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Chronic DiarrheaChronic Diarrhea
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DiarrheaDiarrhea
Loosely defined as passage of abnormally liquid or unformed stools at an increased frequency.
Adults (typical western diet) stool weight > 200g/d
caused by an imbalance in the physiologic mechanisms of the GI tract, resulting in impaired absorption and/or excessive secretion.
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2 common conditions (<200 g/d) must be distinguished from diarrhea:
◦Pseudodiarrhea Frequent passage of small volumes of stool Associated with rectal urgency ; accompanies
IBS/proctitis
◦Fecal Incontinence involuntary discharge of rectal contents
most often caused by neuromuscular disorder/structural/anorectal problems
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DiarrheaDiarrhea
Type Duration
Acute < 2 weeks
Persistent 2-4 weeks
Chronic > 4 weeks
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Chronic DiarrheaChronic Diarrhea
Warrants evaluation to exclude serious underlying pathology
Most of the causes: NON- infectious
Classification by pathophysiological mechanism rational approach to management
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Approach to Chronic Approach to Chronic Diarrhea:Diarrhea:Laboratory tools are extensive
costly and invasive rationally directed by a careful History and PE.
When this strategy is unrevealing, simple triage tests (Hx, PE, routine blood studies) are often warranted.◦Characterize the mechanism of diarrhea◦ Identify diagnostically helpful assoc.◦Assess px’s fluid/electrolyte &
nutritional status
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HISTORYHISTORY
Family History:
IBD
Sprue
Presence of:
fecal incontinencefeverweight losspain exposure(travel, medications, contacts) common extraintestinal manifestations (skin, arthralgias, oral aphtous ulcers
Diarrhea
Onset
Duration
Pattern
Aggravating and relieving factors (diet)
Characteristics
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Physical Findings
Thyroid mass Wheezing Murmurs Edema
Hepatomegaly Abdominal
masses
Lymphadenopathy
Mucocutaneous abnormalities Perianal
fistula Anal sphincter
laxity
Celiac disease
Blood Studies
Peripheral blood leukocytosis↑sedimentation rateC- reactive protein
Anemia
Eosinophilia
Tissue transglutaminase Ab
Inflammation
Blood loss/nutritional
deficiency
Parasites, neoplasia, collagen
vascular disease, allergy,
eosinophilic gastroenteritis
Celiac disease
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Chronic DiarrheaChronic Diarrhea2/3 of cases, the causes remain
unclear after the initial encounter further testing is required:◦Quantitative stool collection and
analyses important objective data and establish a diagnosis/characterize the type of diarrhea as a triage for focused additional studies
◦Stool ( >200g/d ) electrolyte concentration, pH, occult blood testing, leukocyte inspection/protein assay, fat quantitation, and laxative screens.
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Chronic DiarrheaChronic DiarrheaWhen a specific diagnosis is suggested on the
initial encounter, therapeutic trial is often appropriate, definitive, and highly cost effective. Examples:
◦ Chronic watery diarrhea ceases with fasting in an otherwise healthy young adult may justify a trial of lactose-restricted diet
◦ Bloating w/ diarrhea after a mountain backpacking trip trial of metronidazole (giardiasis)
Any patient with chronic diarrhea + hematochezia evaluated with stool microbiologic studies and colonoscopy
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Chronic DiarrheaChronic DiarrheaSecretory diarrheas
◦Microbiologic studies should be done, including: fecal bacterial cultures, inspection for ova and parasites and Giardia antigen assay
◦Suggested history & other findings screening for peptide hormones (gastrin, VIP, calcitonin, TH/TSH, urinary 5-HIAA, and histamine)
◦Upper endoscopy, colonoscopy w/ biopsy and small bowel barium x-rays rule out structural/occult inflammatory disease
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Chronic DiarrheaChronic DiarrheaOsmotic diarrhea
◦Tests for 2 most common causes: Lactose intolerance/malabsorption lactose breath
testing or therapeutic trial w/ lactose exclusion & lactose challenge
Magnesium ingestion fecal magnesium levels◦pH low fecal pH suggests CHO malabsorption
Steatorrhea◦Endoscopy w/ small bowel biopsy(includes
aspiration for Giardia and quantitative cultures)◦Small-bowel radiograph◦(-) radiograph/ pancreatic exocrine disease
Pancreatic exocrine insufficiency ruled out secretin-cholecystokinin stimulation test
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Chronic DiarrheaChronic DiarrheaChronic inflammatory-type of
diarrheas (presence of blood/leukocytes in the stool)◦Stool cultures◦Inspection for ova/parasites◦C. difficile toxin in assay◦Colonoscopy w/ biopsies◦Small-bowel contrast studies