Gastrointestinal [CHRONIC DIARRHEA]

Secretory vs Osmotic vs Inflammatory

Chronic diarrhea is persistent or recurrent symptoms for >4 Secretory Osmotic Inflammatory
weeks; it’s usually the result of a chronic underlying condition. Secretagogues: VIP, Ø Absorption = Fat,
It becomes initially important to differentiate pathologically and Gastrin, Toxins Protein, Osmolar Load,
Nrml Osmotic Gap ↑Osmotic Gap Blood
clinically. The Osmotic Gap, Blood/Mucous, and Pattern of
Ø Blood Ø Mucous Ø Blood Ø Mucous Mucous
Bowel Habits provide clues to clinically separate the different Nocturnal Sxs Ø Nocturnal Sxs
types. Ø Change with NPO Change with NPO
Normal Fecal Fat ↑ Fecal Fat
The Secretory type of diarrhea is caused by molecules that
transform the normal absorptive gut to a secretory one. This may
Measure Stool Osmoles Calculated Stool Osmoles = Osmotic Gap
be via hormones (VIPoma, Gastrinoma) or a persistent infection
(reported value) (Stool Na + Stool K) *2
(enterotoxins). It produces an enterotoxigenic picture: Normal
280 210 = 70, Osmotic
Osmotic Gap (not osmotic), no blood or mucous (not
280 278 = 2, Secretory
inflammatory), and because the toxin is already there, no
changes in BM after NPO.

The Osmotic diarrhea is caused by something being in the Chronic Diarrhea Medications
Medication
lumen that draws water out of the body and into the lumen. This
is usually a product of malabsorption (lactose, gluten, fat,
protein). There won’t be an inflammatory picture (no blood or Laxatives Laxatives
Is it a classic cause of
mucous) but something other than Na + K will make up the chronic diarrhea? Lactose Test
osmolarity of stool, thus there will be an ↑Osmotic Gap. Lactose Def.
Furthermore, tests will likely find ↑Fecal Fat (a byproduct of
No
malabsorption). If the osmotic load is taken away (that is, go
NPO) this diarrhea gets a lot better. Infection
Stool Culture
Really Need W/U
The Inflammatory diarrhea looks like acute inflammatory
diarrhea: Blood and Mucous. But because it recurs, or has
been chronic, it’s likely due to a medical disease (like IBD). Stool Osmolar Gap
Fecal Fat
Specific Diseases within Chronic Diarrhea Fecal WBC
Osmotic diarrheas have been discussed in the malabsorption Fecal FOBT
syndromes lecture. Inflammatory diarrhea is discussed in the NPO
acute diarrhea (Bloody Diarrhea) and in the Inflammatory
Bowel Disease lecture (Crohn’s and UC). Let’s cover some
Normal Gap ↑ Gap Blood
secretory diseases here.
Ø Fat Fat WBC
Ø Blood Ø WBC ↓ w/ NPO Mucous
i. Gastrinoma
Ø Change NPO
Persistent ulcers despite treatment with diarrhea raise suspicion
for Zollinger-Ellison syndrome and the presence of a gastrin-
producing tumor. First, measure a serum gastrin then allow Secretory Osmotic Inflammatory
for an increased gastrin on secretin stimulation. Do a CT scan
Hormone Levels EGD w/ Bx Colonoscopy
or a SRS (Somatostatin Receptor Scintillography) to find the
Colonoscopy Secretin Test
tumor then resect. (See GI Gastric Disorders)
Toxins Specific Tests
ii. VIPoma
Chronic diarrhea without a real presentation to go along with it.
High Serum VIP is sufficient for diagnosis. Resect it. VIPoma Celiac, Whipple’s, Crohn’s
Gastrinoma Tropical Sprue, Ulcerative Colitis
iii. Carcinoid Carcinoid Lactose Deficiency, Radiation Colitis
A tumor usually found in the small intestine that has no C.difficile Biliary /Pancreatic Diverticulitis
symptoms until it metastasizes to the liver. There, serotonin Insufficiency Invasive Infxn
enters the blood stream causing right heart failure, flushing, (See Malabsorption) Ischemic Colitis
and Diarrhea. Get a Urinary 5-HIAA to confirm the diagnosis
and resect (see GI Cancers).

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