Chronic Diarrhea

• Abdul Waris Khan

• Soepel: 5th

• Dept: Internal medicine

SOEPEL• Subjective: a 44 years old female presented to ER

wit complains of loose stools for the past 1 month.

• H/O presenting illness: she complains of loose stools

for 1 month associated with blood in stools. She is a

known case of IBD

• Objective: appropritae history and P.E

• Evaluation: haemorrhoids, bleeding per rectum,

infective diarrhea, inflammatory diarrhea

• Plan: stool culture

• Elaporation: rehydration, antiobiotics if infective

cause and elemination of the cause.

Definition

Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency.

For adults on a typical Western diet, stool weight >200 g/d can generally be considered diarrheal.

Acute if <2 weeks

Persistent if 2–4 weeks

Chronic if >4 weeks in duration.

• In contrast to acute diarrhea, most of the

causes of chronic diarrhea are

noninfectious.

Slide TitleProduct B

• • Feature 1

• Feature 2

• Feature 3

• Secretory Causes:-o Due to derangements in fluid and electrolyte

transport across the enterocolonic mucosa.

• They are characterized clinically by watery, large-

volume fecal outputs that are typically painless and

persist with fasting.

o Medications (e.g, laxatives ,nsaids)

o Bowel Resection, Mucosal Disease, or Enterocolic Fistula (e,g. ileal resection,

bile acid mal absorbtion)

o Defects in Ion Absorption (addison’s disease)

• Osmotic Causes:-o occurs when ingested, poorly absorbable, osmotically active solutes draw

enough fluid into the lumen to exceed the reabsorptive capacity of the

colon. Osmotic diarrhea characteristically ceases with fasting or with

discontinuation of the causative agent.

o Osmotic Laxatives

o Carbohydrate Malabsorption (e,g. lactase deficiency)

• Steatorrheal Causes:-o Fat malabsorption may lead to greasy, foul-smelling, difficult-to-

flush diarrhea often associated with weight loss and nutritional

deficiencies due to concomitant malabsorption of amino acids

and vitamins.

o Intraluminal maldigestion

o Mucosal malabsorption (celiac disease)

o Lymphatic obstruction

• Inflammatory Causes:-o Inflammatory diarrheas are generally accompanied by pain,

fever, bleeding, or other manifestations of inflammation.

o Depending on lesion site, may include fat malabsorption,

disrupted fluid/electrolyte absorption, and hypersecretion or

hypermotility from release of cytokines and other inflammatory

mediators.

o The unifying feature on stool analysis is the presence of leukocytes

or leukocyte-derived proteins such as calprotectin.

o Inflammatory Bowel Disease

• Dysmotility Causes:-

• IBS, hyperthyroidism, carcinoid syndrome,

and certain drugs (e.g., prokinetic agents)

may produce hypermotility with resultant

diarrhea.

• Factitial Causes:-o Factitial diarrhea accounts for up to 15% of

unexplained diarrheas referred to tertiary care

centers.

o Munchausen syndrome

Approach to the Patientwith Chronic Diarrhea

• The history, physical examination and routine blood studies should attempt to characterize the mechanism of diarrhea.

• Patients should be questioned about the onset, duration, pattern, aggravating (especially diet) and relieving factors, and stool characteristics of their diarrhea.

• The presence or absence of fecal incontinence, fever, weight loss, pain, and common extraintestinalmanifestations (skin changes, arthralgias, oral aphthous ulcers) should be noted. E,g in IBD

• Peripheral blood leukocytosis, elevated

sedimentation rate, or C-reactive protein suggests

inflammation

• Anemia reflects blood loss or nutritional deficiencies

• Blood chemistries may demonstrate electrolyte,

hepatic, or other metabolic disturbances

• Measuring tissue transglutaminase antibodies may

help detect celiac disease

Management • Treat causes.

• Rehydration

• If severely dehydrated, give 0.9% saline + 20mmol K+/L IVI.

• Codeine phosphate or loperamide reduces stool frequency.

• If dehydrated and bloody diarrhea for >2 weeks administer IV fluids as well.

• Avoid antibiotics except in infective causes, as this can cause antibiotic resistance.

References Harrison internal medicine

Kumar and cark clinical emdicine

Oxford handbook of clinical medicine