolerance
• h/o fever ( infectious), weight loss( malnutrition, malignancy)
• h/o exposure( travel,contacts with diarrhea patients,medications)
• Family history- IBS,celiac sprue
• Past medical history- h/o abdominal surgery,radiaton exposure,alcohol use
disorder
• History of hospitalization (iatrogenic)
• History of supplementary medications (sorbitol,used as a base in certain
supplements, can cause diarrhoea as it is an osmotically active sugar)
• Is the patient an alcoholic? (alcoholic patients can have insufficiency of
the pancreas)
• Is the patient diabetic? (motility of the gut is affected)
EXAMINATION FINDINGS

General examination
• Lymphadenopathy: in chronic infections and malignancy
• Weight loss: In chronic infections and malignancy

Eye examination
• Episcleritis: Inflammatory Bowel Disease
• Exopthalmos: Hyperthyroidism
Skin changes:
• Dermatitis herpetiformis: celiac disease
• Erythema nodosum: ulcerative colitis
• Flushing : carcinoid
• Oral ulcer: IBS,celiac
Abdominal examination
• Look for scars (Post-surgical causes of diarrhoea)
• Bowel sounds (Hypermotile causes of diarrhoea)
• Presence of tenderness (Infectious causes, inflammatory causes)
• Presence of mass (Malignant causes)

Rectal examination
• For presence of blood,sphincter function and fistulas
Other signs:
• Patients suffering from amyloidosis show signs of orthostatic hypotension
and peripheral neuropathy.
• Patients of Inflammatory Bowel disease and Whipple’s disease show signs
of arthritis.
• Presence of tremors indicate hyperthyroidism.
• A patient of colitis can present with signs of chronic liver disease.
LAB INVESTIGATIONS

• Complete blood picture:

Anemia
Leucocytosis

• Serum chemistry screening can provide important information about the

patient's fluid and electrolyte status, his or her nutritional status, liver
problems, and dysproteinemia.
STOOL ANALYSIS

• 6 types of stool analysis to be done.

1)Sodium and potassium concentrations in stool water may be measured, so

that the fecal osmotic gap can be calculated.
• The fecal osmotic gap is best calculated as 290 −2([Na+] + [K+]).
• Osmotic diarrheas are characterized by osmotic gap >125 mOsm/kg,
whereas secretory diarrheas typically have osmotic gaps <50 mOsm/kg
2) Stool pH may be assessed. Values of <5.6 are consistent with
carbohydrate malabsorption.

3) Fecal occult blood testing with any of the available agents should be
conducted. A positive test result suggests the presence of inflammatory
bowel disease, neoplastic diseases, or celiac sprue or other spruelike
syndromes
4)The presence of white blood cells in the stool suggests an inflammatory
diarrhea.

5)The presence of excess stool fat should be evaluated by means of a Sudan

stain or by direct measurement. The presence of excessively large and
numerous fat globules by stain or measured stool fat excretion >14 g/24 h
suggests malabsorption or maldigestion. Stool fat concentration of >7%
strongly suggests pancreatic exocrine insufficiency.
6) Laxative screening should be done in any patient with chronic diarrhea
that has defied diagnosis
EVALUATION OF SPECIFIC DIARRHEA
TREATMENT OF CHRONIC DIARRHEA

• Generally, empirical antibiotic therapy is less useful for chronic diarrhea than for acute diarrhea,
because infection is a much less likely cause.
REFERENCES

• Harrisons 21st edition

• API textbook of medicine 19th edition
• Goldman- ceil medicine 26th edition
• CMDT 2022