APPROACH TO A PATIENT WITH CHRONIC DIARRHOEA

DR. SHIRIN MIRZA HOUSE PHYSICIAN MEDICAL UNIT-I, HFH

4/11/12

DEFINITION
Traditionally,

diarrhea has been defined as an increase in daily stool weight (> 200 g/day). --- impractical can be considered an increase in stool frequency (3 or more stools/day) and/or the presence of loose or liquid stools.

Diarrhea

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CLASSIFICATION
Acute

diarrhea Chronic diarrhea

weeks cut off point

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CAUSES

Chronic Fatty Diarrhea malabsorption syndromes

Chronic Inflammatory Diarrhea

Chronic Watery Diarrhea

Secretory Diarrhea Osmotic Diarrhea Drug-Induced Diarrhea

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 Infectious Endocrine Functional

Diarrhea diarrhea Diarrhea (diagnosis of exclusion)

Irritable Bowel Syndrome

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HISTORY

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AGE

Young patients
Inflammatory Bowel Disease Tuberculosis Functional bowel disorder (Irritable bowel)

Older patients
Colon Cancer Diverticulitis

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DIARRHEA PATTERN

Diarrhea alternates with Constipation

Colon Cancer Laxative abuse Diverticulitis Functional bowel disorder (Irritable bowel)

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 Intermittent

Diarrhea

Diverticulitis Functional bowel disorder (Irritable bowel) Malabsorption

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 Persistent

Diarrhea

Inflammatory Bowel Disease Laxative abuse

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SMALL BOWEL/LARGE BOWEL

Small

intestine or proximal colon involved

Large stool Diarrhea Abdominal cramping persists after Defecation

Distal

colon involved

Small stool Diarrhea Abdominal cramping relieved by Defecation

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DIURNAL VARIATION

No relationship to time of day: Infectious Diarrhea Morning Diarrhea and after meals

Gastric cause Functional bowel disorder (e.g. irritable bowel) Inflammatory Bowel Disease

Nocturnal Diarrhea (always organic)

Diabetic Neuropathy Inflammatory Bowel Disease

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WEIGHT LOSS
Despite

Hyperthyroidism Malabsorption

normal appetite

Associated

Inflammatory Bowel Disease

with fever

Weight

Pancreatic Cancer Tuberculosis Diabetes Mellitus Hyperthyroidism Malabsorption

loss prior to Diarrhea onset

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STOOL CHARACTERISTICS
Water: Blood,

Chronic Watery Diarrhea

pus or mucus: Chronic Inflammatory Diarrhea bulky, greasy stools: Chronic Fatty Diarrhea

Foul,

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MEDICATION AND DIETARY INTAKE

drug

induced diarrhea Food borne illness waterborne illness High fructose corn syrup Excessive sorbitol or mannitol Excessive coffee or other caffeine

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TRAVEL
Travelers Infectious

diarrhea diarrhea

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ASSOCIATED SYMPTOMS
Abdominal Alternating Tenesmus Unintentional Fever

pain constipation

wt. loss

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PAST MEDICAL HISTORY

Childhood

diarrhea-resolves-re-emergence in adulthood celiac disease diabetes

Uncontrolled Pelvic

radiotherapy

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PAST SURGICAL HISTORY

Jejunoileal

bypass with vagotomy

Gastrectomy Bowel

resection

Cholecystectomy
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RED FLAGS-suggestive of organic causes

Painless diarrhea Recent onset in an older patient Nocturnal diarrhea (especially if wakes patient) Weight loss Blood in stool Large stool volumes: >400 grams stool per day Anemia Hypoalbuminemia increased ESR

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PHYSICAL EXAMINATION

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GPE
General Vital Body

appearance and mental status

signs weight volume depletion,autonomic

Orthostasis-

dysfunction

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 exophthalmos

(hyperthyroidism)

aphthous ulcers (IBD and celiac disease) Whipple's disease) (malignancy, infection or

lymphadenopathy

enlarged

or tender thyroid (thyroiditis, medullary carcinoma of the thyroid) (liver disease, IBD, laxative abuse, malignancy)

clubbing
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SKIN LESIONS
dermatitis

herpetiformis (celiac disease)

erythema nodosum and pyoderma gangrenosum (IBD) (Addison's disease)

hyperpigmentation

flushing (carcinoid syndrome) necrotizing erythema (glucagonoma).

migratory

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ABDOMINAL EXAMINATION

Surgical scars abdominal tenderness Masses Hepatosplenomegaly Borborygmus on auscultation

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malabsorption bacterial overgrowth obstruction, or rapid intestinal transit.

PERINEAL AND RECTAL EXAMINATION

Signs

of incontinence

skin changes from chronic irritation, gaping anus, weak sphincter tone.

Crohn's

disease

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perianal skin tags Ulcers fissures abscesses Fistulas stenoses.

impaction or masses might be noted.

SYSTEMIC EXAMINATION
wheezing

and right-sided heart murmurs (carcinoid syndrome) (IBD, Whipple's disease)

arthritis

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INVESTIGATIONS

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BLOOD TESTS
CBC TSH Serum electrolytes Serum albumin

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STOOL EVALUATION

Stool pH (<6 in carbohydrate malabsorption ) Fecal electrolytes (Fecal sodium and osmolar gap)
Differentiates chronic watery diarrhea category

Fecal occult blood test Fecal leukocytes

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 Fecal Stool

fat (abnormal if >14 grams/24 hours) ova and parasites (2-3 samples) lamblia antigen

Giardia

Indicated for diarrhea >7 days and >10 stools/day

Clostridium

difficle toxin

Indicated if recent antibiotics or hospitalization

Consider
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testing stools for laxative abuse

ENDOSCOPY
PROCTOSIGMOIDOSCOPY

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TREATMENT

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NON-SPECIFIC THERAPIES
Dietary

modifications

Smaller, more frequent meals Dec. carbohydrates Dec. fat intake Avoidance of milk Avoid sorbitol and mannitol

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 No

good evidence to support use of bulking agents

Bismuth opioids

subsalicylate (i.e., Pepto-Bismol )

and opioid agonists

Loperamide- first line therapy diphenoxylate-atropine (Lomotil ) Codeine and other narcotics for refractory cases

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SPECIFIC THERAPIES
Clonidine

Diabetic diarrhea moderate and severe diarrhea-predominant IBS

Somatostatin

refractory diarrhea
AIDS, post

chemotherapy, GVHD, and hormone secreting tumors.

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 bile

acid binders (ie, cholestyramine) enzyme supplementation empiric fluoroquinolones

pancreatic

antimicrobials

therapy

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Case Presentation:

A 60-year-old woman diarrhea for the past 3 months denies nausea, vomiting, or fever Her appetite is poor. She initially attributed the diarrhea to travel, but her symptoms have not resolved over several weeks. traveled to Singapore prior to the onset of symptoms.

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The most clinically useful definition of diarrhea for this patient would rely on:
A-

Symptom description

B-An

increase in daily stool weight (> 200 g/day) tests

C-Laboratory D-Report

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of loose or watery stools

How would you begin to diagnose this patient's complaint?

A-History B-History,

and physical examination physical examination, and laboratory

studies

C-History,

physical examination, laboratory studies, and colonoscopy with biopsy physical examination, laboratory studies, and sigmoidoscopy with biopsy

D-History,
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How would you assess illness severity?

A-Length B-Impact

of time since symptoms first appeared of diarrhea on daily function examination

C-Physical D-

Stool frequency

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Initial empirical therapy of chronic diarrhea for this patient should include:

A- Psyllium B-Bismuth subsalicylate

C-Loperamide

D-Codeine

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ROME II CRITERIA FOR IBS

At

least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:

Relieved with defecation; and/or Onset associated with a change in frequency of stool; and/or Onset associated with a change in form (appearance) of stool

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Evaluation of Patient
There is a long list of investigations for the diagnostic of etiology of ch. diarrhea .
SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA Large stool volume Increased frequency with large volume stool No urgency No tenesmus No mucus No blood
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Small amount of stool Increased frequency with small volume stool urgency Tenesmus present Mucus in stool Blood may be present

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THANX

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