Approach to a patient with

diarrhea
Dr. Mohamed Abu Hmaid
DIARRHEA
Diarrhea is a common symptom that
can range in severity from an acute,
self-limited complaint to a severe,
life-threatening illness. Patients may
use the term "diarrhea" to refer to
increased frequency of bowel
movements, increased stool liquidity,
a sense of fecal urgency, or fecal
incontinence
Definition
In the normal state, approximately 10 L of
fluid enter the duodenum daily, of which all
but 1.5 L are absorbed by the small
intestine. The colon absorbs most of the
remaining fluid, with only 100 mL lost in
the stool. diarrhea is defined as a stool
weight of more than 200 g/24 h
 Diarrhea can be considered an increase in
stool frequency (3 or more stools/day)
and/or the presence of loose or liquid stools
It is helpful to distinguish acute from
chronic diarrhea, as the evaluation and
treatment are entirely different
Mechanisms of Diarrhea
1) Osmotic load within the intestine resulting in
retention of water within the lumen
2) Excessive secretion of electrolytes and
water into the intestinal lumen
3) Exudation of fluid and protein from the
intestinal mucosa
4) Altered intestinal motility resulting in rapid
transit through the colon
Types of diarrhea
Watery diarrhea

-osmotic diarrhea
-secretory diarrhea
Inflammatory diarrhea
Fatty diarrhea
Types of watery diarrhea
Osmotic diarrhea
Osmotic contents
Response to fasting
St. osm > 280 mo/l
Stool Na > 100 mos
increase volume

Secretory diarrhea
Dec.Na.absorption
No response
St. osm < 280 mo/l
Stool Na < 100 mos
Very large volume
Osmotic Diarrhea
Occurs when poorly absorbed material
retains fluid within the intestinal lumen
Occurs in patients with malabsorption or
lactose intolerance in which undigested
sugars accumulate in the intestinal lumen
exerting a considerable osmotic load
Magnesium-containing laxatives and antacids
(Maalox) probably produce diarrhea through
a similar mechanism
Secretory Diarrhea
The intestinal mucosa secretes . amounts of water
and electrolytes under the stimulation of a variety of
substances
Cholera and enterotoxigenic E. coli
Bile acids and long chain fatty acids (postileal
resection, Crohn s disease, malabsorption
syndromes)
Gastrointestinal hormones (VIPoma, gastrinoma,
carcinoid)
Anthraquinone laxatives
Mechanism: Agents . intracellular cAMP.
.secretion (Na+K)+ ATPase is also inhibited)
inflammatory Diarrhea
Results from the outpouring of blood protein,
or mucus from an inflamed or ulcerated
mucosa
Ulcerative colitis
Crohn s disease
Invasive infections
Infiltrative disorders like Whipple s disease
Lymphoma
Motility Disorders
May or may not lead to diarrhea
Irritable bowel syndrome (IBS) a motor
disorder that causes abdominal pain and
altered bowel habits with diarrhea
predominating
Diabetes mellitus neurogenic dysfunction
Scleroderma stasis of the bowel with
resultant bacterial overgrowth, steatorrhea
and diarrhea
ACUTE DIARRHEA
Diarrhea that is acute in onset and
persists for less than 3 weeks is most
commonly caused by infectious agents,
bacterial toxins (either ingested
preformed in food or produced in the
gut), or drugs
Causes of acute infectious
diarrhea
Noninflammatory Diarrhea
1.Viral-Norwalk virus, Norwalk-like virus, Rotavirus
2.Protozoal-Giardia lamblia, Cryptosporidium
3.Bacterial-Preformed enterotoxin production

Staphylococcus aureus, Bacillus

cereus, Clostridium perfringens
Enterotoxin production; Enterotoxigenic E coli
(ETEC), Vibrio cholerae
Inflammatory Diarrhea
Viral Cytomegalovirus
Protozoal-Entamoeba histolytica
Bacterial-Cytotoxin production;
Enterohemorrhagic E coli, Vibrio
parahaemolyticus, Clostridium difficile.

Mucosal invasion; Shigella, Campylobacter jejuni

Salmonella, Enteroinvasive E coli ,Aeromonas
Plesiomonas,Yersinia enterocolitica,Chlamydia
Neisseria gonorrhoeae, Listeria monocytogenes
Causes of chronic diarrhea
Osmotic diarrhea

CLUES:Stool volume decreases with fasting;

increased stool osmotic gap
1. Medications: antacids, lactulose, sorbitol
2. Disaccharidase deficiency: lactose
intolerance
3. Factitious diarrhea: magnesium (antacids,
laxatives)
Secretory diarrhea
Large volume ( >1 L/d); little change with fasting;
normal stool osmotic gap

1. Hormonally mediated: VIPoma, carcinoid,

medullary carcinoma of thyroid (calcitonin),
Zollinger-Ellison syndrome (gastrin)
2. Factitious diarrhea (laxative abuse):
phenolphthalein, cascara, senna
3. Villous adenoma
4. Bile salt malabsorption (ileal resection; Crohn's
ileitis; postcholecystectomy)
5. Medications
Inflammatory conditions
Fever, hematochezia, abdominal pain

1. Ulcerative colitis
2. Crohn's disease
3. Microscopic colitis
4. Malignancy: lymphoma, adenocarcinoma
(with obstruction and pseudodiarrhea)
5. Radiation enteritis
Malabsorption syndromes
Weight loss, abnormal laboratory values; fecal fat
> 7-10 g/24 h,

1. tropical sprue,celiac disease, Whipple's disease,

eosinophilic gastroenteritis, Crohn's disease, small
bowel resection (short bowel syndrome)
2. Lymphatic obstruction: lymphoma, carcinoid,
infectious (TB, MAI), Kaposi's sarcoma,
sarcoidosis, retroperitoneal fibrosis
3. Pancreatic disease: chronic pancreatitis, pancreatic
carcinoma
4. Bacterial overgrowth: motility disorders (diabetes,
vagotomy, scleroderma), fistulas, small intestinal
diverticula
Motility disorders
Systemic disease or prior abdominal surgery

1. Postsurgical: vagotomy, partial

gastrectomy, blind loop with bacterial
overgrowth
2. Systemic disorders: scleroderma, diabetes
mellitus, hyperthyroidism
3. Irritable bowel syndrome
Chronic infections
Parasites: Giardia lamblia, Entamoeba
histolytica, Cyclospora
AIDS-related:
Viral: Cytomegalovirus, HIV infection (?)
Bacterial: Clostridium difficile,
Mycobacterium avium complex
Protozoal: Microsporida ,Cryptosporidium,
Isospora belli
 Recent ingestion of improperly stored or
prepared food implicates food poisoning,
especially if other people were similarly
affected. Exposure to unpurified water
(camping, swimming) may result in
infection with Giardia or Cryptosporidium
Patient presentation and history
Stool volumemay suggest the disease
location and underlying pathophysiologic
mechanism. For example, very-large-
volume stools (> 750 mL/day) imply small
bowel disease and secretory diarrhea.
Conversely, small-volume stools (< 350
mL/day) are typical of colonic diseases and
functional gastrointestinal disorders
 Stool consistencybroad spectrum from formed to
watery, and tends to correlate with the rate of
intestinal transit.
Secretory diarrheas are mostly liquidwhereas
functional diarrheas are typically soft or semi-
solid. Stool floats if it is filled with gas from
fermentation of malabsorbed carbohydrates.
Mucusis typical to both inflammatory and
noninflammatory diarrheas, such as ulcerative
colitis and IBS.
 Stool appearanceclassify diarrhea as watery,
bloody (inflammatory), or fatty (steatorrhea).
Watery diarrheais caused by various conditions,
including carbohydrate malabsorption,
medications, bile acid malabsorption, Crohn's
disease, microscopic colitis, chronic mesenteric
ischemia, postsurgical diarrhea, hyperthyroidism,
colonic adenomas and carcinomas, ethanol-
induced diarrhea, laxative abuse, and the very rare
hormone-secreting tumors.
 Steatorrheadescribes greasy, oily, foul
smelling, bulky, or voluminous stools that
are often difficult to flush, might contain
undigested food particles, and sometimes
leaves an oily stain in the toilet bowl. These
characteristics suggest pancreatic disease,
short bowel syndrome, celiac disease,
giardiasis, and small bowel bacterial
overgrowth (SBBO).
 Bloody diarrheasuggests mucosal inflammation and
disruption. Bright red blood points to a more distal source.
Ulcerative colitis, Crohn's colitis, radiation colitis,
malignancies, graft-vs-host disease (GVHD), and certain
chronic infections (eg, cytomegalovirus) cause bleeding.
Hemorrhoids and anal fissures that often develop
secondary to diarrhea can cause bright red bleeding and
streaks of blood on toilet paper.
Severity assessment
The impact of diarrhea on daily function is
used to assess illness severity. Patients with
severe illness are often unable to leave
home for prolonged periods,. severe illness
might cause orthostasis, extreme thirst, or
other symptoms that suggest volume
depletion.
onset
Infectious diarrhea tends to start abruptly,
may be associated with fever, and often
affects other individuals in the patient's
household.
Gradual onset is more typical of most other
chronic illnesses. Episodic exacerbation is
typical in IBS, IBD, and
recurrentClostridium difficilecolitis.
 The duration of illness is also an important
diagnostic and prognostic indicator. Acute
diarrhea (< 4 weeks) is typically caused by
infectious agents and usually resolves
spontaneously. Conversely, chronic diarrhea
is less likely to resolve without intervention.
Very long-standing (ie, several years'
duration) and/or recurrent symptoms
suggest a functional illness rather than
organic disease.
 Onset of diarrheasoon after
eatingand/orrelief with fastingmight
suggest malabsorption ,maldigestion, rapid
intestinal transit following surgery, or an
exaggerated gastrocolic reflex as seen in
IBS.If these symptoms are present, the
patient should be asked about the intake of
common triggers such as milk, fructose,
fiber, and sorbitol (a sweetener found in
sugar-free gum and candies)
Associated Symptoms
Abdominal pain: In IBS and IBD, the pain
is typically crampy, intermittent, and
relieved with bowel movements. In chronic
pancreatitis and chronic intestinal ischemia,
the pain is worse after meals and is
sometimes so severe that the patient
becomes afraid to eat (sitophobia)
Associated Symptoms
Intermittent constipation: IBS,fecal
impaction, with resultant overflow
incontinence
Bloating is common in IBS, IBD, SBBO,
and malabsorptive syndromes such as
giardiasis, celiac disease, and lactose
intolerance
Tenesmus : rectal irritation from ulcerative
colitis, Crohn's colitis, radiation proctitis, or
rectal masses.
Associated Symptoms
weight loss suggest an organic, rather than
functional disorder, unless the latter
condition is associated with significant
depressive features
Fever : in IBD, Whipple's disease,
malignancies, and chronic infection
Associated Symptoms
extraintestinalmanifestations, : episcleritis(red eye with or without itching or
burning),
uveitis(eye pain, blurred vision,
photophobia, headache), aphthousulcers,
arthritis (spinal, sacroiliac, or peripheral),
and skin lesions (pyodermanodosum,
pyodermagangrenosum) in IBD. aphthousulcers and dermatitis herpetiformisin celia
c
disease. Postprandial flushing : dumping
syndrome. Wheezing and intermittent
flushing in carcinoidsyndrome.
Past medical history
Recurrence from childhood in celiac d.
frequent bowel movements associated with
somatic symptoms such as fibromyalgia, chronic
fatigue syndrome, temporomandibular joint
disease, or chronic pelvic pain suggests IBS
A history of urinary incontinence, complicated
vaginal delivery, pelvic irradiation, neurologic
dysfunction, or diabetes mellitus increases the risk
of fecal incontinence
Past medical history
Poorly controlled diabetes can develop
"diabetic diarrhea
Pelvic radiotherapy can cause acute or
chronic proctosigmoiditis
Solid organ and bone marrow
transplantation (BMT) recipients develop
diarrhea secondary to chronic infectionor
GVHD
eating disorder or extensive use of medical
care raises concern for laxative abuse.
Past Surgical History
(jejunoileal) bypass surgery
gastrectomy with vagotomy
Bowel resection
cholecystectomy
History of Use of Medications/Herbal
Therapies
osmotically active agents (eg, antacids, milk
of magnesia), antibiotics, nonsteroidal anti-
inflammatory drugs (NSAIDs),
prostaglandins, colchicine, metformin,
digoxin, selective serotonin reuptake
inhibitors, and antineoplastic agents.
Diarrhea is also a side effect of herbal
therapies including St. John's wort,
echinacea, feverfew, garlic, saw palmetto,
ginseng, cranberry extract, pokeroot tea,
and aloe vera
Drugs Causing Diarrhea
Antibiotics
-Clindamycin
-Ampicillin
-cephalosporins
Antacids + Mg++
Anti-HTN Agents
-Propranolol
-Methyldopa
-Hydralazine
Antimetabolites
CV Agents
-digitalis
Alcohol
Nutritional Supplements
Potent Diuretics
-Furosemide
-Bumetanide
Family History,
positive family history of IBD,celiac
disease,colon cancer,and IBSare at increased
risk of developing these diseases
Demographic, and Sociocultural Factors
Age.Microscopic colitis, chronic intestinal
ischemia, and colorectal adenomas and
carcinomas are more common in older
people. IBD has a bimodal distribution with
typical onset in the teens to 30s, and then
from age 50-70 years. IBS usually presents
in young adulthood. New IBS symptoms in
an individual over age 50 would suggest the
need to evaluate for other disease.
Demographic, and Sociocultural Factors
Sex.IBS, Celiac disease, microscopic colitis and
laxative abuse are all more common in women
than men.
Ethnicity.Lactose intolerance is most prevalent in
Asians, Native Americans and blacks; IBD in
Ashkenazi Jews; and celiac disease in Western
Europeans]
Travel/nationality.Chronic diarrhea affects 1%
of all international travelers.Travel to developing
nations, especially those in Africa or East Asia,
increases the likelihood of a parasitic or bacterial
cause of chronic diarrhea
Demographic, and Sociocultural Factors
Past hospitalization.Nosocomialdiarrhea
is usually secondary to medications,
parenteralnutrition, orC difficileinfection.
Residence in a chronic skilled nursing
facility is a leading risk factor for
incontinence
Demographic, and Sociocultural Factors
Sexual history.A thorough sexual history
should be obtained to assess the risk for
HIV infection. Gonorrhea, chlamydia, and
herpes simplex virus
Occupation.Healthcare workers are at
increased risk forC difficilecolitis. They
are also more likely to present with
factitious diarrhea from laxative abuse.
Demographic, and Sociocultural Factors
History of abuse.Physical and sexual abuse
Emotional factors.IBS and IBD.
Alcohol use.cause a watery diarrhea that resolves
with cessation. Chronic alcohol abuse can cause
pancreatitis and steatorrhea.
Extreme exercise.Long-distance runners and
cyclists frequently experience diarrhea
Physical Examination
vital signs Orthostasis suggests volume
depletion or autonomic dysfunction
(possibly from diabetes or adrenal
insufficiency).
general appearance and mental status may
signify toxicity or chronic debilitation.
Weight loss or wasting is commonly due to
severe underlying illness and malnutrition
Physical Examination
skin lesions are associated with specific
causes of chronic diarrhea. These include
dermatitis herpetiformis(celiac disease),
erythemanodosumand pyodermagangrenosum(IBD), hyperpigmentation(Addison's disease
), flushing (carcinoidsyndrome), and migratory necrotizing
erythema(glucagonoma).
Physical Examination
The abdominal exam is generally
nonspecific. Surgical scars, abdominal
tenderness, masses, and
hepatosplenomegaly should be noted.
Borborygmus on auscultation suggests
malabsorption, bacterial overgrowth,
obstruction, or rapid intestinal transit.
Tenderness with palpation is a nonspecific
finding.
Physical Examination
The perineal, anal, and rectal examinations
are important. Signs of incontinence include
skin changes from chronic irritation, gaping
anus, and weak sphincter tone.Crohn's
disease is associated with perianal skin tags,
ulcers, fissures, abscesses, fistulas, and
stenoses,Fecal impaction or masses might
be noted.
Physical Examination
associated findings include 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), arthritis (IBD, Whipple's disease),
wheezing and right-sided heart murmurs
(carcinoid syndrome), and clubbing (liver
disease, IBD, malignancy)
Evaluation
In over 90% of patients with acute diarrhea, the
illness is mild and self-limited and responds
within 5 days to simple rehydration therapy or
antidiarrheal agents
Patients with signs of inflammatory diarrhea
manifested by any of the following require prompt
medical attention: high fever (> 38.5 °C), bloody
diarrhea, abdominal pain, or diarrhea not
subsiding after 4 5 days. Similarly, patients with
symptoms of dehydration must be evaluated
(excessive thirst, dry mouth, decreased urination,
weakness, lethargy)
 The osmotic gap is the difference between
the measured osmolality of the stool (or
serum) and the estimated stool osmolality
and is normally less than 50 mosm/kg
An increased osmotic gap implies that the
diarrhea is caused by ingestion or
malabsorption of an osmotically active
substance
Evaluation
Stool Analysis-Twenty-four-hour stool
collection for weight and quantitative fecal
fat A stool weight of more than 300 g/24 h
confirms the presence of diarrhea, justifying
further workup. A weight greater than
1000 1500 g suggests a secretory process.
A fecal fat in excess of 10 g/24 h indicates a
malabsorptive process
 2. Stool osmolality An osmotic gap confirms
osmotic diarrhea. A stool osmolality less than the
serum osmolality implies that water or urine has
been added to the specimen (factitious diarrhea).
3. Stool laxative screen In cases of suspected
laxative abuse, stool magnesium, phosphate, and
sulfate levels may be measured. Phenolphthalein,
senna, and cascara are indicated by the presence of
a bright-red color after alkalinization of the stool
or urine. Bisacodyl can be detected in the urine
4. Fecal leukocytes The presence of
leukocytes in a stool sample implies an
underlying inflammatory diarrhea.
5. Stool for ova and parasites The presence
of Giardia and E histolytica is detected in
routine wet mounts. Cryptosporidium and
Cyclospora are detected with modified acid-
fast staining.
Blood Tests
Routine laboratory tests CBC, serum electrolytes, liver
function tests, calcium, phosphorus, albumin, TSH,
total T4, beta-carotene, and prothrombin time should
be obtained. Anemia occurs in malabsorption
syndromes (vitamin B12, folate, iron) and
inflammatory conditions. Hypoalbuminemia is present
in malabsorption, protein-losing enteropathies, and
inflammatory diseases. Hyponatremia and non anion
gap metabolic acidosis may occur in profound
secretory diarrheas. Malabsorption of fat-soluble
vitamins may result in an abnormal prothrombin time,
low serum calcium, low carotene, or abnormal serum
alkalinephosphatase
Other laboratory tests
EMA, tTG
D-xylose test
Hydrogen breath test
Bile salt breath test
Schilling test
Other laboratory tests
In patients with suspected secretory diarrhea,
serum VIP (VIPoma), gastrin (Zollinger-Ellison
syndrome), calcitonin (medullary thyroid
carcinoma), cortisol (Addison's disease), and
urinary 5-HIAA (carcinoid syndrome) levels
should be obtained
Proctosigmoidoscopy With Mucosal Biopsy:
Examination may be helpful in detecting
inflammatory bowel disease (including
microscopic colitis) and melanosis coli, indicative
of chronic use of anthraquinone laxatives.
Imaging
plain abdominal radiograph:Calcification confirms the
diagnosis of chronic pancreatitis.
An upper gastrointestinal series or enteroclysis study
is helpful in evaluating Crohn's disease, lymphoma, or
carcinoid syndrome.
Colonoscopyis helpful in evaluating colonic inflammation
due to inflammatory bowel disease.
Upper endoscopy with small bowel biopsy is useful in
suspected malabsorption due to mucosal diseases. Upper
endoscopy with a duodenal aspirate and small bowel
biopsy is also useful in patients with AIDS and to
document Cryptosporidium, Microsporida, and M avium-
intracellulare infection.
Abdominal CT is helpful to detect chronic pancreatitis or
pancreaticendocrine tumors, crohn.s disease.
Thank you