APPROACH TO A PATIENT APPROACH TO A PATIENT WITH CHRONIC DIARRHOEAWITH CHRONIC DIARRHOEA

DEFINITIONDEFINITION

Traditionally, diarrhea has been defined as an increase in daily stool weight (> 200 g/day). --- impractical

Diarrhea can be considered an increase in stool frequency (3 or more stools/day) and/or the presence of loose or liquid stools.

CLASSIFICATIONCLASSIFICATION

Acute diarrheaChronic diarrhea

4 weeks– cut off point

CAUSESCAUSES Chronic Fatty Diarrhea – malabsorption

syndromes

Chronic Inflammatory Diarrhea

Chronic Watery Diarrhea – Secretory Diarrhea – Osmotic Diarrhea – Drug-Induced Diarrhea

Infectious Diarrhea

Endocrine diarrhea

Functional Diarrhea (diagnosis of exclusion) – Irritable Bowel Syndrome

HISTORYHISTORY

AGEAGE

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

Older patientsOlder patients – Colon Cancer – Diverticulitis

DIARRHEA PATTERNDIARRHEA PATTERN

Diarrhea alternates with alternates with Constipation

– Colon Cancer

– Laxative abuse

– Diverticulitis

– Functional bowel disorder (Irritable bowel)

Intermittent Intermittent Diarrhea

– Diverticulitis

– Functional bowel disorder (Irritable bowel)

– Malabsorption

Persistent Persistent Diarrhea

– Inflammatory Bowel Disease

– Laxative abuse

SMALL BOWEL/LARGE SMALL BOWEL/LARGE BOWELBOWEL

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

DIURNAL VARIATIONDIURNAL 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

WEIGHT LOSSWEIGHT LOSS Despite normal appetite

– Hyperthyroidism – Malabsorption

Associated with fever – Inflammatory Bowel Disease

Weight loss prior to Diarrhea onset – Pancreatic Cancer – Tuberculosis – Diabetes Mellitus – Hyperthyroidism – Malabsorption

STOOL CHARACTERISTICSSTOOL CHARACTERISTICS

Water: Chronic Watery Diarrhea

Blood, pus or mucus: Chronic

Inflammatory Diarrhea

Foul, bulky, greasy stools: Chronic Fatty Diarrhea

MEDICATION AND DIETARY MEDICATION AND DIETARY INTAKEINTAKEdrug induced diarrheaFood borne illness waterborne illness High fructose corn syrup Excessive sorbitol or mannitol Excessive coffee or other caffeine

TRAVELTRAVEL

Traveler’s diarrhea

Infectious diarrhea

ASSOCIATED SYMPTOMSASSOCIATED SYMPTOMS

Abdominal pain

Alternating constipation

Tenesmus

Unintentional wt. loss

Fever

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

Childhood diarrhea-resolves-re-emergence in adulthood– celiac disease

Uncontrolled diabetes

Pelvic radiotherapy

PAST SURGICAL HISTORYPAST SURGICAL HISTORY

Jejunoileal bypass

Gastrectomy with vagotomy

Bowel resection

Cholecystectomy

RED FLAGS-suggestive of organic RED FLAGS-suggestive of organic causescauses 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

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

GPEGPE

General appearance and mental status

Vital signs

Body weight

Orthostasis- volume depletion,autonomic dysfunction

exophthalmos (hyperthyroidism)

aphthous ulcers (IBD and celiac disease)

lymphadenopathy (malignancy, infection or Whipple's disease)

enlarged or tender thyroid (thyroiditis, medullary carcinoma of the thyroid)

clubbing (liver disease, IBD, laxative abuse, malignancy)

SKIN LESIONSSKIN LESIONS

dermatitis herpetiformis (celiac disease)

erythema nodosum and pyoderma gangrenosum (IBD)

hyperpigmentation (Addison's disease)

flushing (carcinoid syndrome)

migratory necrotizing erythema (glucagonoma).

ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION

Surgical scars

abdominal tenderness

Masses

Hepatosplenomegaly

Borborygmus on auscultation– malabsorption – bacterial overgrowth– obstruction, or rapid

intestinal transit.

PERINEAL AND RECTAL PERINEAL AND RECTAL EXAMINATIONEXAMINATION

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 EXAMINATIONSYSTEMIC EXAMINATION

wheezing and right-sided heart murmurs (carcinoid syndrome)

arthritis (IBD, Whipple's disease)

INVESTIGATIONSINVESTIGATIONS

BLOOD TESTSBLOOD TESTS

CBC TSH Serum electrolytes Serum albumin

STOOL EVALUATIONSTOOL 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

Fecal fat (abnormal if >14 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

ENDOSCOPYENDOSCOPY

PROCTOSIGMOIDOSCOPY

TREATMENTTREATMENT

NON-SPECIFIC THERAPIESNON-SPECIFIC THERAPIES Dietary modifications

– Smaller, more frequent meals

– Dec. carbohydrates

– Dec. fat intake

– Avoidance of milk

– Avoid sorbitol and mannitol

No good evidence to support use of bulking agents

Bismuth subsalicylate (i.e., Pepto-Bismol )

opioids and opioid agonists – Loperamide- first line therapy– diphenoxylate-atropine (Lomotil )– Codeine and other narcotics – for

refractory cases

SPECIFIC THERAPIESSPECIFIC THERAPIES

Clonidine-– Diabetic diarrhea– moderate and severe diarrhea-predominant IBS

Somatostatin – refractory diarrhea

• AIDS, • post chemotherapy, • GVHD, • and hormone secreting tumors.

bile acid binders (ie, cholestyramine)

pancreatic enzyme supplementation

antimicrobials –empiric fluoroquinolones therapy

Case Presentation: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.

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

A- Symptom description 

B-An increase in daily stool weight (> 200 g/day) 

C-Laboratory tests 

D-Report of loose or watery stools

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

A-History and physical examination

B-History, physical examination, and laboratory studies

C-History, physical examination, laboratory studies, and colonoscopy with biopsy

D-History, physical examination, laboratory studies, and sigmoidoscopy with biopsy

How would you assess illness How would you assess illness severity?severity? A-Length of time since symptoms first

appeared 

B-Impact of diarrhea on daily function

C-Physical examination

D- Stool frequency

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

 A- Psyllium

B-Bismuth subsalicylate 

C-Loperamide

 D-Codeine 

ROME II CRITERIA FOR IBSROME 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

THANXTHANX……