surawicz sun 2a with basic slide - american college of...
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Chronic Diarrhea
Christina Surawicz, MD, MACGProfessor of Medicine
University of Washington
Annual ACG Postgraduate CourseOct 30, 2011Oct. 30, 2011
Diagnostic Approach to Chronic Diarrhea
●Bloody
●Fatty
●Watery
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Diarrhea with Blood → Coli s Infection IBD Ischemia Ischemia Some drugsNSAIDS Isotretinoin
SCAD – Segmental Colitis Associated with Di ti l DiDiverticular Disease
Radiation Diversion colitis
Infection Uncommon
Stool Culture O + PSalmonella ∙ ParasitesCampylobacter • AmebaYersinia • TrichurisAeromonasPlesiomonas C. difficile (recurrent)
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Chronic Bloody Diarrhea: Work – up
Colonoscopy/biopsy= helpful to
distinguish IBD vs. infection
Colorectal Biopsy
IBD Infectionh b l lArchitecture Abnormal Normal
Inflammation Acute & Chronic Acute
Basal inflammation Yes None
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Normal Colon
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Chronic Bloody Diarrhea
History + exam History + exam
Stool cultures, O + P, in some
Colonoscopy and colorectal biopsy -py p ymainstay of diagnosis
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Steatorrhea – Clinical Clues Dietary history – intake compared to others
W i ht l Weight loss Stools –Not always diarrhea, may be bulkyHard to flushOily droplets floating on toilet
( )water (unhydrolyzed TG)
Steatorrhea – Vitamin Malabsorption
Fat soluble vitamins D A K EFat soluble vitamins D A K E
D - OsteomalaciaA - Night blindnessK - Easy bruisabilityK Easy bruisability
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Fecal Fat Analysis Qualitative I start with this I start with thisCan be subjective - variable lab personnelNormal is less than 20 drops/ hpf
Quantitative – 24 hr on 100 gm fat dietW i hWeight < 200 – 300 gm
Fat < 7 gm / 24 hr
Stool Fat Tests – Caveats High carbohydrate diet – increases stool weight
to 300 – 400 gms3 4 g Voluminous stools will raise fat excretion (up to
14 g/24 hour) Correct for fat intake - low fat diets False positives - Olestra, Brazil nuts Panc biliary source Panc – biliary source
> 9.5 gm / 100 gm stool∙ A guide – not 100%
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Steatorrhea
Luminal Mucosal
Pancreatic insufficiency ∙ Celiac sprue Bile salt deficiency ∙ Crohn’s disease Bacterial overgrowthBacterial overgrowth
Luminal - Pancreatic Insufficiency∙Direct function test: secretin test is a
research toolresearch tool
∙ Indirect tests ∙Serum trypsin∙Fecal chymotrypsin∙Fecal elastase
∙All have poor sensitivity/specificity
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Fecal Elastase 1 (FE1) 6% of pancreatic enzymes Abnormal: < 200 μg/gram stoolAbnormal: < 200 μg/gram stool But abnormal in many other conditionsCeliac disease IBD IBS
HIVHIV Diabetes
(Leeds et al, Nature Rev Gastro Hep 2011)
Pancreatic Insufficiency
Empiric trial of enzymes – reasonableEmpiric trial of enzymes reasonable• High dose – monitor wt gain or fecal fat• If respond, image pancreas
Another option is to rule out mucosal disease Another option is to rule out mucosal disease first
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Luminal - Bile Salt Deficiency
● Secondary- Cirrhosis, including PSC and PBC- Ileal disease or resection
< 100 cm - watery diarrhea> 100 cm - fatty diarrhea
● Primary- Primary bile salt deficiency, ususally
a watery diarrhea
Luminal - Small Intestinal Bacterial Overgrowth (SIBO)
Structural causes SI diverticulosis SI diverticulosis Stricture Surgical diversions
Dysmotility Scleroderma Intestinal pseudo-obstruction
Others ? Diabetes IBS Acid suppression
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SIBO Diagnosis• Clue:
• High folate - bacteria produceg p• Low B12 – bacteria consume
• SB aspirate – difficult to get accurate specimen
• Breath tests – not great
• Therapeutic trial of antibiotic – probably best
Mucosal - Celiac Disease
• Diarrhea • Infertilit and• Diarrhea • Infertility and recurrent fetal loss
• Weight Loss • Microscopic colitis
• Iron deficiency • Abnormal liver enzymesy y
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Celiac Diagnosis Antibody tests - On gluten
- IgA tTG or EmA and Serum IgA (2-3 % of sprue patients are IgA deficient) - tTG preferred- Not antigliadin ab
Small bowel biopsy +Response to therapy
Genotype-HLADQ2, DQ8Rules out if negativeCan use if mild sx, neg serology and borderline biopsy
Malabsorption - think about… Parasites Giardia Cryptosporidia Cyclospora
Post gastric surgery
Chronic mesenteric ischemia
Radiation
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Malabsorption - Uncommon Small Intestinal Diseases
CausesCollagenous sprueCollagenous sprueWhipple’s diseaseEosinophilic enteritis LymphomaAmyloid
Diagnosis DiagnosisRadiologic imagingCapsule studyDBE for biopsy
Watery Diarrhea If Not Bloody and
Not Steatorrhea,
It’s Watery . . .
All the rest
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Watery Diarrhea – Medical History
Diabetes, other diseases Surgery – gall bladder, stomach, intestineg y g , , Family history Celiac IBD
Sexual history Infections HIV
Travel History – Traveler’s diarrhea High risk areas
Watery Diarrhea – History • Medications
% f ll d id ff i ll• 7% of all drug side effects especially “new” ones
• Antimicrobials• PPIs (lansoprazole)• NSAIDS, 5-ASAs
SSRIs• SSRIs• Psycholeptics• Allopurinol
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Watery Diarrhea - Diet
AlcoholDairyNutritional supplementsOTC drugsHerbals Fructose and sorbitol – osmotic diarrhea
Watery Diarrhea -Diabetes
Visceral autonomic neuropathyVisceral autonomic neuropathy Bacterial overgrowth Celiac sprue Pancreatic insufficiency Unabsorbed CHO (Sugarless g
sweets)
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Watery Diarrhea - Post Cholecystectomy Diarrhea
Incidence 20%Incidence 20% Can be delayed Rarely severe Low bile acid absorption in TI at night Rx – bile acid bindersRx bile acid binders
Watery Diarrhea - Mucosal Disease
Colon ColonCrohn’sMicroscopic colitisColon cancer
Small bowel diseases Small bowel diseases Previously Mentioned
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Watery Diarrhea – Initial Evaluation
History + Exam
Initial labsCBCChemistries (total protein, albumin)Thyroid tests
C li lCeliac serologyESR/CRP Stool FOBT
Watery Diarrhea - Infections
Stool culture low yield
If only several months, considerParasitesAmebaGiardiaCryptosporidia, Cyclospora Blastocystis hominis (?)Candida (?)
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Watery Diarrhea – Infections (Cont’d)
Stool culture low yieldy
Bacteria SalmonellaAeromonas Plesimonas PlesimonasC. difficile (recurrent)
Watery Diarrhea – Evaluation
Colonoscopy + biopsyColonoscopy + biopsyCrohn’s
Microscopic colitis
Colon cancer
EGD + duodenal biopsy
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Chronic Diarrhea – Yield of Biopsy at Colonoscopy
Series vary: 10—20%Series vary: 10 20%Most commonly:
IBDMicroscopic ColitisPseudomelanosis coliPseudomelanosis coliSpirochetosis
Probably Shouldn’t Biopsy Normal Cecum
Cecal and rectal biopsy in 85 healthy adultsCecal and rectal biopsy in 85 healthy adults
Cecal biopsies had increased microscopic inflammation, abnormal architecture and cryptitis compared to rectal biopsies
Paski et al, Amer J Gastroenterol 2007
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When to Biopsy TI
Chronic diarrhea and right lower quadrantChronic diarrhea and right lower quadrant pain are the best indications to biopsy normal TI
Still yield low 1 – 2 %
Factitious Diarrhea
Surreptitous laxatives
Eating disorders
Secondary gain
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Watery Diarrhea
If work-up negative so far,Consider other stool tests
Fecal fatLaxative screen
O tiOsmotic gap
Stool Osmotic Gap
Normal 290 - 2 (Na+K)
Secretory < 50Osmotic > 125Contamination > 375
Lab will not do test on solid stool, so can use to confirm diarrhea
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Secretory DiarrheaContinues with fast
∙ Hormonal:Hormonal: ZE - GastrinVIP - VIPCarcinoid - 5HIAA (24 hr urine)Medullary Ca - CalcitoninThyroidThyroid
∙ Idiopathic secretory diarrhea
Idiopathic Secretory DiarrheaOften sudden onset
Up to 20 pound weight loss, then stablep p g ,Lasts 2 years
1. EpidemicContaminated food or water“Brainerd” diarrhea (Minnesota)( )
2. SporadicTravel to local lakes or otherNo one else sick
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Other Diagnostic Tests Abdominal CT / SB x-rays
Capsule
Enteroscopy/double balloon enteroscopy
When I am stumped . . . I Take More History
Diarrhea onset
After Infectious gastroenteritisPI – IBS
After GI tract surgeryAfter GI tract surgeryPost-cholecystectomyPost anti reflux surgery
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When I am stumped . . . ITake More History
Family history
Example: Celiac disease in 65 yo with sent for evaluation of recurrent C. difficile
When I am stumped . . . I MayRedo an Important Study
Pancreatic insufficiency – a womanPancreatic insufficiency a woman with steatorrhea and poor response to enzymes, had a normal CT + EUS
A repeat CT showed pancreatic atrophyA repeat CT showed pancreatic atrophy
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When I am stumped . . . I MayOrder a Special Study
A woman with protein losing enteropathyA woman with protein losing enteropathy,
Extensive evaluation negative except diffuse edema of small intestine
? Sli ht ↑ i hil i d d l b ? Slight ↑ eosinophils in duodenal bx
DBE → eosinophilic enteritis
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When I am stumped . . .Empiric Trials
Cholestyramine
Pancreatic enzymes
A ibi iAntibiotics
Antimotility agents
Case – 63 y o Woman
6 months watery diarrheaOnset after trip to MissouriLarge volume, 6 – 7/day even fastingNo abdominal painPrerenal azotemia twiceIV fluid dependentu d depe de t20 lb wt loss, now stableSounds secretory
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Normal w/u
Stool culture, O + P,Celiac antibodiesEGD + BxColon + BxAbdominal CT scan
Her 24 HR Stool980 gm – on a “good” day
f t (d d b hi h l )12 gm fat (dragged by high volume)Laxative screen normalNa 119, K 17 Osmotic gap 290 -2 (119 + 17) = 3
l l t d i b tt th dcalculated is better than measured osmsThus, secretory diarrhea
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Secretory Diarrhea
- Infection – R/O’d
- Mucosal – R/O’d
- Iatrogenic – R/O’d
- Hormonal ?
Evaluation
• VIP – nl VIP level
• ZE – nl gastrin off PPI
• Carcinoid – nl 24 hr urine 5HIAA
• Medullary Carcinoma Thyroid – nlcalcitonin
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Evaluation
G d l i tGradual improvement over 3 mos
Dx: Sporadic Idiopathic secretory diarrhea
Summary1. History, + stool characteristics & initial labs
will guide w/ug2. Reasonable w/u will diagnose most
Check Diet/medsExclude infectionEndoscopy and Biopsy
– upper & lower3. If normal further w/u to include therapeutic
trials4. Uncommon causes are uncommon
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