AN APPROACH TO A AN APPROACH TO A PATIENT WITH CHRONIC PATIENT WITH CHRONIC

DIARRHEADIARRHEA

Dr Basharat HussainDr Basharat Hussain

HOUSE OFFICERHOUSE OFFICER

Dated:20Dated:20thth SEPT’06 SEPT’06

CHRONIC DIARRHEACHRONIC DIARRHEA

DIARRHEA: passage of abnormally liquid/ DIARRHEA: passage of abnormally liquid/ unformed stools at an increased frequencyunformed stools at an increased frequency

FOR ADULT Stool wt > 200g 1dayFOR ADULT Stool wt > 200g 1day

ACUTE DIARRHEA: If duration is < 2 wk.ACUTE DIARRHEA: If duration is < 2 wk.

PERSISTENT DIARRHEA: duration is < 2-4 PERSISTENT DIARRHEA: duration is < 2-4 wks.wks.

CHRONIC DIARRHEA: diarrhea lasting > 4 CHRONIC DIARRHEA: diarrhea lasting > 4 wks.wks.

PSEUDO DIARRHEA: frequent passage of PSEUDO DIARRHEA: frequent passage of small volumes of stool and is often associated small volumes of stool and is often associated with urgency and accompanies irritable bowl with urgency and accompanies irritable bowl syndrome/ proctitis.syndrome/ proctitis.

FECAL INCONTINANCE:FECAL INCONTINANCE:

It is involuntary discharge of rectal contents and most It is involuntary discharge of rectal contents and most often caused by neuromuscular disorders or often caused by neuromuscular disorders or structural anorectal sphincter problem.structural anorectal sphincter problem.

CLASSIFICATION OF CHRONIC CLASSIFICATION OF CHRONIC DIARRHEADIARRHEA

According to patho physiological mechanism.According to patho physiological mechanism.

1.1. Secretory Diarrhea.Secretory Diarrhea.

2.2. Osmotic Diarrhea.Osmotic Diarrhea.

3.3. Steatorrheal Diarrhea.Steatorrheal Diarrhea.

4.4. Dysmotility Diarrhea.Dysmotility Diarrhea.

5.5. Inflammatory Diarrhea.Inflammatory Diarrhea.

6.6. Factitial Diarrhea.Factitial Diarrhea.

SECRETORY DIARRHEASECRETORY DIARRHEAIt is due to derangement of fluid & electrolyte It is due to derangement of fluid & electrolyte

transport across mucosa.transport across mucosa.

It is characterized byIt is characterized by WateryWatery Large volume fecal output > 1 Ltr per day.Large volume fecal output > 1 Ltr per day. Painless Painless Persists with fastingPersists with fasting No fecal osmotic gapNo fecal osmotic gap

CAUSES ARE:CAUSES ARE: Laxative abuse.Laxative abuse. Chronic ethonol ingestion.Chronic ethonol ingestion. Drugs / toxins.Drugs / toxins. Idiopathic Secretory Diarrhea.Idiopathic Secretory Diarrhea. Bowl resection & Fistula.Bowl resection & Fistula. Carcinoid, Vipoma.Carcinoid, Vipoma. Congenital electrolyte absorption defect.Congenital electrolyte absorption defect.

OSMOTIC DIARRHEAOSMOTIC DIARRHEA

It occurs when ingested, poorly absorbable, It occurs when ingested, poorly absorbable, osmotically active solutes draw enough fluid osmotically active solutes draw enough fluid lumen wards.lumen wards.

It ceases with fasting.It ceases with fasting.

CAUSES ARE:CAUSES ARE: Osmotic laxatives.Osmotic laxatives. Lactase deficiencyLactase deficiency

STEATORRHEAL DIARRHEASTEATORRHEAL DIARRHEA

Steatorrhea is define as stool fat exceeding > Steatorrhea is define as stool fat exceeding > 7gm per day.7gm per day.

Fat malabsorption may lead to greasy foul Fat malabsorption may lead to greasy foul smelling, difficult to flush diarrhea.smelling, difficult to flush diarrhea.

It is offten associated with weight loss & It is offten associated with weight loss & nutritional deficiency due to malabsorption of nutritional deficiency due to malabsorption of A.A & vitamins.A.A & vitamins.

CAUSES ARE:CAUSES ARE: Intraluminan maldigation.Intraluminan maldigation. Mucosal malabsorption like Mucosal malabsorption like Coelic DiseaseCoelic Disease Tropical SpruTropical Spru Whipples DiseasesWhipples Diseases A beta lipoprotenemiaA beta lipoprotenemia

DYSMOTILITY DIARRHEADYSMOTILITY DIARRHEA Rapid transit may accompany diarrhea as a secondary Rapid transit may accompany diarrhea as a secondary

phenomenon.phenomenon. Primary dysmotility is unusual cause of true diarrhea.Primary dysmotility is unusual cause of true diarrhea.SECONDRY CAUSES ARE:SECONDRY CAUSES ARE: Visceral NeuromyopathiesVisceral Neuromyopathies Hyper ThyroidismHyper Thyroidism Prokinetic DrugsProkinetic Drugs Diabetic Diarrhea often accompanied by autonomic Diabetic Diarrhea often accompanied by autonomic

neuropathiesneuropathies IBSIBS

INFLAMMATORY DIARRHEAINFLAMMATORY DIARRHEA

Diarrhea accompanying fever, pain and bleeding.Diarrhea accompanying fever, pain and bleeding. Stool analysis show leukocytosis.Stool analysis show leukocytosis.

CAUSES ARE:CAUSES ARE: Ulcerative colitis.Ulcerative colitis. Crohn disease.Crohn disease. Microscopic colitis.Microscopic colitis. Collagenous colitis.Collagenous colitis. Eosinophilic gastritis.Eosinophilic gastritis.

CLINICAL APPROACHCLINICAL APPROACH

History, Physical Examination and routine blood History, Physical Examination and routine blood studies should attempt to characterize the studies should attempt to characterize the mechanism of diarrhea.mechanism of diarrhea.

Assess the patient fluid and electrolyte and Assess the patient fluid and electrolyte and nutritional status.nutritional status.

HISTROY & EXAMINATIONHISTROY & EXAMINATION Pt. should be questioned about on set duration, Pt. should be questioned about on set duration,

pattern, aggravating and relieving factors, pattern, aggravating and relieving factors, stool characteristics and extra intestinal stool characteristics and extra intestinal manifestation like skin changes, arthralgia.manifestation like skin changes, arthralgia.

GENERAL & SYSTEMIC EXAMINATION GENERAL & SYSTEMIC EXAMINATION TO DONE THOROUGLY.TO DONE THOROUGLY.

INVESTIGATIONSINVESTIGATIONS

1.1. PERIPHERAL BLOOD COUNTPERIPHERAL BLOOD COUNT Decreased Hb (blood loss).Decreased Hb (blood loss).

Leukocytosis (infections).Leukocytosis (infections).

Eosinophilia (parasitosis)Eosinophilia (parasitosis)

Raised ESR (inflammation, tumor).Raised ESR (inflammation, tumor).

INVESTIGATIONSINVESTIGATIONS Increased Urea (Dehydration)Increased Urea (Dehydration) Hypokalemia (Vipoma).Hypokalemia (Vipoma). Raised ALP (Liver Mets).Raised ALP (Liver Mets).2.2. STOOL CULTURE AND MICROSCOPY FOR STOOL CULTURE AND MICROSCOPY FOR

OVA AND CYSTOVA AND CYST3.3. PROCTOSIGMOIDOSCOPYPROCTOSIGMOIDOSCOPY All pts shold have a sigmoidoscopy and All pts shold have a sigmoidoscopy and

rectalbiopsy. It may show a pigmented mucosa rectalbiopsy. It may show a pigmented mucosa (Melanosis coli).Rectalbiopsy show pigment laden (Melanosis coli).Rectalbiopsy show pigment laden macrophag.macrophag.

INVESTIGATIONSINVESTIGATIONS

4.4. COLONOSCOPYCOLONOSCOPY All pts with chronic diarrhea and All pts with chronic diarrhea and

hematochezia should be evaluated stool hematochezia should be evaluated stool microbiologic studies and colonoscopy & microbiologic studies and colonoscopy & mucosal biopsy.mucosal biopsy.

5.5. SPECIFIC INVESTIGATONSSPECIFIC INVESTIGATONS TFT’sTFT’s Serum GastrinSerum Gastrin Serum CalcitoninSerum Calcitonin

Serum Vasoactive Intestinal peptideSerum Vasoactive Intestinal peptide Duodenal and jajunal biopsyDuodenal and jajunal biopsy Small bowl eneamiaSmall bowl eneamia ..

Ulcerative ColitisUlcerative ColitisCrohn DiseaseCrohn DiseaseColorectal CarcinomaColorectal Carcinoma

CHRONIC DIARRHEA WITH BLOODCHRONIC DIARRHEA WITH BLOOD

Stool CultureStool Culture Rectal BiopsyRectal Biopsy Colonoscopy & BiopsyColonoscopy & Biopsy

DIRRHEA WITHOUT BLOODDIRRHEA WITHOUT BLOOD

Stool cultureStool culture Rectal biopsyRectal biopsy

f abnormal f abnormal Do ColonoscopyDo Colonoscopy Shows UCIShows UCI PMCPMC

If Normal If Normal Barium eneamaBarium eneama SBFTSBFT Serum VIPSerum VIP TFT’sTFT’s 5 HIAA5 HIAA

If Melanosis coli If Melanosis coli Look for purgativeLook for purgative abuseabuse

DO DO BLOOD TESTBLOOD TEST

DECREASEDDECREASED HBHB DODO SBFTSBFT

INCREASED MCV INCREASED MCV LOW FOLATELOW FOLATE DODO JAJUNALJAJUNAL BIOPSYBIOPSY

IFIF NORMALNORMAL DODO USGUSG CTCT ERCPERCP

TREATMENTTREATMENT

TREATMENT OF UNDERLYING TREATMENT OF UNDERLYING CAUSECAUSE

… …..THANKS!!THANKS!!