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SPEAKER: Dr ASHOK KUMAR
CHAIRPERSON: Dr ARDAMAN SINGH
DIARRHEA: is defined as passage of abnormally liquid or unformed stool at an increased frequency. For adult on typical western diet, stool wt>200g/d can be considered diarrhea.
PSEUDODIARRHEA: frequent passage of small vol. of stool,is often asso. With rectal urgency and a/c IBS or proctitis.
FECAL INCONTINENCE: is involuntary passage of rectal contents and is most often caused by neuromuscular disorders or structural anorectal problems
Pseudodiarrhea and fecal incontinence occur at prevalence rate comparable to or higher than that of chr. Diarrhea and should always be considered in pt. complaining of diarrhea.
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Acute diarrhea: <2 wk
Chronic diarrhea: >4 wk
Persistent diarrhea :2-4 wk
4 weeks– cut off point3
SECRETORY CAUSES Exogenous stimulant laxative Chronic ethanol ingestion Endogenous laxatives(dihydroxy
bile acids) Bactrial inf. Bowel resection,disease ,fistula Partial bowel obst.,fecal impaction Harmone producing
tumors(carcinoid,VIPoma,medullary ca) thyroid,mastocytosis,gastrinoma,colorectal villus adenoma)
Addison’s disease Congenital electrolyte abs. defect idiopathic
OSMOTIC CAUSES Osmotic laxative(MG+
+,PO4,SO4--) Lactase and other disaccharide
defeciency Nonabs. CHO (sorbitol,lactulose
polyethylene glycol)INFLAMMATORY CAUSES Idiopathic inflm,bowel
disease(CD,UC) Lymphocytic and collagenous
colitis Immune-related mucosal
disease(1,2nd immunodeficiences,food allergy,eosinophilic gastroenteritis,GVHD) Infections(invasive bacteria,viruses,and parasites,Brainerd diarrhea)
Radiation injury Gastrointestinal malignancies
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STEATORRHEAL CAUSES Intraluminal
maldigestion(pancreatic exocrine deficiency,bactrial overgrowth,bariatric sx,liver dis.)
Mucosal malabsorbtion(celiac sprue,whipple’s disease,inf, abetalipoproteinemia , ischemia)
Post mucosal obst (1, 2nd lympathic obst.)
FACTITIAL CAUSES Munchausen Eating disorders
DYSMOTILE CAUSES
Irritable bowel syndrome(including post-infectious IBS) Visceral neuromyopathies
Hyperthyroidism
Drugs(prokinetic agents) Postvagotomy
IATROGENIC CAUSES Cholecystectomy Ileal resection Bariatric surgery Vagotomy,fundoplication
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Antibiotics Antiretroviral agents Antineoplastic agents Anti-inflammatory agents (NSAIDs, gold, 5-ASA) Antiarrhythmics (quinidine) Antihypertensives (β blockers) Oral hypoglycemics (metformin, acarbose) Antacids (magnesium-containing) Acid-reducing agents (H2 blockers, PPIs) Colchicine Prostaglandin analogs (misoprostol) Theophylline Vitamin and mineral supplements Herbal products Heavy metals
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Due to derangement in fluid and electrolyte transport across the enterocolonic mucosa.
CLUE:Watery,Large volume ( >1 L/d),painless, little change with fasting; normal stool osmotic gap
1.Medications2. Bowel resection,mucosal
disease,enterocolic fistula).3. Hormonally mediated (uncommon)4.Congen.defect in ion absorption:
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When ingested,poorly absorbable,osmotically active solute draw enough fluid into lumen to exceed the reabsorptive capacity of the colon.
CLUES: Stool volume decreases with fasting; increased stool osmotic gap(>50mosmol/l).
1 magnesium (antacids, laxatives)2. Medications3 Disaccharidase deficiency
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As stool leaves the colon, fecal osmolality is equal to the serum osmolality, ie, approximately 290 mosm/kg. Under normal circumstances, the major osmoles are Na+, K+, Cl–, and HCO3–. The stool osmolality may be estimated by multiplying the stool (Na+ + K+) × 2 (multiplied by 2 to account for the anions)
The osmotic gap is the difference between the measured osmolality of the stool (or serum) and the estimated stool osmolality and is normally less than 50 mosm/kg
An increased osmotic gap implies that the diarrhea is caused by ingestion or malabsorption of an osmotically active substance
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>7g/d fat in stool(Small intestine disease15-25g/d,pancriatic exocrine def.>32g/d).
CLUE:greasy ,Foul smelling,difficult to flush,as/o with wt. loss ,nutritional def.(amino a,vitamins).
Intraluminal maldigestion Mucosal malabsorption Postmucosal lymphatic obstruction
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CLUE:Fever, hematochezia, abdominal pain
Mechanism depending on lesion site(fat malabsorption,fluid/electrolyte,hypermotility from cytokinins)
1.Inflammatory bowel disease2. Microscopic colitis3.Immunodeficiency4.Eosinophillic gastroenteritis 11
Parasites: Giardia lamblia, Entamoeba histolytica, Cyclospora
AIDS-related: Viral: Cytomegalovirus, HIV infection
Bacterial: Clostridium difficile, Mycobacterium avium complex
Protozoal: Microsporida, Cryptosporidium, Isospora belli
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Abnormal intestinal motility secondary to systemic disorders or surgery may result in diarrhea due to rapid transit or to stasis of intestinal contents with bacterial overgrowth resulting in malabsorption
Stool feature suggestive of secretory diarrhea,mild steatorrhea may be there.
Hyperthyroidism, diabetic diarrhea ,carcinoid syndrome.
medications(PGs ,prokinetic drugs). Irritable bowel syndrome.
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Approximately 15% of patients with chronic diarrhea have factitial diarrhea caused by surreptitious laxative abuse or factitious dilution of stool.
Munchausen syndrome(self inj. For secondary gain,women),eating disorder.
Hypotension,hypokalamia. Psy. conselling beneficial. 14
OsmoticSecretory
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Onset Congenital Abrupt Gradual Travel history
Exposure to contaminated water
Weight loss
Dietary history
Chloridorrhea Infections, idiopathic secretory
diarrhea All other etiologies Infectious diarrhea Aeromonas, Plesiomonas Giardiasis, Cryptosporidiosis Brainerd diarrhea Malabsorption, pancreatic exocrine
insufficiency, neoplasm “Sugar-free” foods with sorbitol,
mannitol , lactase deficiency, fructose intolerance
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Previous treatments
Systemic illness
Abdominal pain
Excessive flatus/bloating
IV drug use, sexual promiscuity
Secondary gain/Fixation on body image
Institutionalized patients
Medications, radiation enteropathy, surgery (bowel, gallbladder), pseudomembranous colitis
Hyperthyroidism, IBD, diabetes
Mesenteric vascular insufficiency, IBD, IBS
Carbohydrate malabsorption, small bowel bacterial overgrowth
HIV infection
Laxative abuse
Medication, C. difficile colitis, tube feeding, ischemia, fecal impaction with overflow diarrhea
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Epidemiological and historical features Implication
Young patients Inflammatory Bowel Disease Tuberculosis Functional bowel disorder (Irritable bowel)
Older patients Colon Cancer Diverticulitis
DiarrheaDiarrhea alternates with alternates with ConstipationConstipation
Colon Cancer Laxative abuse Diverticulitis Functional bowel disorder (Irritable bowel)
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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
Intermittent DiarrheaDiverticulitisFunctional bowel disorder (Irritable bowel) Malabsorption
Persistent Diarrhea Inflammatory Bowel DiseaseLaxative abuse
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Despite normal appetite HyperthyroidismMalabsorption
Associated with fever Inflammatory Bowel Disease
Weight loss prior to Diarrhea onset Pancreatic Cancer TuberculosisDiabetes MellitusHyperthyroidism TRAVEL
Traveler’s diarrhea
Infectious diarrhea21
Water: Chronic Watery Diarrhea Blood, pus or mucus: Chronic Inflammatory Diarrhea
Foul, bulky, greasy stools: Chronic Fatty Diarrhea
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SMALL BOWEL DIARRHEASMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEALARGE BOWEL DIARRHEA
Large stool volumeLarge stool volume Small amount of stoolSmall amount of stool
Increased frequency with Increased frequency with large volume stoollarge volume stool
Increased frequency with Increased frequency with small volume stoolsmall volume stool
No urgency No urgency urgencyurgency
No tenesmusNo tenesmus Tenesmus presentTenesmus present
No mucusNo mucus Mucus in stoolMucus in stool
No bloodNo blood Blood may be presentBlood may be present
Central abdominal pain Central abdominal pain Pain in left iliac fossa Pain in left iliac fossa relived by defecationrelived by defecation
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drug induced diarrhea
Food borne illness
waterborne illness
High fructose corn syrup
Excessive sorbitol or mannitol
Excessive coffee or other caffeine 24
Childhood diarrhea-resolves-re-emergence in adulthood– celiac disease
Uncontrolled diabetes
Pelvic radiotherapyPAST SURGICAL HISTORY Jejunoileal bypass
Gastrectomy with vagotomy
Bowel resection
Cholecystectomy25
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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Celiac sprue (dermatitis herpetiformis) Mastocytosis (urticaria pigmentosa) Amyloidosis (macroglossia, purpura) Addison’s disease (hyperpigmentation) Glucagonoma (migratory necrolytic
erythema) Carcinoid syndrome (flushing) Degos’ disease (malignant atrophic
papulosis) IBD (erythema
nodosum,pyoderma gangrenosum)
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Peripheral neuropathy, orthostatic hypotension
Thyroid nodule
Right-sided cardiac murmur, hepatomegaly
Arthritis
Lymphadenopathy Peripheral vascular
disease/abdominal bruits
Amyloidosis
Medullary carcinoma of the thyroid
Carcinoid syndrome
IBD, Whipple’s, infections
AIDS, lymphoma Mesenteric vascular
insufficiency
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General appearance and mental status
Vital signs
Body weight
Exophthalmos (hyperthyroidism)
Aphthous ulcers (IBD and celiac disease)
Lymphadenopathy (malignancy, infection or Whipple's disease)
Enlarged or tender thyroid (thyroiditis, medullary carcinoma of thyroid)
Clubbing (liver disease, IBD, laxative abuse, malignancy)30
Surgical scars
abdominal tenderness
Masses
Hepatosplenomegaly
Borborygmus on auscultation malabsorption bacterial overgrowth obstruction, or rapid
intestinal transit.31
Signs of incontinence – skin changes from chronic irritation, gaping anus, weak sphincter tone.
Crohn's disease perianal skin tags Ulcers fissures abscesses Fistulas stenoses.
Fecal impaction or masses might be noted. SYSTEMIC EXAMINATION wheezing and right-sided heart murmurs,episodic flushing,dyspnea
(carcinoid syndrome)
Arthritis,uveitis,polyarthralgia,cholestatic,liver disease(IBD, Whipple's disease)
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24-hour stool collection for weight and quantitative fecal fat–A stool wt. of > 300 g/24 h confirms the presence of diarrhea, justifying further workup. A wt. >1000–1500 g suggests a secretory process. A fecal fat > 10 g/24 h indicates a malabsorptive process
Categorize diarrhea into watery, inflammatory, fatty Timed collection is best, spot tests on random stool
sample more practical- Occult blood- White blood cells - pH- Sudan stain for fat- Cultures- Laxative screen- Electrolytes, osmolality
-Stool for ova and parasites34
Occult blood and white blood cells:- Primarily define inflammatory diarrhea- Wright stain: Sensitivity 70%, specificity 50% for leukocytes- Fecal calprotectin and lactoferrin less operator dependent
pH:- Low pH (< 6) generally indicative of carbohydrate malabsorption
Sudan stain:- Fatty diarrhea (steatorrhea) - Gold standard: Quantitative estimation of stool fat on collected specimen - Qualitative estimation feasible on random sample, - Semiquantitative methods (number and size of fat globules) correlate well with quantitative collection
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Stool cultures:- Infection: Usually inflammatory diarrhea- Bacterial infection rarely cause of chronic diarrhea in immunocompetent host - Routine cultures are low yield - Special techniques for Aeromonas and Plesiomonas- Ova and Parasites- Always consider giardiasis (stool ELISA for Giardia antigen)
Laxative screen:- High index of suspicion- Stool for bisacodyl and phenolphtalein, urine for anthraquinones- Confirm on another sample before confronting patient
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Stool electrolytes:Stool osmotic gap: 290 – 2([Na+] + [K+]) - Gap < 50 mOsm/Kg: Pure secretory diarrhea- Gap > 125 mOsm/Kg: Pure osmotic diarrhea- Gap 50-125 mOsm/kg: Mixed or mild carbohydrate malabsorption
Measured stool osmolality:- Not used to calculate gap- Useful in cases of unexplained diarrhea- Low measured stool osmolality (< 290 mOsm/Kg) suggestive of contamination with water or dilute urine
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Fecal fat (abnormal if >10 grams/24 hours)
Stool ova and parasites (2-3 samples)
Giardia lamblia antigen Indicated for diarrhea >7 days and >10 stools/day
Clostridium difficle toxin Indicated if recent antibiotics or hospitalization
Consider testing stools for laxative abuse
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39Fig. 22.21 The “face” of a Giardia lamblia trophozoite.
Routine laboratory tests–CBC, serum electrolytes, liver function tests, ca++, phosphorus, albumin, TSH, total T4, and prothrombin time should be obtained.
Anemia occurs in malabsorption syndromes (vitamin B12, folate, iron) and inflammatory conditions.
Hypoalbuminemia is present in malabsorption, protein-losing enteropathies, and inflammatory diseases.
Hyponatremia and non–anion gap metabolic acidosis may occur in profound secretory diarrheas. Malabsorption of fat-soluble vitamins may result in an abnormal prothrombin time, low serum calcium, low carotene, or abnormal serum alkaline phosphatase 40
In patients with suspected secretory diarrhea
serum VIP (VIPoma)
gastrin (Zollinger-Ellison syndrome)
calcitonin (medullary thyroid carcinoma)
cortisol (Addison's disease)
urinary 5-HIAA (carcinoid syndrome)
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Calcification on a plain abdominal radiograph confirms the diagnosis of chronic pancreatitis.
An upper gastrointestinal series or enteroclysis study is helpful in evaluating Crohn's disease, lymphoma, or carcinoid syndrome.
Colonoscopy is helpful in evaluating colonic inflammation due to IBD.
Upper endoscopy malabsorption due to mucosal diseases. with a duodenal aspirate and small bowel biopsy is also useful in patients with AIDS and to document Cryptosporidium, Microsporida, and M avium-intracellulare infection.
Abdominal CT is helpful to detect chronic pancreatitis or pancreatic endocrine tumors.
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Chronic diarrhea
Blood PR
Features,stool,
Suggest malabsorptio
nPain aggravated
before BM,relieved
withBM ,sense incomplete evacuation
No blood features of malabsorp
tion
Colonoscopy +Biopsy Small
bowel:imaging,biopsy,aspirate
Suspect IBS
ConsiderFunctional diarrhea
Dietary exclusion
eg.Lactose sorbitol
Limited screen for organic
disease43
Low Hb,Alb,abnormal MCV,MCH; excess fat in stool
Opioid Rx + follow up
Persistent chronic diarrhea
Titrate Rx to speed of
transit
Colonoscopy + Biopsy
Small bowel:X
ray,biopsy,aspirate;stool
48-h fat
Stool vol,OSM,PH;Laxative screen;Hor
monal screen
Stool fat >20g/d
Pancreatic function
Normal and stool fat <14g/d Full gut
transit
Chronic diarrhea
Screening test all normal
Low k+
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Treatment depend upon specific etiology Curative ,suppressive or empirical.
CURATIVE:recetion of colorectal ca.,antibiotic for whipple dis.,drug discontinuation of a drug.
SUPPRESSIVE:(supress the underlying mechanism) Lactose avoid in lactase def. Gluten diet for celiac sprue. Glucocorticoids and anti inflammatory for IBD PPI for gastrinoma Cholestyramine for ileal bile acid malabsorbtion Octreotide for malignent carcinoid syndrome Prostaglandin (-) indomethacin:medullary ca thyroid Pancreatic replacement:pancreatic insufficiency
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EMPERICAL:mild to mod. Watery diarrhea(diphenoxylate,loperamide),severe(codeine,opium)
Avoid in IBD as toxic megacolon ppt.
Clonidine:diabetic diarrhea
Fluid and electrolyte Fat soluble vitamin
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Drug Class Agent DoseOpiates Diphenoxylate
LoperamideCodeineMorphineTincture of opium
2.5-5 mg QID2-4 mg QID15-60 mg QID2-20 mg QID2-20 drops QID
Adrenergic agonist Clonidine 0.1-0.3 mg TID
Somatostatin analog Octreotide 50-250 µg SQ TID
Bile acid-binding resin Cholestyramine 4 g once daily to QID
Fiber supplements PsylliumCalcium polycarbophil
10-20 g daily5-10 g daily
Others ProbioticsHerbals (berberine, arrowroot) 48
THANKS..
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