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Chronic Diarrhea

Chronic Diarrhea. Presented by Dr. Rabeea Zaki. Essentials of Diagnosis. Diarrhea > 4 weeks Classification: Medications Osmotic Diarrhea Secretory Diarrhea Inflamatory Diarrhea Malabsorption conditiions Motility disorders Chronic Infections Systemic disorders.

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Chronic Diarrhea

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  1. Chronic Diarrhea Presented by Dr. RabeeaZaki

  2. Essentials of Diagnosis • Diarrhea > 4 weeks • Classification: • Medications • Osmotic Diarrhea • Secretory Diarrhea • Inflamatory Diarrhea • Malabsorptionconditiions • Motility disorders • Chronic Infections • Systemic disorders

  3. General Considerations • Medications: • Cholinesterase inhibitors • SSRI • ARBs • PPIs • NSAIDs • Metformin • Allopurinol • Orlistat

  4. General Considerations • Osmotic diarrhea: • Resolves during fasting • Secretory Diarrhea: • Little change in stool output during fasting • Increased intestinal secretion or decreased absorption

  5. General Considerations • Malabsorption disorders: • Small mucosal intestinal diseases • Intestinal resections • Lymphatic obstruction • Small intestinal bacterial overgrowth • Pancreatic insufficiency • Motility disorders: • Surgery • Systemic disorders

  6. General considerations • Chronic infections: • Giardiasis, Amebiasis • Immunocompromised patients susceptible to mycobacterium aviumintracellulare, microsporidia, cyptosporidum, cytomegalovirus, cyclospora • Chronic Systemic Conditions: • Thyroid disease, diabetes, collagen vascular disease • Alterations in motility or intestinal absorption

  7. Clinical Findings • Osmotic diarrheas: • Abdominal distension • Bloating • Flatulence • Secretory Diarrheas: • High volume (>1 L/day) watery diarrhea • Dehydration • Electrolyte imbalance

  8. Clinical Findings • Inflamatory Conditions: • Abdominal pain • Fever • Weight Loss • Hematochezia • Malabsorption Syndromes • Weight Loss • Osmotic Diarrhea • Steatorrhea • Nutritional Defeciencies

  9. Features of Malabsorption

  10. Differential Diagnosis • Common Causes: • IBS • Parasites • Caffeine • Laxative abuse • Osmotic causes: • Lactase defeciency • Medications: antacids, lactulose, sorbitol, olestra • Factitious: magnesium containing antacids or laxatives

  11. Differential Diagnosis • Secretory Diarrhea • Hormonal: ZE syndrome, Carcinoid, VIPoma,medullary thyroid carcinoma, adrenal insufficiency • Laxative abuse: cascara, senna • Medications • Inflamatory Bowel conditions: • IBD • Microscopic colitis • Cancer with obstruction and pseudodiarrhea • Radiation colitis

  12. Differential Diagnosis • Malabsorption • Small bowel: Celiac disease, whipple disease, tropical sprue, eosinophillicgstroenteritis, small bowel resectinCrohns disease • Lymphatic obstruction: Lymphoma, carcinoid, tuberculosis • Pancreatic insufficiency, Chronic pancreatitis, Cystic Fibrosis, Pancreatic Cancer • Bacterial overgrowth eg diabetes, • Reduced bile salts:ileal resection, chrons disease, post cholecystecomy

  13. Differential Diagnosis • Motility disorders • IBS • Postsurgical: vagotomy, partial gastrectomy, blind loop with bacterial overgrowth • Chronic Infections: • Parasites: Giardiasis, amebiasis, strongylodiasis • Systemic disorders: • Diabetes, Hyperthyroidsim, Scleroderma

  14. Diagnosis • Laboratory Tests: • Blood CP, Serum electrolytes, LFTs, Ca, Phosphorous, Albumin, TSH • INR, ESR, CRP • Serologic testing: Tissue transglutaminase antibodies and antiendomysial antibodies recommended for most patients with signs of malabsorption

  15. Diagnosis • Stool Studies: • Analyze stool sample for ova and parasites, electrolytes (osmotic gap), qualitative staining for fat, occult blood, leukocytes, lactoferrin • Leukocytes or lactoferrin: suggest IBD • Giardia and entemebahystolytica may be detected in wet mounts • Cryptosporidium and cyclospora are found with modified acid fast staining • Increased osmotic gap suggests osmotic diarrhea or malabsorption • Positive fecal fat stain suggests malabsorption disorder

  16. Diagnosis • 24 hour stool collection for weight and quantitative fecal fat • Stool weight < 200 g/ 24 hrsexcludes diarrhea and suggests some functional disorder like IBS • Stool weight > 200 g/24 hrs confirms diarrhea • Stool weight 1000-1500 g/ 24 hrs secretory diarrhea • Fecal fat > 10 g/24 hrs suggest malabsorption disorder

  17. Diagnosis • Suspected malabsorption: • obtain serum folate, B12, S.iron, Vitamin D, Vitamin A and PT • Suspected Secretory Diarrhea: • Obtain serum VIP (vipoma), chromogranin A (carcinoid), calcitonin (medullary thyroid carcinoma), gastrin (ZE syndrome), glucagon, urine 5-hydroxyindoleacetic acid (carcinoid)

  18. Diagnosis • Imaging Studies: • Abdominal CT: Pancreatitis, Pancreatic carcinoma, Neuroendocrine tumors • Small intestinal imaging with barium, ct and MRI: crohns disease, small bowel lymphoma, carcinoid and jejunal diverticula • Somatostatin receptor scintigraphy: Neuroendocrine tumours

  19. Diangosis • Diagnostic procedures: • Sigmoidoscopy, Colonoscopy with mucosal biopsy: IBD and melanosis coli • Upper endoscopy with small bowel biopsy: Celiac disease, whipple disease, AIDS related cryptosporidium, microsporidia and mycobacterium aviumintracellulare infection • Breath hydrogen test to diagnose bacterial overgrowth

  20. Treatment • Medications: • Loperamide (imodium): 4mg orally initially then 2 mg after each loose stool (Max 16 mg/d) • Diphenoxylate with atropine (Lomotil): 1 tablet three or four times daily as needed • Codein 15-60mg orally or tincure of opium helpful in chronic intractable diarrheas • Clonidine orally or clonidine patch is helpful in secreotry diarrheas, diabetic diarrhea and cryptosporidiasis

  21. Treatment • Medications: • Octreotide 50 mcg to 250mcg three times daily subcutaenously is helpful in case of secreotry diarrheas due to neuroendocrine tumours and AIDS related diarrheas • Cholestyramine Resin: may be given orally in case of bile salt induced diarrhea secondary to intestinal resection or ileal disease • Therapeutic Procedures: • Consider discontinuing medications causing diarrhea

  22. Outcome • Complications: • Dehydration • Electrolyte Imbalance • Malabsorption, Weight Loss and vitamin defeciencies

  23. Questions • Features of Malabsorption include all of the following except • Steatorrhea • Secretory Diarrhea • Peipheral Neuropathy • Acrodermatitisenteropathica

  24. Answer • 2. Secreotry Diarrhea

  25. Question • Which of the following statement is true? • Stool weight 1000-1500 suggest inflamatory diarrhea • Stool weight > 200 confirms secretry diarrhea • Stool weight < 200 excludes diarrhea • Fecal fat < 10 g/d suggests malabsorption disorder

  26. Answer • 3. Stool weight < 200 excludes diarrhea

  27. Take Home Message • Chronic diarrhea lasts more than 4 weeks. • Has wide range of causes. • Common Causes are IBS, parasites, Caffeine and Laxative abuse • Careful assessment and detection of the underlying cause is needed to prevent serious sequele.

  28. Thank You

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