MANAGEMENT OF CHRONIC DIARRHEA

SPEAKER: ANGAN KARMAKAR

CHAIRPERSON: DR. K D BISWAS(DEPT. OF GASTROENTEROLOGY)

Definition

• Increased stool weight > 200 gm/d• 3 or more bowel movements• Increased fluidity of stool• > 4 weeks

Among Indians• Average stool weight 311 g/d

• Bowel movement >3/d (9% of population)

Initial Evaluation:HISTORY

• Duration, pattern, epidemiology

• Severity, dehydration

• Stool volume & frequency

• Stool characteristics

• Nocturnal symptoms

• Fecal urgency, incontinence

• Associated symptoms (abdpain, cramps, bloating, fever, weight loss, etc)

• Extra-intestinal symptoms

• Relationship to meals, specific foods, fasting, & stress

• Medical, surgical, travel, water exposure history

• Recent hospitalizations, antibiotics

• History of radiation

• Current/recent medications

• Diet (including excessive fructose, sugar alcohols, caffeine)

• Laxative abuse

Stool characteristics

• Blood in stool – IBD, malignancy

• Watery stool – osmotic,secretory

• Oily stool – malabsorption,maldigestion

• Relationship with fasting –secretory diarrhea

• Nocturnal diarrhoea – organic

• Excess flatus - malabsorption

Initial Evaluation:PHYSICAL EXAMINATION

Fever

Bowel sounds

Anemia, edema

Abdominal distention, tenderness, masses

Hepatomegaly, lymphadenopathy

DRE

Skin, joints, thyroid, peripheral neuropathy,

murmur

• CBC (Hb%,Hct, MCV, WBC count),ESR

• electrolytes, BUN /Cr, glucose, LFTs, Ca, albumin

• HIV serology, CRP, INR/PTT, TSH, B12, folate, Vit D, iron

• anti-transglutaminase IgA Ab, anti-endomyseal IgA Ab

• Stool studies– OPC: Giardia , Microsporidia, Cryptosporidiosis

– Fecal leukocytes

– occult blood: inflammatory, malignancy

Initial Evaluation:TESTING

– Stool electrolytes for osmotic gap = 290 – 2[Na + K]

Small gap(<50)= secretory

Large gap(>100)= osmotic

Measured osmolality <290= addition of water, urine

– Stool pH (<6 suggests carbohydrate malabsorption)

– Fat content (48h or 72h quantitative or Sudan stain)

>7gm/9% of fat intake for 24 hrs= steatorrhoea

CHRONIC OSMOTIC DIARRHEA

• CLUES:

Osmotic gap >100

Stool volume: decreases with fasting

Bloating

Stool analysis: stool pH(low)

laxative screen(Mg)

• CARBOHYDRATE MALABSORPTION

Dietary review

Breath hydrogen test using lactose, mucosal

lactase assay

Therapeutic trial: elimination diet

CHRONIC SECRETORY DIARRHEA

• CLUES:

Large volume(>1 litre)

Little change with fasting (except bile salt diarrhea)

Normal osmotic gap

Further approach

• stool culture

• Microscopy for OPC

• Antigen testing

• CT/MRI of abdomen,pelvis

• Sigmoidoscopy/colonoscopy + mucosal biopsy

• Enteroscopy + mucosal biopsy & aspirate

• Capsule enteroscopy

• Selective testing

plasma peptides- gastrin, VIP

Urine autacoids & metabolites

Others – TSH, cortisol, SPEP, Ig

• Therapeutic trial

Bile acid binding agent

• 25% of all cases: undiagnosed

• Idiopathic secretory diarrhea

CHRONIC INFLAMMATORY DIARRHEA

• CLUES:

Fever

Hematochezia

Abdominal pain

Weight loss

Further approach

• Sigmoidoscopy or colonoscopy + mucosal biopsy

• CT/MRI – abdomen, pelvis

• Enteroscopy + mucosal biopsy

• Exclude infection : biopsy, serology, culture

(TB, parasite, virus)

CHRONIC FATTY DIARRHEA

• CLUES:

Weight loss

Fecal fat >7-10gm/24 hr

Anemia

Hypoalbuminemia

Vitamin deficiency

Further approach

• Exclude structural disease

CT abdomen, enteroscopy + small intestinal biopsy & aspirate

• Exclude bile acid deficiency

empiric trial of bile acid

duodenal aspirate for bile acid conc

• Exclude pancreatic exocrine deficiency

Pancreatic exocrine insufficiency

• Smaller stool volume, higher fat content

>9.5 gm fat/100 gm stool- pancreatic/biliarydysfunction

• Oil in stool

• Less hypocalcemia( w.r.t mucosal disaease)

• TESTS: therapeutic trial: pancreatic enzymes

stool elastase/chymotrypsin conc

secretin test

FACTITIOUS DIARRHEA

• Laxative abuse

• Munchausen’s syndrome

• Polle’s syndrome

• Addition of water, urine

• Treatment

counseling

MICROSCOPIC COLITIS

• Elderly female

• Normal colonoscopy

• two types – collagenous colitis and lymphocytic colitis

• Treatment:

Bismuth, mesalamine

Steroid, immunosuppressive

Anti TNF-α

BILE ACID INDUCED DIARRHEA

• Causes:

Chronic cholestatic liver disease

ileal resection

• Diagnosis:

1. Therapeutic trial

2. Measuring conjugated bile acid in

duodenal aspirate

Empiric therapy for chronic diarrhea

INDICATIONS:

• initial therapy prior to diagnostic testing

• diagnostic tests fail to confirm a diagnosis

• diagnosis established, but no specific treatment available or it fails to provide any benefit

American Gastroenterological Association (AGA) guidelines

Empiric therapy for chronic diarrhea

• Antibiotics

TREATMENT OF IBS-D

MAS – Indian persrpective

• Tropical sprue: broad spectrum antibiotic

folate, vit B12

• Coeliac disease: Gluten free diet

• Giardia infection: antibiotic

• Intestinal tuberculosis: ATD (9-12 months)

MEDICAL MANAGEMENT OF IBD

DRUGS FOR CHRONIC DIARRHEA IN AIDS

BOVINE COLOSTRUM

Cryptosporidium Nitazoxanide

Microsporidia Albendazole

Isospora TMP/SMX

CMV Ganciclovir/ Foscarnet

MAC Macrolide + Ethambutol

AIDS enteropathy

GI lymphoma

ART induced Crofelemer

TAKE HOME MESSAGES

• History, examination and assesment of stool characteristics : MOST IMPORTANT

• Stepwise approach for finding etiology

• Judicious application of empiric therapy

THANK YOU