Diarrhea

Dr. Ali A. Ramadhan

M.B.Ch.B., FIBMS, FKBMS (G & H)

1
 Definition
• Diarrhea is passage of abnormally liquid or
unformed stools at an increased frequency
& / or weight:
– Most patients consider increased fluidity of stool
(a stool that takes the shape of its container) as
the essential characteristic.
– Stool frequency is a surrogate marker of
diarrhea (  3 bowel movements/day are
considered to be abnormal).
– Stool weight >200 g./day in Western countries
(>300 g/d in developing countries) may be
abnormal. 2
 Classification
• Diarrhea can be classified in one of several
ways:
1.Time course: acute if <2 weeks, persistent
if 2–4 weeks, chronic if >4 weeks
2.Volume: large vs. small
3.Pathophysiology: secretory vs. osmotic
4.Stool characteristics: watery vs. fatty vs.
inflammatory
5.Epidemiology: eg travelers diarrhea
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 Question
• Chronic diarrhea lasts more than
A.1 week
B.3 weeks
C.4 weeks
D.6 weeks
E.2 months

TA: C
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Acute diarrhea

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 Aetiology
1. Infections (>90%):
1. Bacteria: Escherichia coli, Salmonella,
Shigella, Clostridium difficile, Campylobacter...
2. Viruses: Adenovirus, Norovirus, Rotavirus
3. Parasites: Giardia lamblia, Entamoeba
histolytica
2. Drugs: antibiotics, cytotoxic drugs, proton pump
inhibitors, NSAIDs
3. Food allergies
4. Gastro-Intestinal Ischemic Injury (GI3)
5. Initial presentation of chronic diarrhea. 6
 Clinical Features
• Acute diarrhea is common: worldwide, >1
billion individuals suffer one or more
episodes of acute diarrhea each year.
• Associated symptoms: abdominal cramps,
urgency, tenesmus, nausea & vomiting,
fever, myalgia.
• Signs: diffuse tenderness, active bowel
sounds.

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 Management
1. Evaluation:
• Most episodes of acute diarrhea are mild and self-
limited & do not need investigations.
• Indications for diagnostic evaluation:
History Examination:
1)Elderly patients 1)Fever > 38.5 C
2)Bloody diarrhea (dysentery) 2)Severe diarrhea
3)Significant abdominal pain leading to volume
4)Inflammatory bowel disease (IBD) depletion
5)Immuno-compromised patients
6)Hospitalized patients
7)Recent antibiotic use
8)Pregnant women
9)Food handlers 8
 Management (Con.)
• Assess degree of dehydration:

– Severe dehydration: reduced urine output, cool moist

extremities, rapid & feeble pulse, low or undetectable
blood pressure, peripheral cyanosis.
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 Management (Con.)
• The cornerstone investigation is microbiologic
analysis of the stool (general stool examination).
• Stool for Vibrio cholera (VC) especially in epidemics
• Further investigations will depend on the clinical
status and results of stool examination: CBC,
electrolytes, sigmoidoscopy, abdominal X-ray.

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 Management (Con.)
2. Fluid resuscitation:
•This is necessary to avoid dehydration.
•Use oral rehydration solution (ORS).
•Use intravenous fluid in
1)Severely dehydrated patients, especially infants & elderly.
2)Patients who can not tolerate or who have inadequate oral
intake.
•Give deficit and maintenance:
• No dehydration: ORS after each stool (up to 2 L/day)
• Some dehydration: ORS after each stool (2-4 L/day)
• Severe dehydration: give normal saline or Ringer lactate
(30 ml/Kg in 30 minutes; give up to 100 ml/Kg in the first 4
hours and 200 ml/Kg in 24 hours) 11
 Management (Con.)
3. Antibiotics are used in:
– If a specific pathogen is found.
– Moderately to severely ill patients with febrile
dysentery
– Patients who are immunocompromised, have
mechanical heart valves or recent vascular
grafts, or are elderly.
– Antibiotic prophylaxis for travelers with
immunocompromise, inflammatory bowel
disease (IBD), hemochromatosis, or gastric
achlorhydria.
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 Management (Con.)
4. Antimotility and antisecretory agents:
•Loperamide may be given in moderately severe non-
febrile and non-bloody diarrhea, to control symptoms.
It should be avoided in febrile dysentery
•Bismuth subsalicylate may reduce vomiting and
diarrhea but avoid in immunocompromised or renal
impairment because of the risk of bismuth
encephalopathy
5. Public authority notification:
•You should be aware to identify if an outbreak of
diarrheal illness is occurring and to alert the public
health authorities promptly. 13
 Question
• All of the followings are indications for
evaluation of acute diarrhea EXCEPT:
A.Immuno-compromised patients
B.Fever of 39.0 C
C.Recent antibiotic use
D.Pregnant women
E.Young patients

TA: E 14
Chronic diarrhea

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 Overview
• In contrast to acute diarrhea, most of the
causes of chronic diarrhea are noninfectious
• It can be classified into osmotic, secretory,
malabsorptive and inflammatory.
• The most common cause is irritable bowel
syndrome (IBS).
• Generally, >90% of cases are due to three
diseases: IBS, inflammatory bowel disease
and colon cancer.
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 Osmotic diarrhea
• Features:
– Stool volumes are <1 L/ d
– Cessation of stooling when they are fasting.
– Stool osmotic gap = 290 - 2 x [stool sodium + stool
potassium]
– Gap >100 mOsm/kg suggests osmotic diarrhea.
• Causes: ingestion of laxatives, carbohydrate
malabsorption.
• Evaluation: review diet and medications, breath
testing and laxative screen.
• Ingestion of osmotic laxatives in factitious diarrhea
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 Secretory diarrhea
• Features:
– Watery, large-volume fecal outputs, causing severe
dehydration and electrolyte disturbances
– Painless and persist despite fasting.
– Stool osmotic gap is <50 mOsm/kg.
• Causes
1. Dysmotility: IBS, DM, postvagotomy,
2. Infection eg enterotoxins.
3. Medications and toxins: laxatives,
4. Neuroendocrine: carcinoid, gastrinoma.
5. Malabsorption: bile acid malabsorption.
6. Structural: malignancies,
• Investigations: stool cultures, endoscopy, estimation of 18
secretagogues (eg gastrin)
 Malabsorptive diarrhea
• Features:
– Loss of fat, carbohydrates, or protein in the stool
– Steatorrhea means excess fat in the stool. The stool is
bulky, greasy, pale, offensive, floats in the toilet and is
difficult to wash
– Undigested food in the stool, weight loss and nutritional
deficiencies
• Causes
• Malabsorption syndromes: celiac disease, short bowel
syndrome, small intestinal bacterial overgrowth.
• Maldigestion: Pancreatic exocrine insufficiency.
• Investigations: Celiac serology, endoscopy,
pancreatic imaging, breath testing, 72-hour fecal fat
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 Inflammatory diarrhea
• Features:
– Small-volume, bloody, mucoid stools; with
abdominal pain; patient is febrile and toxic
• Causes
– Infectious diseases: CMV, TB, amebiasis,
pseudomembranous colitis (Cl. difficile infection)
– Inflammatory bowel disease
– Others: diverticulitis, ischemic colitis, neoplasia
(colorectal cancer, lymphoma), radiation colitis
• Investigations: Colonoscopy, intestinal imaging

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 Question
A 30 years old female who is known case of diabetes
presented with loose bowel motions for 4 months
duration. The stool is watery and large in volume. There
is no abdominal pain. The diarrhea does not change with
fasting. There is no fever. The most likely type of diarrhea
is
a)Acute diarrhea
b)Inflammatory diarrhea
c)Malabsorptive diarrhea
d)Osmotic diarrhea
e)Secretory diarrhea

TA: E 21
 History
• HPI:
1. Timing: ? Nocturnal diarrhea
2. Severity of the diarrhea: assess dehydration
3. Stool characteristics, eg the presence of blood, mucus, or food
particles.
4. Aggravating & relieving factors:
1. Relation to meals or fasting: Osmotic diarrhea stop with
fasting.
2. Review diet
5. Associated symptoms:
1. Urgency and incontinence suggest a problem with rectal
compliance
2. Excessive flatus in carbohydrate malabsorption.
3. Abdominal pain & cramps. 22
 History (Con)
• ROS:
– Chronic weight loss may suggest intestinal
malabsorption or a serious constitutional process
e.g. malignancy, IBD, or hyperthyroidism.
– Fever may indicate inflammatory causes.
• PMHx: radiation therapy, DM, immunocompormised.
• PSHx: prior abdominal surgeries
• Drug Hx: especially laxative abuse.
• Family Hx of similar conditions, IBD
• SEHx: travel Hx, residence in a rural or urban
environment, the source of drinking water, use of
alcohol or illicit drugs
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 Examination
• General examination:
– Vital signs, signs of dehydration, lymphadenopathy,
skin lesions, thyroid examination.
– Features to suggest malabsorption or IBD eg
anemia, edema, or clubbing.
• Systemic examination:
– CVS: Right-sided heart murmurs with carcinoid
syndrome. Signs of peripheral vascular disease in
chronic mesenteric ischemia.
– Abdomen: mass, tenderness, hepatomegaly, rectal
examination.
– Arthritis in IBD, Whipple's disease,
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 Investigations
• The laboratory tools are extensive.
• The investigations must be directed by a
careful history and physical examination.
• Routine blood studies to characterize the
mechanism of diarrhea, identify diagnostic
associations, and assess the patient’s
fluid/electrolyte and nutritional status.

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 Treatment
• Treatment of chronic diarrhea depends on the
specific etiology.
• It may be curative, suppressive, or empirical.
• Suppressive treatment eg elimination of gluten for
celiac disease.
• Empirical treatment (if no cause is identified):
– Mild opiates (eg diphenoxylate or loperamide) for mild to
moderate diarrhea
– Codeine for severe diarrhea.
– Clonidine for diabetic diarrhea.
– Fluid and electrolyte repletion.
– Replacement of fat-soluble vitamins in steatorrhea. 26
THANK
YOU

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