EVALUATION AND

MANAGEMENT OF
CHRONIC DIARRHEA
OBJECTIVES
1. Understand definition of Chronic Diarrhea and
recognize difference between osmotic and
secretory types.
2. Identify various causes of Chronic diarrhea.
3. Evaluate cases of Chronic Diarrhea including
history, exam, and testing.
4. Understand endoscopy guidelines including
EGD, Colonoscopy, and Capsule endoscopy.
5. Determine appropriate work-up on basis of
whether feces is watery, fatty, or bloody.
6. Choose effective treatments for respective cases
of chronic diarrhea.
 1ST - RULE OUT CONSTIPATION
• Sometimes patient thinks it is diarrhea when
actually it is overflow from constipation.

• Pelvic Floor Dysfunction can happen if trouble

with IAS, HX abdominal/pelvic surgery,
Connective tissue disorder, DM, adverse drug
effects, dehydration.

• Check upright KUB for fecal loading.

RED FLAGS
 Fever
 Blood Loss

 Unexplained weight loss

 Abdominal Pain

 Nocturnal episodes

 REFER TO ER OR call GI.

DEFINITION OF DIARRHEA
1. Loose stools
2. More than 3 BM per day
3. Stool output weight>200 gram/day
DEFINITION
 CHRONIC diarrhea: duration > 4 weeks.

Functional Diarrhea , ROME III

criteria: daytime painless diarrhea > 3months.
PATHOPHYSIOLOGY OF DIARRHEA
Normal: fluid input to S.I. 10 L/day
absorption out of S.I. 9 L /day
absorption out of Colon 0.9L /day

Normal Stool: 100ml per day

Input comes from: food, drinks, salivary, gastric,

pancreatic, biliary, small intestine, colon.

Water flows through ion transporter channels, ie

cAMP
DIGESTIVE INPUT SIGNALS
1. G-cell: gastrin signals release of HCl into
stomach
2. Enteroendocrine cells: CCK stimulates
Gallbladder, pancreas, and S.I. motility.
3. Duodenal S-cells: Secretin stimulates release
of Bicarbonate from pancreas with H20 into
duodenum.
4. D-cell: VIP stimulates motility and pancreas.
5. Vagal Nerve: cholinergic GI stimulation.
6. T4: stimulates GI motility.
IC Valve
TYPES OF DIARRHEA
• Osmotic
• Secretory

• In Practice: Watery
Fatty
Bloody
OSMOTIC DIARRHEA
1. Unmeasured osmotic substances hold water in
lumen of colon.
2. Improves with FASTING or elimination.
3. Fecal Osmolar Gradient will be >125.

4. If lactose intolerant, low stool pH.

5. Can be watery or fatty stool.
6. KEY here is history of lactose intolerance or
laxatives.
OSMOTIC DIARRHEA
• Laxatives like PEG, Lactulose, or Magnesium
salts
• Fructose in our diet
• Lactose ( if lactase deficient)
• Sorbitol, Mannitol ( sugar free gums, drinks)
FOG
FECAL OSMOLAR GRADIENT
FOG= 290 – 2 {fecal Na + K} mmol/l
• If <50 secretory
• If > 125 osmotic
• If between 50-125 overlap osmotic/secretory
 OSMOTIC DIARRHEA

Low pH
Stool Analysis
Carbohydrate
FOG>125 malabsorption

Dietary review
High Mg output
Breath H2 test
Inadvertent ingestion
(lactose)
Laxative abuse
Lactase assay
SECRETORY DIARRHEA
1. Amount of fluid input exceeds absorption
2. Not affected by fasting and can continue at
night
3. Related to excess secretion or inadequate
absorption
4. Related to abnormal GI motility
5. Stool Na and Cl will be high and FOG<50
6. Can be Fatty, Watery, Bloody, Mixed
 SECRETORY
DIARRHEA

4. Cholestyramine
1. Exclude 2. Exclude
3. Selective testing trial for
Infection Structural disease
bile acid diarrhea

Bacterial pathogens Plasma peptides

"Standard" Small bowel Gastrin
Aeromonas radiographs Calcitonin
Plesiomonas
VIP
Somatostatin

Other pathogens
"Standard" Sigmoidoscopy or
colonoscopy/biopsy Urine
Ova & parasites
Coccidia 5-HIAA
Microsporidia Histamine
Giardia antigen

CT scan of abdomen
Other tests
TSH
ACTH stimulation
Serum protein
Small bowel bx electrophoresis
Immunoglobulins
and
aspirate for quantitative
culture
CAUSES OF SECRETORY DIARRHEA

1. Infection
2. Alteration of intestinal surface area
3. Inflammation
4. Dysregulation/dysmotility
5. Neuroendocrine tumor (NET)
Note - Infections, IBD, and NET not covered
in depth here
INFECTION
1. C .Diff produces enterotoxins which kill
enterocytes
2. Cholera type infections induces cGMP ion-
transporters to increase Chloride secretion
3. Parasites- always consider this one
4. Viral CMV, HIV, and HSV affect colon if
immunocompromised
ALTERED SURFACE AREA

1. Ileal resection: reduces bile salt absorption

2. Ileocecal resection: altered bacterial
concentrations reach small bowel

3. Surgical scar/strictures: cause

stasis
4. Celiacdisease: reduces SI surface absorption
5. Inflammation: increased cytokines leads to
increased wall-thickening with leakage and decreased
absorption
DYSREGULATION
1. diabetic autonomic dysfunction
2. post-vagotomy
3. sympathectomy
4. scleroderma, associated SI diverticulosis
5. hyperthyroidism
SECRETORY CAUSES
Fatty Watery
Bloody IBS
Chronic
IBD pancreatitis Neuroendocrine
Infection EPI Infection
Radiation Celiac IBD
Ischemia SIBO
SIBO Microscopic
Cancer Cirrhosis Celiac
Cholestasis DM
Bile Salt Non-osmotic
Depletion laxative
Short Gut
Villous adenoma
Alcohol (sugar)
STEATORRHEA

Decreased fat solubilization: inadequate bile salts

micelles

1. Intestinal stasis: SIBO and lower duodenal pH

2. CP/ ZES: pancrease enzyme insufficiency or
enzyme deactivation by HCL
3. Cholestasis decreases bile salt secretion
4. Cholecystectomy: increases BS secretion
5. Ileal resection leads to BS depletion or
malabsorption
 FATTY
DIARRHEA

1. Exclude
Structural Disease

Small bowel biopsy

and aspirate for Small Bowel
radiographs CT Scan of abdomen
quantitative
culture

2. Exclude
pancreatic exocrine
insufficiency

Stool chymotrypsin
Bentiromide test Secretin test
activity
LENGTH OF ILEAL RESECTION
DETERMINES IF FATTY OR WATERY

1. <100cm resected : compensated with

reduced BS returned to Liver. Unabsorbed BS pull
water through colon wall into lumen get watery
diarrhea. OK to use cholestyramine.
2. >100cm resected: decompensated with
no BS return to liver leading to reduced BS
secretion; decreased micelle formation. May not be
OK to use cholestyramine. Will get mixed
fatty/watery diarrhea. Tx with low fat diet.
INFLAMMATION
 Wall-thickening
 Leaky wall

 Impaired absorptive transporters

 INFLAMMATORY
DIARRHEA

Exclude Exclude
Structural Disease Infection

Bacterial pathogens
Small bowel "Standard"
Radiographs Aeromonas
Plesiomonas Tuberculosis

Sigmoidoscopy or Other Pathogens

colonoscopy/bx Parasite
Viruses

CT scan of abdomen

Small bowel biopsy

EVALUATION OF DIARRHEA
1. History
2. Medication
3. Physical Exam
4. Labs/tests
5. Imaging
6. Endoscopy
HISTORY

1. Stool: Duration, Frequency, Intermittent vs.

continuous, affected by fasting, blood, greasy,
watery, mucus, Nocturnal, incontinence.
2. Physical Symptoms reveal Clues and Severity
3. Weight loss
HISTORY
 Hx Surgery, radiation therapy.
 PMHx: Chronic pancreatitis, Peptic Ulcers,
Thyroid disease, Diabetes, HIV.
 Check Diet: caffeine, FODMAPs, lactose, alcohol,
diet sweeteners.
 Travel History.

 Well water ( giardia).

 Sick contacts.
MEDICATIONS
1. OTC and Prescription
2. Vitamin C (it is an acid)
3. Cholinergics
4. Laxatives: osmotic and non-osmotic
PHYSICAL EXAM
1. Important for severity of problem
2. Sometimes can give clue to etiology
a) flushing= carcinoid, VIPoma
b) cirrhosis, telangectasia= alcohol
c) thyroid nodules= medullary carcinoma
d) dermatitis= celiac disease
e) aphthous ulcers= inflammation
f) rectal exam : DRE
LABS

Stool tests:
A. C. Diff, O&P, Cx/S
B. Calprotectin, Lactoferrin, FOBT, fecal WBCs
C. FOG( Na&K), pH, Mg ( if suspecting laxative).
d. Elastase
e. Sudan III fat stain
Serology:
a. CBC, BMP , TSH, albumin, vitamins(A,D,E,K), INR
b. TTG and IgA, HLA DQ2/ DQ8 (for Celiac)
c. CRP, ESR
d. B12 and Folate ( for SIBO)
IMAGING
• CT with IV Contrast: colitis, enteritis,
diverticulitis, pancreatic tumor.
• MRE or CTE with and without contrast :
small bowel inflammation, fistula.
• MRCP: biliary dilatation.

XR or non-contrast CT: fecal loading

pancreatic calcification
INDICATIONS FOR ENDOSCOPY

• Colonoscopy
• EGD
• EUS
• SI Capsule

ASGE Guidelines: GIE Vol. 71, No. 6:2010

COLONOSCOPY
• If mucus, blood, copious watery
• If suspect: IBD, microscopic, serrated villous
adenoma, cancer, NSAID ileitis/colitis,
eosinophilic colitis.

• Flexible Sigmoidoscopy : suspect distal viral

or ischemia when full colon is high-risk

ASGE Guidelines: GIE Vol. 71, No. 6:2010

EGD/EUS
 Giardia
 Gastric ulcers

 ZES

 Celiac

 SI Crohns

 Lymphangectasia

 Lymphoma

ASGE Guidelines: GIE Vol. 71, No. 6:2010

SMALL BOWEL CAPSULE
 If colonoscopy and EGD normal and suspect
small bowel source for inflammation

 CT and MRI may not show mucosal lesion or

bleeding

ASGE Guidelines: GIE Vol. 71, No. 6:2010

CASE #1: MICROSCOPIC COLITIS
• 11/2015: 30 yo female presents with chronic alcohol
abuse, severe neuropathy, large ascites.
• She reports history of Crohns diagnosed at 26yo. Had
diarrhea and colonoscopy in 2012. Tried
Lialda but stopped medication. Now
reports 2 BM per day.
• Treated for cirrhosis and discharged to Acute Rehab
for severe neuropathy.
CASE #1. MICROSCOPIC
• 5/2016: f/up to GI clinic after lifeflight for UGIB with
HEMATEMESIS. EGD showed Grade 1 varices.
Still reports BM 2 per day. NO Crohns
medication. Focus on cirrhosis.

• Strength and spirit improving

• Request made for Colon OP Report and PATH from

2012. Although she has HX CROHN’s, she makes no
relevant complaint yet.
CASE #1. MICROSCOPIC

 9/2016: Cirrhosis now compensated, neuropathy

improving. SOBER and outlook positive. NOW:
She reports that for past 5 years she had 6-10
watery BM/day . No blood, no tenesmus.

 Colon report 2012: lymphocytic colitis.

 Look at Medication list.
CASE #1. MED LIST
 Lyrica • Sertraline
 baclofen,

 ativan
• melatonin
 MVI • thiamine
 Sertraline
• Lasix
 Mag Oxide
• Synthroid
• Iron
• Vitamin C
MICROSCOPIC COLITIS

• 12/100,000 people prevalence similar to IBD

• Associated: NSAIDs and PPI
• Labs not necessary but fecal WBC and calprotectin
are elevated ( 50-75%)
• Collagenous
• Lymphocytic
• Secretory, Inflammatory

Sleisenger & Fordtran

LYMPHOCYTIC

Sleisenger & Fordtran

COLLAGENOUS

Sleisenger & Fordtran

Reproduced from Munch A, Aust D, Bohr J, Et al. Microscopic Colitis: current status, present and past.
Jcrohns Colitis 2012;6:932
TREATMENT OF MICROSCOPIC COLITIS
 Modify Med List. {She changed to Lexapro}

 Budesonide 9mgQD x 4wks, taper 3mg every

weeks
 Alternative: Bismuth subsalicylate 8 tabs/day x 8
weeks
 Alternative: Prednisolone
CASE #1. 3RD F/UP MICROSCOPIC COLITIS

• 12/2017
• Repeat Colonoscopy in December 2017: NORMAL
• NEW Med list:
– Lyrica
– MVI
– Mag Ox
– Nadolol
– Synthroid
– Vistaril

Doing well January 2017.

 CASE #1. Microscopic Colitis

Microscopic Colitis can recur. OK to retreat

empirically without scope but 1st check Stool
tests for infection, and blood for ESR/CRP.
CASE# 2: SIBO
• 19 yo female from NH going to college in ME, active
as rock climber and backcountry pursuits presents
with HX diarrhea past 2 years. 4-6 per day but some
days>10 per day.
• Brown, watery or mushy, not greasy, No blood.
Weight stable.
• Frequent bloating, nausea, and occasional bilious
vomit.
• MED: lexapro
• FM HX: Mom has IBS-C.
CASE #2: SIBO
 PCP at NH did CRP, ESR, TTG/IgA, Stool Cx,
O&P, RUQ SONO, XRAY.
 Patient tried Lactose-Gluten Free, Elavil,
Bentyl.
 Vitamin D level normal 28, Albumin 4.9,
Calprotectin<50.
 We did a COLON and EGD: normal.

 HBT : both CH4 and H2 both increase>20ppm

CASE # 2: SIBO

 DX: SIBO with mixed CH4 and H2 production

 Treat: Flagyl / Keflex each 500mg PO TID 7-10
days. Per UptoDate
 Use low SIBO diet

 Refer to Dietician
SIBO
1. Intestinal Stasis, scleroderma, gastroparesis,
DM, Ileocecal Valve resection, Enteroenteric
Fistula, Stricture from radiation, IBD, Stenosis
from ischemia or inflammation.
2. Bacteria consume nutrients>> low B12, high
Folate>> increase H2/CH4>> bloating and
diarrhea

Dr. Ali Rezaie, Curr. GI Reports, SIBO , (2016)18.8.

HYDROGEN BREATH TESTING:

ingest tracer-food, bacteria convert to H2 and CH4

which are absorbed into blood, go to lungs, exhaled.
If more than 20ppm increase, it shows SIBO.

Dr. Ali Rezaie, Curr. GI Reports, SIBO , (2016)18.8.

Dr. Ali Rezaie, Curr. GI Reports, SIBO , (2016)18.8.
CASE# 3: EPI
 63yo Male with Hx Alcoholism, severe anxiety,
chronic abdominal pain, and smoking.
 He presents due to 70 lb weight loss during last
6 months, profound weakness.
 More than 10 watery brown BM per day.

 Great appetite but still loses weight, No nausea.

No postprandial dyspepsia.
CASE #3: EPI
 Albumin 2.5
 PreAlbumin 15

 D(OH) level 14

 CT Abdomen: pancreatic calcifications c/w

Chronic pancreatitis

 COLONOSCOPY: normal, repeat in 10 yrs

EPI
EXOCRINE PANCREATIC INSUFFICIENCY
 Results from Cystic Fibrosis or Chronic
pancreatitis
 Undigested food will flush through with extra
water from Small intestine.
 Reduced HCO3 and enzyme output.

 Reduced pH which decreases micelle production

therefore bile salt precipitation.
 Calcifications can be seen even on XRAY.
CASE # 3: EPI
• Weight-based pancrease enzymes started
• No testing for Fecal elastase done
• Vitamin D ordered 50,000 IU PO weekly 10 weeks
• F/up 8 weeks after hospital: 20 lb. weight
gain, BM now 2-3 per day and formed. Less fatigue.
• Working on Anxiety
• REMEMBER to adjust ENZYME DOSE to weights
CASE #4: BILE SALT DIARRHEA
• 76yo female yellow explosive liquid 6-10 BM/day
for years.
• Frequent UTI and tinea cruris
• Hx CCy, Nissen, GERD, CAD
 Case #4: Bile Salt Diarrhea

• Meds: • Meds:
– zoloft, – Cipro PRN,
– lisinopril, – Lipitor,
– MVI, – TUMs,
– Metoprolol – Plavix,
– omeprazole, – Cranberry,
– ASA – Vitamin C.
CASE#4: BILE SALT DIARRHEA
• Trial Colestipol but she can not swallow uncrushable
tablet.
• Questran: 4 grams with 6 ounce fluid BID adjust dose
to avoid constipation.

• She dropped omeprazole, Vitamin C, and Cipro.

• She is down to 1-2 BM/day.
• NO more UTI.
CASE#5: IBS-D

• 47yo female with watery orange diarrhea since

age 17. Improves a little bit with fasting. No
nocturnal BMs. No oil slick in bowl. Some
chronic pain RUQ/RLQ. Sometimes has to strain
but no hemorrhoids. Problem is sucking life out
of her.
• Hx TAH, Appy, CCY, episiotomy.
• Hx ERCP x 5 for bile leak issue
• Hx Nutcracker esophagus tx with tramadol.
CASE #5: IBS-D

• Tried Low FODMAP. No diet sweeteners. Little

alcohol
• Tried: immodium, Bentyl, Xifaxan, Questran,
Elavil, Xifaxan.
CASE #5: IBS-D
 Work-UP: normal colon, Normal CTwIV scan,
FOG is 110, stool pH 9, Fecal Sudan normal, Cx
neg. O&P neg, gastrin 19, VIP<13, Urine
5HIAA,Chromgranin A 31, Calcitonin<2,
Calprotectin 20, CRP 0.6, ESR 2, , fecal elastase
>500.
 B12 219, Folate 17 all normal.
WHAT’S NEXT?
 She is a bit better fasting not so bad at night so
probably secretory.

 Has chronic Abdominal Pain so possibly IBS-D.

 Surgical history warrants consideration

incompetent pelvic floor.
CASE #5: IBS-D
 Eluxodoline 75mg q HS, normal dose 75mg BID.
Hold dose on days you have alcohol. This can
titrate to 100mg BID, see contraindications.
Updated 3/2017, do not use if no gallbladder.

 RESULT: problem resolved. 2 BM/day.

 Explanation: IBS-D with abdominal pain.
TREATMENT OPTIONS
1. Lomotil or diphenoxylate to start day and after
each loose stool or before outings. MAX 10 per day
then call.
2. Cholestyramine for bile salts 2 tab 1gram po BID
or 4 gram packet BID. Adjust dose to avoid
constipation.
3. Clonidine for diabetic dysfunction. 0.1mg QD-TID.
4. Pancrease enzymes: for EPI, use weight based
dosage. Taken with meals as one eats the food.
TREATMENT OPTIONS
1. Dicyclomine: 5-10mg PO BID-QID prn
2. Amitryptiline: 10-50mg PO qHS. Adjust as
needed
3. Eluxodoline : See updated package insert and
contradindication if no gallbladder 3/2017.
4. Lotronex: need to follow packge insert
5. Antimicrobial and Anti-inflammatory agents
REFERENCES
1. Dr. L. Schiller, MD. AGA DDSEP8 Chapter 9,
Diarrhea.

2. Dr. Schiller,MD., Dr. JH Sellin,MD. Chapter 16:

Sleisenger & Fordtran’s Gastrointestinal and Liver
Diseases, Pathology, Diagnosis, Treatment. 10th
edition.

3. ASGE guidelines. Journal GIE 2010 vol 71,

No. 6:2010.

4. Dr. Ali Rezaie, Curr. GI Reports, SIBO , (2016)18.8.

TAKE HOME

 Diarrhea is really a symptom. We need find

diagnosis for the chronic diarrhea.