approach to a patient with chronic diarrhoea

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APPROACH TO A
PATIENT WITH
CHRONIC DIARRHOEA
DR. SHIRIN MIRZA
HOUSE PHYSICIAN
MEDICAL UNIT-I, HFH
DEFINITION
► 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.
CLASSIFICATION
► Acute
diarrhea
► Chronic diarrhea
►4
weeks– cut off point
CAUSES
►
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
HISTORY
AGE
Young patients
►



Inflammatory Bowel Disease
Tuberculosis
Functional bowel disorder (Irritable bowel)
Older patients
►


Colon Cancer
Diverticulitis
DIARRHEA PATTERN
Diarrhea alternates with Constipation
►

Colon Cancer

Laxative abuse

Diverticulitis

Functional bowel disorder (Irritable bowel)
► Intermittent
Diarrhea
 Diverticulitis
 Functional bowel disorder (Irritable bowel)
 Malabsorption
► Persistent
Diarrhea
 Inflammatory Bowel Disease
 Laxative abuse
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
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
WEIGHT 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 CHARACTERISTICS
► Water:
Chronic Watery Diarrhea
► Blood,
pus or mucus: Chronic
Inflammatory Diarrhea
► Foul,
bulky, greasy stools: Chronic Fatty
Diarrhea
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
TRAVEL
► Traveler’s
diarrhea
► Infectious
diarrhea
ASSOCIATED SYMPTOMS
► Abdominal
pain
► Alternating
constipation
► Tenesmus
► Unintentional
► Fever
wt. loss
PAST MEDICAL HISTORY
► Childhood
diarrhea-resolves-re-emergence
in adulthood– celiac disease
► Uncontrolled
► Pelvic
diabetes
radiotherapy
PAST SURGICAL HISTORY
► Jejunoileal
bypass
► Gastrectomy
► Bowel
with vagotomy
resection
► Cholecystectomy
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
►
PHYSICAL EXAMINATION
GPE
► General
► Vital
► Body
appearance and mental status
signs
weight
► Orthostasis-
dysfunction
volume depletion,autonomic
► exophthalmos
►
(hyperthyroidism)
aphthous ulcers (IBD and celiac disease)
► lymphadenopathy
Whipple's disease)
(malignancy, infection or
► enlarged
or tender thyroid (thyroiditis, medullary
carcinoma of the thyroid)
► clubbing
(liver disease, IBD, laxative abuse,
malignancy)
SKIN LESIONS
► dermatitis
►
herpetiformis (celiac disease)
erythema nodosum and pyoderma gangrenosum
(IBD)
► hyperpigmentation
►
(Addison's disease)
flushing (carcinoid syndrome)
► migratory
necrotizing erythema (glucagonoma).
ABDOMINAL EXAMINATION
►
Surgical scars
►
abdominal tenderness
►
Masses
►
Hepatosplenomegaly
►
Borborygmus on auscultation
 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
perianal skin tags
Ulcers
fissures
abscesses
Fistulas
stenoses.
► Fecal
impaction or masses might be noted.
SYSTEMIC EXAMINATION
► wheezing
and right-sided heart murmurs
(carcinoid syndrome)
► arthritis
(IBD, Whipple's disease)
INVESTIGATIONS
BLOOD TESTS
►
►
►
►
CBC
TSH
Serum electrolytes
Serum albumin
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
► 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
ENDOSCOPY
► PROCTOSIGMOIDOSCOPY
TREATMENT
NON-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
► opioids
subsalicylate (i.e., Pepto-Bismol )
and opioid agonists
 Loperamide- first line therapy
 diphenoxylate-atropine (Lomotil )
 Codeine and other narcotics – for refractory
cases
SPECIFIC 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
therapy
–empiric fluoroquinolones
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 diarrhea for this patient would
rely on:
► A-
Symptom description
► B-An
increase in daily stool weight (> 200
g/day)
► C-Laboratory
► D-Report
tests
of loose or watery stools
How would you begin to
diagnose 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
severity?
► A-Length
of time since symptoms first appeared
► B-Impact
of diarrhea on daily function
► C-Physical
► D-
examination
Stool frequency
Initial empirical therapy of chronic
diarrhea for this patient should
include:
►
A- Psyllium
►
B-Bismuth subsalicylate
► C-Loperamide
►
D-Codeine
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
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
Small amount of stool
Increased frequency
with large volume
stool
Increased frequency
with small volume
stool
No urgency
urgency
No tenesmus
Tenesmus present
No mucus
Mucus in stool
No blood
Blood may be present
Central abdominal
pain
Pain in left iliac fossa
relived by defecation
THANX…
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