DiarrheaDiarrhea

DefinitionDefinition increase in the increase in the frequencyfrequency of of

bowel movementsbowel movements increase in increase in stool liquiditystool liquidity in some cases increase in daily in some cases increase in daily

stool weightstool weight (>200g/d) (>200g/d)

Pathophysiological mechanismsPathophysiological mechanisms

secretory diarrhea (increased intestinal sesecretory diarrhea (increased intestinal secretion)cretion)

Osmotic diarrheaOsmotic diarrhea Decreased intestinal surface area and/or iDecreased intestinal surface area and/or i

ntestinal absorptionntestinal absorption

Rapid transit of intestinal contents (shorteRapid transit of intestinal contents (shortened transit time)ned transit time)

Pathophysiological mechanismsPathophysiological mechanisms secretory diarrhea (increased intessecretory diarrhea (increased intes

tinal secretion)tinal secretion)

infections (cholera toxin, E-col, salmonella, staphylococcal) Hormonal (Gut Hormones, ZES, VIP), cancer (calcitonin, Prostaglandins) miscellaneous (laxatives abuse, villous adenoma of the rectum)

agents Adenylate cyclase

cAMP system

secretory diarrhea

active NaCl

Pathophysiological mechanisPathophysiological mechanismsms

Osmotic diarrheaOsmotic diarrheaIt caused by accumulation of the followings It caused by accumulation of the followings

in the gut lumen in the gut lumen

water

salts

poorly absorble solutes maldigestion of ingested food failure to transport an osmotically active dietary nonelectrolyte (E: glucose)

intestinal Lumen

being osmotically active

diarrhea

Causes of diarrhea in enteral nutrition

Pathophysiological mechaPathophysiological mechanismsnisms

Decreased intestinal surface areDecreased intestinal surface area and/or intestinal absorptiona and/or intestinal absorption

E: surgical removal; malabsorptioE: surgical removal; malabsorption syndromen syndrome

Pathophysiological mechanismsPathophysiological mechanisms Rapid transit of intestinal contents (shRapid transit of intestinal contents (sh

ortened transit time)ortened transit time)

E: irritable bowel syndrome [Functional diarrhea] laxatives abuse post vagotomy diarrhea post gastrectomy dumbing syndrome

stoolvolumeliquiditycontact time increase

small bowel mucosa

contents

increase in intestinal motility (intestinal hurry)

reduce

Calculation of osmotic gapCalculation of osmotic gap

EtiologyEtiology

Acute DiarrheaAcute Diarrhea infectioninfection Food poisoningFood poisoning Systematic diseases (influenza, sepsiSystematic diseases (influenza, sepsi

s, measle, etc)s, measle, etc) MiscellanousMiscellanous

EtiologyEtiologyAcute DiarrheaAcute Diarrhea

infectioninfection(A) viral (A) viral (B) bacterial(B) bacterial

campylobacteriacampylobacteria ShigellaShigella E. ColiE. Coli SalmoneilaSalmoneila etcetc

(C) fungal(C) fungal(D) parasitic (amebic Trophozoites, Giardia)(D) parasitic (amebic Trophozoites, Giardia)

Food poisoningFood poisoning bacterial, plants, chemical poison(arsenbacterial, plants, chemical poison(arsen

ic,...)ic,...) Systematic diseases (influenza, sepsiSystematic diseases (influenza, sepsi

s, measle, etc)s, measle, etc) MiscellanousMiscellanous

Allergic diseases Allergic diseases Allergic purpura, enteropathy..Allergic purpura, enteropathy..

endocronic diseases (ZES, etc.)endocronic diseases (ZES, etc.) Drugs: laxatives, 5-Fu, etc.Drugs: laxatives, 5-Fu, etc.

EtiologyEtiologyChronic DiarrheaChronic Diarrhea IntestinalIntestinal Gastric(chronic gastritis,subtotal gastrectoGastric(chronic gastritis,subtotal gastrecto

my , etc.)my , etc.) Pancreatic (Chronic Pancreatitis, PancreatiPancreatic (Chronic Pancreatitis, Pancreati

c Cancer, etc.)c Cancer, etc.) Hepatobiliary(liver cirrhosis, obstructive jHepatobiliary(liver cirrhosis, obstructive j

aundice)aundice) Endocronic (Hyperthyroids crisis, ZES, CarEndocronic (Hyperthyroids crisis, ZES, Car

cinoids) cinoids) Drugs (Reserpin, Ismelin, Laxatives, etc.)Drugs (Reserpin, Ismelin, Laxatives, etc.) Others (uremia, hypogammaglobulemia, etOthers (uremia, hypogammaglobulemia, et

c.)c.)

Chronic DiarrheaChronic Diarrhea

IntestinalIntestinal infections(T.B., Chronic bacteria dyseninfections(T.B., Chronic bacteria dysen

tery, etc.)tery, etc.) parasitics (Amebia dysentery, Giardiasiparasitics (Amebia dysentery, Giardiasi

s, etc.)s, etc.) IBD (ulcerative colitis, Chron’s, etc.)IBD (ulcerative colitis, Chron’s, etc.) malabsorption synd. (lactase deficiencmalabsorption synd. (lactase deficienc

y, etc.)y, etc.) tumorstumors

Mechanisms and causes of secretory Mechanisms and causes of secretory diarrheadiarrhea

TABLE 4 - 6. MECHANISMS AND CAUSES OF SECRETORY DIARRHEA

Reduction in mucosal surface area

Postresection diarrhea

Short - bowel syndrome

Extensive mucosal disease and Inflammation

Viral gastroenteritis

Celiac disease

Whipple's disease

Crohn's disease

Lymphoma

Absence of ion transport mechanism

Congenital chloridorrhea

Bacterial toxins

Cholera

Enterotoxigenic Escherichia coli

Shigella

Staphylococcus

Clostridium perfringens

Luminal secretagogues

Bile acids

Fatty acids, hydroxy - fatty acids

Phenolphthalein, ricinoleic acid, bisacodyl

Circulating secretagogues

Gastrin (Zollinger - Ellison syndrome)

Vasoactive intestinal polypeptide (VIPoma, ganglioneuroma, neuroblastoma, pheochromocytoma)

Calcitonin, prostaglandins (medullary carcinoma of the thyroid)

Somatostatin (somatostatinoma)

Glucagon (glucagonoma)

Serotonin, kinins (carcinoid tumor)

Thyroxine (hyperthyroidism)

Histamine (mastocytosis)

Drugs and poisons

Misoprostol

Olsalazine

Colchicine

Propranolol

Quinidine

Heavy metals

Abnormal circulation

Radiation enteritis

Mesenteric ischemia

Mesenteric venous thrombosis

Lymphangiectasia

Disordered regulation

Postvagotomy diarrhea

Postsympathectomy

Endoscopic image: infectious colitis in Endoscopic image: infectious colitis in 7-year-old girl7-year-old girl