1. Presented by Dr. Rabeea Zaki
Chronic Diarrhea
Presented by
Dr. Rabeea Zaki

2. Essentials of Diagnosis
Diarrhea > 4 weeks
Classification:
Medications
Osmotic Diarrhea
Secretory Diarrhea
Inflamatory Diarrhea
Malabsorption conditiions
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 avium intracellulare, microsporidia, cyptosporidum, cytomegalovirus, cyclospora
Chronic Systemic Conditions:
Thyroid disease, diabetes, collagen vascular disease
Alterations in motility or intestinal absorption

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

8. Clinical Findings Inflamatory Conditions: Malabsorption Syndromes
Abdominal pain
Fever
Weight Loss
Hematochezia
Malabsorption Syndromes
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, eosinophillic gstroenteritis, small bowel resectin Crohns 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 entemeba hystolytica 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 hrs excludes diarrhea and suggests some functional disorder like IBS
Stool weight > 200 g/24 hrs confirms diarrhea
Stool weight g/ 24 hrs secretory diarrhea
Fecal fat > 10 g/24 hrs suggest malabsorption disorder

17. Diagnosis Suspected malabsorption: Suspected Secretory Diarrhea:
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)

19. 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

20. 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 avium intracellulare infection
Breath hydrogen test to diagnose bacterial overgrowth

23. 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

24. Treatment Medications: Therapeutic Procedures:
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

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

26. Questions
Features of Malabsorption include all of the following except
Steatorrhea
Secretory Diarrhea
Peipheral Neuropathy
Acrodermatitis enteropathica

27. Answer
2. Secreotry Diarrhea

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

29. Answer
3. Stool weight < 200 excludes diarrhea

30. 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.

31. Thank You