1. APPROACH TO A PATIENT WITH CHRONIC DIARRHOEA DR. SHIRIN MIRZA HOUSE PHYSICIAN MEDICAL UNIT-I, HFH

2. DEFINITION ► Traditionally, diarrhea has been defined as an increase in daily stool weight (> 200 g/day). --- impractical ► Diarrhea can be considered an increase in stool frequency (3 or more stools/day) and/or the presence of loose or liquid stools.

3. CLASSIFICATION ► Acute diarrhea ► Chronic diarrhea ► 4 weeks– cut off point

4. CAUSES ► Chronic Fatty Diarrhea – malabsorption syndromes Chronic Fatty Diarrhea Chronic Fatty Diarrhea ► Chronic Inflammatory Diarrhea Chronic Inflammatory Diarrhea Chronic Inflammatory Diarrhea ► Chronic Watery Diarrhea Chronic Watery Diarrhea Chronic Watery Diarrhea  Secretory Diarrhea Secretory Diarrhea Secretory Diarrhea  Osmotic Diarrhea Osmotic Diarrhea Osmotic Diarrhea  Drug-Induced Diarrhea Drug-Induced Diarrhea Drug-Induced Diarrhea

5. ► Infectious Diarrhea Infectious Diarrhea Infectious Diarrhea ► Endocrine diarrhea ► Functional Diarrhea (diagnosis of exclusion) Diarrhea  Irritable Bowel Syndrome Irritable Bowel Syndrome Irritable Bowel Syndrome

6. HISTORY

7. AGE ► Young patients  Inflammatory Bowel Disease Inflammatory Bowel Disease Inflammatory Bowel Disease  Tuberculosis Tuberculosis  Functional bowel disorder (Irritable bowel) ► Older patients  Colon Cancer Colon Cancer Colon Cancer  Diverticulitis Diverticulitis

8. DIARRHEA PATTERN ► Diarrhea alternates with Constipation DiarrheaConstipation DiarrheaConstipation  Colon Cancer Colon Cancer Colon Cancer  Laxative abuse Laxative  Diverticulitis Diverticulitis  Functional bowel disorder (Irritable bowel)

9. ► Intermittent Diarrhea Diarrhea  Diverticulitis Diverticulitis  Functional bowel disorder (Irritable bowel)  Malabsorption

10. ► Persistent Diarrhea Diarrhea  Inflammatory Bowel Disease Inflammatory Bowel Disease Inflammatory Bowel Disease  Laxative abuse Laxative

11. SMALL BOWEL/LARGE BOWEL ► Small intestine or proximal colon involved  Large stool Diarrhea Diarrhea  Abdominal cramping persists after Defecation Defecation ► Distal colon involved  Small stool Diarrhea Diarrhea  Abdominal cramping relieved by Defecation Defecation

12. DIURNAL VARIATION ► No relationship to time of day: Infectious Diarrhea Infectious DiarrheaInfectious Diarrhea ► Morning Diarrhea and after meals Diarrhea  Gastric cause  Functional bowel disorder (e.g. irritable bowel)  Inflammatory Bowel Disease Inflammatory Bowel Disease Inflammatory Bowel Disease ► Nocturnal Diarrhea (always organic) Diarrhea  Diabetic Neuropathy Diabetic Neuropathy Diabetic Neuropathy  Inflammatory Bowel Disease Inflammatory Bowel Disease Inflammatory Bowel Disease

13. WEIGHT LOSS ► Despite normal appetite  Hyperthyroidism Hyperthyroidism  Malabsorption ► Associated with fever  Inflammatory Bowel Disease Inflammatory Bowel Disease Inflammatory Bowel Disease ► Weight loss prior to Diarrhea onset Diarrhea  Pancreatic Cancer Pancreatic Cancer Pancreatic Cancer  Tuberculosis Tuberculosis  Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus  Hyperthyroidism Hyperthyroidism  Malabsorption

14. STOOL CHARACTERISTICS ► Water: Chronic Watery Diarrhea Chronic Watery DiarrheaChronic Watery Diarrhea ► Blood, pus or mucus: Chronic Inflammatory Diarrhea Chronic Inflammatory DiarrheaChronic Inflammatory Diarrhea ► Foul, bulky, greasy stools: Chronic Fatty Diarrhea Chronic Fatty DiarrheaChronic Fatty Diarrhea

15. MEDICATION AND DIETARY INTAKE ► drug induced diarrhea ► Food borne illness ► waterborne illness ► High fructose corn syrup ► Excessive sorbitol or mannitol ► Excessive coffee or other caffeine

16. TRAVEL ► Traveler’s diarrhea ► Infectious diarrhea

17. ASSOCIATED SYMPTOMS ► Abdominal pain ► Alternating constipation ► Tenesmus ► Unintentional wt. loss ► Fever

18. PAST MEDICAL HISTORY ► Childhood diarrhea-resolves-re-emergence in adulthood– celiac disease ► Uncontrolled diabetes ► Pelvic radiotherapy

19. PAST SURGICAL HISTORY ► Jejunoileal bypass ► Gastrectomy with vagotomy ► Bowel resection ► Cholecystectomy

20. RED FLAGS-suggestive of organic causes ► Painless diarrhea ► Recent onset in an older patient ► Nocturnal diarrhea (especially if wakes patient) ► Weight loss ► Blood in stool ► Large stool volumes: >400 grams stool per day ► Anemia ► Hypoalbuminemia ► increased ESR

21. PHYSICAL EXAMINATION

22. GPE ► General appearance and mental status ► Vital signs ► Body weight ► Orthostasis- volume depletion,autonomic dysfunction

23. ► exophthalmos (hyperthyroidism) ► aphthous ulcers (IBD and celiac disease) ► lymphadenopathy (malignancy, infection or Whipple's disease) ► enlarged or tender thyroid (thyroiditis, medullary carcinoma of the thyroid) ► clubbing (liver disease, IBD, laxative abuse, malignancy)

24. SKIN LESIONS ► dermatitis herpetiformis (celiac disease) ► erythema nodosum and pyoderma gangrenosum (IBD) ► hyperpigmentation (Addison's disease) ► flushing (carcinoid syndrome) ► migratory necrotizing erythema (glucagonoma).

25. ABDOMINAL EXAMINATION ► Surgical scars ► abdominal tenderness ► Masses ► Hepatosplenomegaly ► Borborygmus on auscultation  malabsorption  bacterial overgrowth  obstruction, or rapid intestinal transit.

26. PERINEAL AND RECTAL EXAMINATION ► Signs of incontinence –  skin changes from chronic irritation,  gaping anus,  weak sphincter tone. ► Crohn's disease  perianal skin tags  Ulcers  fissures  abscesses  Fistulas  stenoses. ► Fecal impaction or masses might be noted.

27. SYSTEMIC EXAMINATION ► wheezing and right-sided heart murmurs (carcinoid syndrome) ► arthritis (IBD, Whipple's disease)

28. INVESTIGATIONS

29. BLOOD TESTS ► CBC ► TSH ► Serum electrolytes ► Serum albumin

30. STOOL EVALUATION ► Stool pH (<6 in carbohydrate malabsorption ) ► Fecal electrolytes (Fecal sodium and osmolar gap)  Differentiates chronic watery diarrhea category ► Fecal occult blood test ► Fecal leukocytes

31. ► Fecal fat (abnormal if >14 grams/24 hours) ► Stool ova and parasites (2-3 samples) ► Giardia lamblia antigen  Indicated for diarrhea >7 days and >10 stools/day ► Clostridium difficle toxin  Indicated if recent antibiotics or hospitalization ► Consider testing stools for laxative abuse

32. ENDOSCOPY ► PROCTOSIGMOIDOSCOPY

33. TREATMENT

34. NON-SPECIFIC THERAPIES ► Dietary modifications  Smaller, more frequent meals  Dec. carbohydrates  Dec. fat intake  Avoidance of milk  Avoid sorbitol and mannitol

35. ► No good evidence to support use of bulking agents ► Bismuth subsalicylate (i.e., Pepto-Bismol ) ► opioids and opioid agonists  Loperamide- first line therapy  diphenoxylate-atropine (Lomotil )  Codeine and other narcotics – for refractory cases

36. SPECIFIC THERAPIES ► Clonidine-  Diabetic diarrhea  moderate and severe diarrhea-predominant IBS ► Somatostatin  refractory diarrhea ► AIDS, ► post chemotherapy, ► GVHD, ► and hormone secreting tumors.

37. ► bile acid binders (ie, cholestyramine) ► pancreatic enzyme supplementation ► antimicrobials –empiric fluoroquinolones therapy

38. Case Presentation: ► A 60-year-old woman ► diarrhea for the past 3 months ► denies nausea, vomiting, or fever ► Her appetite is poor. ► She initially attributed the diarrhea to travel, ► but her symptoms have not resolved over several weeks. ► traveled to Singapore prior to the onset of symptoms.

39. The most clinically useful definition of diarrhea for this patient would rely on: ► A- Symptom description ► A- Symptom description ► B-An increase in daily stool weight (> 200 g/day) ► B-An increase in daily stool weight (> 200 g/day) ► C-Laboratory tests ► C-Laboratory tests ► D-Report of loose or watery stools

40. How would you begin to diagnose this patient's complaint? ► A-History and physical examination ► B-History, physical examination, and laboratory studies ► C-History, physical examination, laboratory studies, and colonoscopy with biopsy ► D-History, physical examination, laboratory studies, and sigmoidoscopy with biopsy

41. How would you assess illness severity? ► A-Length of time since symptoms first appeared ► A-Length of time since symptoms first appeared ► B-Impact of diarrhea on daily function ► C-Physical examination ► D- Stool frequency

42. Initial empirical therapy of chronic diarrhea for this patient should include: ► A- Psyllium ► B-Bismuth subsalicylate ► B-Bismuth subsalicylate ► C-Loperamide ► D-Codeine ► D-Codeine

43. ROME II CRITERIA FOR IBS ► At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:  Relieved with defecation; and/or  Onset associated with a change in frequency of stool; and/or  Onset associated with a change in form (appearance) of stool

45. Evaluation of Patient There is a long list of investigations for the diagnostic of etiology of ch. diarrhea. SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA Large stool volume Small amount of stool Increased frequency with large volume stool Increased frequency with small volume stool No urgency urgency No tenesmus Tenesmus present No mucus Mucus in stool No blood Blood may be present Central abdominal pain Pain in left iliac fossa relived by defecation

47. THANX …