CLINICAL APPROACH TO DIARRHEA. What kind of patients present in the opd. Algorithm to diagnose patients

Clinical approach to diarrhoea

1. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

2. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

3. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

4. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

5. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

6. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

7. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

8. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

9. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

10. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

11. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

12. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

13. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

14. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

15. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

16. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17

17. CLINICAL APPROACH TO
DIARRHEA
-Suyash (3872)
1
Objectives:
❏ To know the pathophysiology of Diarrhea
❏ To know the Clinical Classification of Diarrhea
❏ To know the etiology
❏ Etiology helps us to make a better Diagnosis
❏ And provide a Rational and Cost-effective Treatment
2
Loading…
Diarrhea
❏ Leading cause of Malnutrition among the children ( < 5 years).
❏ Passage of 3 or more loose/liquid stools ; or any frequency greater than what is
normal for the individual (WHO 2017)
❏ >200 g/day stool weight (For Westerners) - Harrison’s Principles of Internal Medicine
❏ Exceptions: Pseudodiarrhea, Fecal incontinence, Breastfeeding baby
3
Classification
❏ Acute (<2 weeks) [>90% causes are Infectious]
❏ Chronic (>4 weeks)
❏ Persistent (2-4 weeks)
4
Loading…
Pathophysiology Of Diarrhea
Possible sites:
❏ Small Intestine
❏ Colon (Ascending and Transverse Colon)
❏ Overflow Diarrhea * H/o Constipation
❏ Pancreas ??
❏ Liver and Bile duct ??
❏ Enteric nervous system
❏ Thyroid gland??
❏ CNS

80-90% Water absorption
(8-9L)
About 1 litre of fluid
reaches the colon (200 ml
excreted)
5
Etiology (Acute Diarrhea)
❏ May even be non-GI pathogens (Legionella pneumophila and SARS-CoV2)
❏ Special considerations include Immunocompromised patients.
❏ Infectious causes:
❏ Viral Gastroenteritis (Rota, Astro, Noro, CMV in IC patients)
❏ Viral Hepatitis (A and E are common)
❏ Bacterial causes (EPEC , EAEC, Campylobacter, Shigella, Salmonella, C. difficile, Listeria (Pregnant?)
❏ Toxin mediated (B. cereus, Staph aureus, C. perfringens, K. pneumoniae, ETEC, V. cholerae)
❏ Parasitic causes (Entamoeba histolytica, Giardia, Cyclospora, Cryptosporidium, Cytoisospora, Blastocytis
hominis, microsporidia
❏ Medications (NSAIDs, ARBs, Antibiotics,Anticancer), Poisons like Laxatives, OP, As.


6
Etiology (Chronic) - mostly non-infectious
❏ Secretory Diarrhea ( misnomer name, can even be because of less absorption i.e,
fast transit time)
❏ H/o alcoholism is important (Alcohol damages the intestinal mucosa)
❏ Any bowel surgery, fistulas
❏ Intake of any laxative or purgative (culture/abuse)
❏ Olmesartan (ARB intake)
❏ Other symptoms suggestive of tumours, Carcinoids (Bronchospasm), Gastrinomas
( peptic ulcers), VIPomas, mThyroidCa, Villous Adenoma
❏ Bile Acid Diarrhea (Idiopathic Bowel Diarrhea) [Endogenous laxative Diarrhea]

7
Etiology (Chronic)
❏ Osmotic : Non-absorbable osmotic solutes. Most common is lactose-intolerance in
our country.
❏ Usually resolves with fasting unlike Secretory (Excptn: BAD)
❏ Non-coeliac Gluten intolerance and FODMAP??
❏ Steatorrhea (>7 g fat/d): Difficult to flush stools, foul smelling, sticking to the
toilet seat.
❏ Pancreatic (>20g fat per day); Small intestinal (>14g), may be biliary (7-20 g/day)
❏ Celiac disease (app 1%), Tropical sprue, Whipple (Mid age men- Arthralgia, fever ,
lymphadenopathy), MAC, untreated Giardiasis, iatrogenic, genetic, idiopathic.
8
Etiology (Chronic)
❏ Enteric lymph obstruction : Fat malabsorption (PMLO)
❏ Inflammatory Bowel Disease (look for associated uveitis, mucosal ulcers, liver
cirrhosis and cholestatic liver disease)
❏ Enteric Nervous system (dysmotility): Hyperthyroidism, Carcinoids, IBS (10%
populn)
❏ Factitious disorder F68.1 (Look for Education status)
9
Clinical Presentation (History)
❏ Sociodemographics including age is very important
❏ History of onset and progression of symptoms is important
❏ Diurnal variations are significant (especially in case of IBS)
❏ Association with recent specific food intake, travel to a distant place should be ruled out.
❏ Patient’s immunocompromised status must be assessed.
❏ Everything should be interpreted on the background of Personal History (including normal bowel
and bladder habits, Alcohol intake)
❏ Family History is important to rule out a genetic cause, but also to rule out any recent pet exposure
(Salmonella)


10
Loading…
Clinical Presentation (History)
❏ Stools: Color, Consistency, Frequency, Blood or mucoid if present
❏ Specific food intake :Dairy food -Campylobacter and Salmonella species
● Eggs -Salmonella species
● Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
● Ground beef - Enterohemorrhagic E coli
● Poultry -Campylobacter species
● Pork -C perfringens, Y enterocolitica
● Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibriospecies, Hepatitis A/E
● Oysters - Calicivirus and Plesiomonas and Vibrio species
● Vegetables -Aeromonas species and C perfringens

11
Clinical Presentation (Examination)
❏ General Examination with vitals
❏ Check for capillary refill and skin turgor test to assess hydration status.




Local Examination (Abdomen):
Ausculataion : Try to differentiate between normal and hyperkinetic bowel sounds.
Don’t forget pr examination if blood in stools
12
Auscultation (Bowel Sounds) Listen for atleast 5 minutes if you can’t hear any
Normal Bowel Sounds
5–30 bowel sounds per minute (about 2
sounds every 5 seconds).

Abnormal Bowel Sounds
Hypoactive: less than 5 bowel sounds per
minute. (Causes?)
Borborhygmini:loud rumbling sounds due
to movement of air within the gut
Gurgling sounds: movement of gas and
fluid via peristalsis
Normal

Hyperactive: extremely increased bowel sounds
Gastroenteritis, laxatives, IBD, bowel obstruction

Hollow, high pitched tinkles: similar to rain on
a tin roof, due to liquid and gas under pressure within
dilated gut
Characteristic of small bowel obstruction

13
Workup?
❏ When would it be required?
❏ Stool Osmotic Gap? (Not usually done as bacteria in colon can ferment
carbohydrates too)
❏ Microbiological Confirmation of Organism (feasible?)
❏ Blood Tests (ESR/CRP, TTA-IgA, Electrolytes K+,Na+)
❏ Barium Swallow (obstruction? )
❏ Endoscopy (Invasive) Blood pr?
❏ Proper Psychiatric Evaluation (if necessary)
14
Treatment
Rational use necessary:
A 25-year-old male patient presents at the pharmacy demanding loperamide with complaints of diarrhoea
(approximately 5 times per day), abdominal pain and nausea for the past 3 to 4 days. He also complains of dry
mouth, abdominal cramping and overall malaise. He states that he recently travelled to Nagaland on an adventure
trip and has returned the day before.
A. Prescribe him loperamide
B. Refer for microbiological testing
C. Ensure him to take Oral Rehydration and take rest
Loperamide (ADRs)?

15
Treatment
❏ ORS remains the cornerstone for all therapy. Diarrhea actually is protective defense
of body. (Adults can consume as much as 1L per hour)
❏ Microbiological testing required: Do not give Antibiotics for C. perfringens
❏ And C. difficle (exception-children- Vancomycin /severe)
❏ Check Antibiotic susceptibility, Availability and Local Healthcare Policy.
❏ Microbial Stewardship.


16
THANK YOU
17