1. Approach to patients with Diarrhea
Abdullah Alyouzbaki
Gastroenterologist and hepatologist
4/10/2016

2. Definition of Diarrhea
Three or more stool motion/Day
Loose –watery stool
Stool weight >200 g

3. Mechanism of Diarrhea

4. Clue for diagnosis Small bowel versus large bowel
Acute versus chronic
Small bowel versus large bowel
Osmotic versus secretary
Inflammatory versus fatty versus secretory

5. Clue for diagnosis

6. Clue for diagnosis fecal osmotic gap=290-2(Na+k)
A fecal osmotic gap of >50 mosm/kg is suggestive of an osmotic diarrhea and a gap of >100 mosm/kg is more specific.

7. Clue for diagnosis

9. Evaluation of Patient with Diarrhea
History
Duration :acute diarrhea (<4 weeks’ duration)
Frequency and volume .
Dehydration or volume depletion.
Stool characteristics.
Relationship of defecation to meals or fasting.
Day versus night.
Fecal urgency or incontinence.

10. Evaluation of Patient with Diarrhea
History
previous surgery, medications, or radiation therapy.
Epidemiological clues.

12. Physical Examination severity of diarrhea and its cause.
bowel sounds, abdominal distention and tenderness.
skin changes, Thyroid nodules, right-sided heart murmur, Arthritis ,Lymphadenopathy ….etc.

15. Further Evaluation of Acute Diarrhea
Infectious?
complete blood count
serum electrolyte concentrations, blood urea nitrogen, and serum creatinine level.
stool sample
fecal lactoferrin or calprotectin levels.
stool cultures .
ELISA testing for giardiasis and serological testing for amebiasis
stool sample for C. difficile toxin.
Proctoscopy , flexible sigmoidoscopy , colonoscopy.

17. Further Evaluation of Chronic Diarrhea

21. Evaluation of Chronic Inflammatory Diarrhea
Mucosal disruption and inflammation (white blood cells or blood in stools) are classified as having inflammatory diarrhea.
Diagnostic considerations include IBD, infections, ischemia, radiation enteritis, and neoplasia.
Colonoscopy ( with T.ileum intubation)should be considered.
Infection needs to be considered as C. difficile, cytomegalovirus, amebiasis, and tuberculosis.

22. Evaluation of Chronic Inflammatory Diarrhea

23. Evaluation of Chronic Fatty Diarrhea
24 hrs. fecal fat of 7–14 g provided that daily fat intake of 100g is consider abnormal.
Sudan stain of a fecal smear.

24. Treatment of Diarrhea
The most important therapy is replacement of any fluid and electrolyte deficits.
Empirical Therapy of Acute Diarrhea:
Antidiarrheal agents Opiates such as loperamide or diphenoxylate with atropine.
Antibiotics or antiprotozoal

25. Empirical Therapy of Chronic Diarrhea
Empirical antibiotic therapy generally is less useful than in acute diarrhea.
Potent antidiarrheal opiates, such as codeine, opium, or morphine.
Therapeutic trials of bile acid-binding resins in idiopathic secretory diarrhea .
Pancreatic enzyme replacement in unexplained steatorrhea have been discussed previously.
Octreotide, a somatostatin analog, is of proven value in the treatment of some forms of diarrhea