Approach to a case of chronic diarrhea.pptx

A CLINICAL GUIDE FOR PHYSICIANS RESIDENTS, AND UG STUDENTS FOR APPROACH TO CHRONIC DIARRHEA

1. Approach to a case of chronic diarrhea Dr AMMAR, JR3 Department of medicine KGMU

2. Basics principles. Classification of chronic diarrhea. Approach to a case of chronic diarrhea. Management. Complications. Outline:

3. Diarrhea : -passage of abnormally liquid, unformed stools, at an increased frequency(at least 3 times per 24 hrs). - stool weighing more than 200gm/ day . General principles:

4. Pseudo- diarrhea : -it signifies frequent passage of small volumes of stool, often associated with rectal urgency & feeling of incomplete evacuation. eg : IBS, proctitis . Fecal incontinence : involuntary discharge of rectal contents often associated with neuromascular disorders or structural anorectal problems.

5. Diarrhea classification based on duration : Diarrhea Acute < 2weeks Subacute(persistent) 2-4weeks Chronic > 4 weeks

6. Chronic diarrhea Secretory Osmotic Fatty Inflammatory Watery

7. Osmotic gap=290-2(Na+ K) Normal = 50-100mosm/kg Osmotic gap <50 Secretory diarrhea Osmotic diarrhea >100

8. Due to de-arrangements in fluids & electrolyte transport across the enterocolonic mucosa. They are characterised clinically by watery, large volume fecal outputs that are typically painless. It persists with fasting.(no malabsorbed solutes). 1. Secretory diarrhea:

9. Medications ( eg : laxatives, ethanol). Bowel resection, mucosal disease or enterocolic fistula( eg : ileal resection, bile acid mal-absorption). Hormones. Addison's disease. Causes of secretory diarrhea:

10. Peptide secreting tumours : (hormones) Carcinoid syndrome ( 5HIAA, Metanephrine ). ZE syndrome( Gastrin ). VIPoma : – resulting in watery diarrhea hypokalemia achlorhydria syndrome also known as “pancreatic cholera”. -stool volume is often > 3L/day. Secretory diarrhea :

11. It occurs when ingested, unabsorbable solutes , osmotically active solutes, draws enough fluid into the lumen to exceed the reabsorptive capacity of the colon. It ceases with fasting or after discontinuation of the causative agents. Osmotic diarrhea:

12. Osmotic laxatives, magnesium containing antacids. Carbohydrate malabsorptions ( lactase-deficiency). Wheat and FODMAP intolerance; ( Fermentable,Oligosaccharides,Disaccharides , Monosaccharides and Polyols ). Causes of osmotic diarrhea:

13. Fat malabsorption leads to greasy, foul smelly, difficult to flush diarrhea often associated with unintentional weight loss and nutritional deficiencies. Fecal fat excretion is usually < 14 gm/day. If fecal fat excretion is 15-25gm/day , it signifies small intestinal diseases. If it is more than 32gm/day, it signifies pancreatic insufficiency. Fatty/ Steatorrheal causes:

14. 1 ). Intra luminal maldigestion : most commonly from pancreatic exocrine insufficiency. Eg : -chronic pancreatitis, a sequel of ethanol abuse causes pancreatic insufficiency . 2.) Mucosal malabsortpion : most common cause is celiac disease, a gluten sensitive enteropathy . Tropical sprue , whipple’s disease . Causes of fatty diarrhea:

15. Lymphatic obstruction : it is cause due to secondary obstruction to trauma, tumour or infections leading to fat malabsorption.

16. The most common cause are: 1). Crohn’s disease: -Skip lesions from mouth to anus. - Perianal abscess & fistulas. -Frequently involved terminal ileum. 2). Ulcerative colitis: - Tenesmus , bloody stool. -Usually involves rectum and colon. Inflammatory causes:

17. Diagnosis are usually done by colonoscopy with biopsy. UC : pseudopolyps , continous areas of inflammation. Crohns : transmural inflammation, skip lesions.

18. Microscopic colitis : Mc middle to older aged women. History of drugs intake such as: NSAIDS, statins , PPI’s. Biopsy usually shows a normal histologic findings . But biopsy from the transverse colon confirms the diagnosis. Inflammatory causes:

19. Parasites: Giardia lamblia , Cyclospora. AIDS related: cytomegalovirus, HIV enteropathy . Bacterium: Clostridium difficile , Mycobacterium avium complex,Tuberculosis . Protozoal: Cryptosporidium, Cyclospora. Chronic infections:

20. Mostly associated with disruption of normal colonic microbiodata in association with antimicrobial used. Most commonly antimicrobials causing are: Clindamycin , ampicillin , cephalosporins ( 2 nd & 3 rd ) and fluoroquinolones . It can pseudomembranous colitis. Treatment is with oral vancomycin , metronidazole and fidaxomicin . It is the most commonly diagnosed diarrheal ilness acquired in the hospital. Clostridium difficle :

21. Hyperthyroidism and certain drugs ( eg : prokinetics ) can produce hypermotility with resultant diarrhea. Diabetic diarrhea, accompanied by peripheral & generalised autonomic neuropathies. IBS. Dysmotility causes:

22. Recurrent abdominal pain at least 1 day per week in the last 3 months. ( ROME IV criteria ). It also improved with defecation. Associated with change in stool frequency. Associated with changes in stool form. More common in women. Related to stress. Irritable bowel syndrome :

23. It accounts for upto 15% of unexplained diarrhea referred to tertiary care centres. Self administer laxatives alone or in combinations with other medications( eg : diuretics) Typically women with histories of psychiatric illness. Surreptitiously add water or urine to stool sent for analysis. They benefit from psychiatric counselling. Eg : Munchausen syndrome( self injuiry for secondary gain). Factitial causes:

24. Antibiotics. Anti retrovirals . Anti neoplastic agents. Antacids.( magnesium containing) Acid reducing agents( H2 blockers, PPI). Statins . Herbal products. Heavy metals. Medications and toxins associated with diarrhea:

25. HISTORY. Obtaining an accurate history is the critical first step in determining the etiology of a patient’s illness.

26. Onset : Abrupt: infections. Exposure to contaminated water : Giardiasis , cryptosporodiosis , Brainerd diarrhea. Weight loss : Mal-absorption, pancreatic exocrine insufficiency, neoplasm. Dietary history : lactase deficiency, fructose intolerance. Travel history : infectious diarrhea .

27. Previous treatment : Medications, radiation enteropathy,surgery . Systemic illness : Hyperthyroidism, IBD, diabetes. Abdominal pain : mesenteric vascular insufficiency, IBD, IBS. Excessive flatus/ bloating : carbohydrate malabsorption , small bowel bacterial overgrowth. IV drug user, sexual promiscuity : HIV infection. Institutionalized patients : medications, Clostridium difficile colitis.

28. Age : 1). Young patients : -Inflammatory bowel disease. -Tuberculosis. -Irritable bowel syndrome. 2). Older patients : -Colon cancer. - Diverticulitis. Diarrhea alternates with constipation : - colon cancer -laxatives abuse. -irritable bowel syndrome.

29. Water : chronic watery diarrhea. Blood, pus, or mucus : chronic inflammatory diarrhea. Foul, bulky, greasy stools : chronic fatty diarrhea. Stool characteristics:

30. Small bowel diarrhea: Large bowel diarrhea: Large stool volume Small amount of stool. Normal frequency. Markedly increased. No urgency Urgency. No tenesmus . Tenesmus present. No mucus. Mucus in the stool. No blood. Blood my be present . Weight loss present Usually no weight loss. Evaluation of the patients:

31. Past medical history : -Uncontrolled diabetes. -Pelvic radiotherapy. -Past surgical history. - Gastrectomy with vagotomy . -Bowel resection .

32. Are there general features to suggest malabsorption or inflammatory bowel disease( IBD) such as anemia , dermatitis herpetiformis , edema ? Is there an abdominal mass or tenderness?. Are there any abnormalities of rectal mucosa, rectal defects, or altered anal spincter function? Physical examination in patients with chronic diarrhea:

33. Are there any mucocutaneous manifestations of systemic disease such as : -dermatitis herpetiformis ( celiac disease). - erythema nodosum ( Ulcerative colitis). -flushing( carcinoid ). -oral ulcers for IBD( crohn’s disease) or in celiac disease?

34. Following investigations should take place for every patients with chronic diarrhea: Complete blood count with differential to examine infections and anemia. ESR & CRP for infections. Thyroid function for hyperthyroidism. Electrolytes abnormalities and renal function. Protein & albumin for protein malnutrition. Stool occult blood for GI bleed. Evaluation:

35. If the patient has any alarming symptoms, COLONOSCOPY is necessary. Alarming symptoms are : Age> 50. Rectal bleed. Progressive abdominal pain. Unintentional weight loss, fever. Laboratory abnormalities such as iron deficiency ,elevated CRP/ESR, elevated fecal calprotectin . First degree relatives with IBD or colorectal cancer.

36. Stool for ova, cyst. Stool electrolytes. Fecal calprotectin / fecal lactoferrin . Fecal chymotrypsin and elastase . Occult blood. Stool fat ( 48-72 hrs is ideal). If patient has recent antibiotics use, checking for C. difficile can be done. Stool assessment:

37. Treatment of chronic diarrhea depends on the specific etiology & may be curative, suppressive or empirical. For all patients with chronic diarrhea , fluids & electrolytes repletion is an important component of management. Replacement of nutrition, vitamins are also necessary. Treatment:

38. Curative treatment : - resection of colorectal cancer. -antibiotics for Whipple’s disease. -discontinuation of a drug. Suppressive treatment : -elimination of dietary lactose for lactase deficiency. -elimination of gluten for celiac sprue . -used of glucocorticosteroids for IBD’s. -bile acid sequestrants for bile acid malabsorption . -PPI’s for gastrinomas . - pancreatic enzyme replacement for pancreatic insufficiency.

39. Opioids : They decreased gut peristalsis. eg : - Loperamide ( μ receptor agonist). - Diphenoxylate also can be used. Clonidine : α 2 adrenergic agonist can be used in diabetic diarrhea ,but the used is limited due to its anti-hypertensive effects. Empirical therapy:

40. It vary ,based on the specific cause. In general, the main complication present for all patients with chronic diarrhea is malabsorption . Physicians should be always look for signs of malnutrition such as anemia , unintentional weight loss. Another complication can be dehydration and acute kidney injuiry from dehydration. Also, electrolytes abnormalities & vitamin deficiency should be checked& corrected. COMPLICATIONS:

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