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APPROACH TO A
PATIENT WITHCHRONIC DIARRHOEA
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DEFINITION
Traditionally, diarrhea has been defined asan increase in daily stool weight (> 200g/day). --- impractical
Diarrhea can be considered an increase instool frequency (3 or more stools/day)and/or the presence of loose or liquidstools.
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CLASSIFICATION
Acute diarrhea
Chronic diarrhea
4 weeks cut off point
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CAUSES
Chronic Fatty Diarrheamalabsorptionsyndromes
Chronic Inflammatory Diarrhea
Chronic Watery Diarrhea Secretory Diarrhea
Osmotic Diarrhea
Drug-Induced Diarrhea
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Infectious Diarrhea
Endocrine diarrhea
Functional 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/LARGEBOWEL
Small intestine or proximal coloninvolved
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 normal appetite Hyperthyroidism Malabsorption
Associated with fever Inflammatory Bowel Disease
Weight loss prior to Diarrhea onset Pancreatic Cancer
Tuberculosis Diabetes Mellitus Hyperthyroidism Malabsorption
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STOOL CHARACTERISTICS
Water:Chronic Watery Diarrhea
Blood, pus or mucus:ChronicInflammatory Diarrhea
Foul, bulky, greasy stools:Chronic FattyDiarrhea
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MEDICATION AND DIETARYINTAKE
drug induced diarrhea
Food borne illness
waterborne illnessHigh fructose corn syrup
Excessive sorbitol or mannitol
Excessive coffee or other caffeine
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TRAVEL
Travelers diarrhea
Infectious diarrhea
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ASSOCIATED SYMPTOMSAbdominal pain
Alternating constipation
Tenesmus
Unintentional wt. loss
Fever
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PAST MEDICAL HISTORY
Childhood diarrhea-resolves-re-emergencein adulthood celiac disease
Uncontrolled diabetes
Pelvic radiotherapy
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PAST SURGICAL HISTORY
Jejunoileal bypass
Gastrectomy with vagotomy
Bowel resection
Cholecystectomy
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RED FLAGS-suggestive oforganic 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 appearance and mental status
Vital signs
Body weight
Orthostasis- volume depletion,autonomicdysfunction
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exophthalmos (hyperthyroidism)
aphthous ulcers (IBD and celiac disease)
lymphadenopathy (malignancy, infection or
Whipple's disease)
enlarged or tender thyroid (thyroiditis, medullarycarcinoma of the thyroid)
clubbing (liver disease, IBD, laxative abuse,malignancy)
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SKIN LESIONS
dermatitis herpetiformis (celiac disease)
erythema nodosum and pyoderma gangrenosum(IBD)
hyperpigmentation (Addison's disease)
flushing (carcinoid syndrome)
migratory necrotizing erythema (glucagonoma).
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ABDOMINAL EXAMINATION
Surgical scars
abdominal tenderness
Masses
Hepatosplenomegaly
Borborygmus on auscultation malabsorption
bacterial overgrowth
obstruction, or rapid intestinaltransit.
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PERINEAL AND RECTALEXAMINATION
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.
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SYSTEMIC EXAMINATION
wheezing and right-sided heart murmurs(carcinoid syndrome)
arthritis (IBD, Whipple's disease)
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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 (
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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
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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 ofbulking agents
Bismuth subsalicylate(i.e., Pepto-Bismol)
opioids and opioid agonists Loperamide- first line therapy
diphenoxylate-atropine (Lomotil)
Codeine and other narcotics for refractorycases
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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)
pancreatic enzyme supplementation
antimicrobialsempiric fluoroquinolonestherapy
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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.
e mos c n ca y use u e n on
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e mos c n ca y use u e n onof diarrhea for this patient would
rely on:
A- Symptom description
B-An increase in daily stool weight (> 200g/day)
C-Laboratory tests
D-Report of loose or watery stools
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How would you begin todiagnose this patient's complaint?
A-History and physical examination
B-History, physical examination, andlaboratory studies
C-History, physical examination, laboratorystudies, and colonoscopy with biopsy
D-History, physical examination, laboratorystudies, and sigmoidoscopy with biopsy
H ld ill
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How would you assess illnessseverity?
A-Length of time since symptoms first appeared
B-Impact of diarrhea on daily function
C-Physical examination
D- Stool frequency
n a emp r ca erapy o c ron c
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n a emp r ca erapy o c ron cdiarrhea 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 beconsecutive, in the preceding 12 months ofabdominal discomfort or pain that has 2 of 3
features:
Relieved with defecation; and/or
Onset associated with a change in frequency ofstool; and/or
Onset associated with a change in form(appearance) of stool
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Evaluation of PatientThere is a long list of investigations for the
diagnostic of etiology of ch. diarrhea .
SMALL BOWELDIARRHEA
LARGE BOWELDIARRHEA
Large stool volume Small amount of stoolIncreased frequencywith large volumestool
Increased frequencywith small volumestool
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
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THANX