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Diarrhea

Diarrhea. Chronic. Sub-Acute. Acute. < 14 days. > 14 days and <4 weeks. > 4 weeks. >3 times in 24h or >1 L in 24h. >3 times in 24h. Unusually soft or liquid. A quick word about acute diarrhea.

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Diarrhea

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  1. Diarrhea Chronic Sub-Acute Acute < 14 days > 14 days and <4 weeks > 4 weeks >3 times in 24h or >1 L in 24h >3 times in 24h Unusually soft or liquid

  2. A quick word about acute diarrhea Generally doesn’t require extensive work up, history (including social and travel) usually gives you an answer Generally only supportive care required Reasons for more intensive investigation: Dysentery >6 stools/day Fever >38.5 without improvement in 48h Immunocompromise Recent hospitalization or antibiotic use

  3. Chronic Diarrhea Watery Inflammatory Osmotic Fatty Secretory

  4. Fatty Steatorrhea Malabsorption Maldigestion Certain gastric surgeries Cirrhosis Cystic fibrosis Bacterial overgrowth Whipple disease Tropical sprue Short bowel syndrome Certain drugs Pancreatic exocrine insufficiency *Stool fat studies (quantitatively timed or qualitatively with Sudan stain), stool chymotrypsin (secretin confirms pancreatic insufficiency)

  5. Inflammatory Frequent small volume stools Crohn’s and UC C.diff Blood +/- mucous or pus Invasive bacterial (Yersinia) and parasitic (Entamoeba histolytica) infections +/- tenesmus Leukocytosis, elevated ESR, possible + fecal calprotectin and leukocytes Colon cancer, lymphoma, radiation colitis

  6. Watery Osmotic Secretory Fecal osmotic gap = 290-2x[stool sodium + stool potassium] >125mOsm/kg <50mOsm/kg Loss of water and electrolytes; causes lead to increased secretion activity in the lumen Poor absorption of osmotic substances leading to water transfer to small intestines Often related to food intake Often nocturnal Unrelated to food intake

  7. Watery Osmotic Secretory Carbohydrate malabsorption Sugar malabsorption (lactose and sucrose) Celiac’s Drugs Sugar alcohols (“sugar free” foods and drinks, certain gums) Bacterial enterotoxins Endocrine disorders Medications Alcohol abuse Neuroendocrine tumors Vasculitis Microscopic colitis

  8. Secretory Diarrhea Continues despite fasting Associated with stool volumes > 1L/day Osmotic gap < 50 mOsm/kg Excess hormone production Other causes Infectious causes Drugs and toxins

  9. Secretory Diarrhea Excess hormone production Infectious causes Drugs and toxins Vibrio cholerae Alcohol Hyperthyroidism Gastrinoma Aeromonas Non-osmotic laxatives (senna, docusate) Carcinoid tumors Brainerd diarrhea Antibiotics VIPoma Colchicine Mastocytosis* Other causes NSAIDs

  10. Carcinoid Syndrome • Symptoms: cutaneous flushing, venous telangiectasia, secretory diarrhea, and bronchospasm • Diagnosis: 24-hour urinary excretion of 5-HIAA  tumor localization and staging

  11. Neuroendocrine Tumors: Summary

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