Chronic diarrheaChronic diarrhea

Prepared by:Prepared by: Sagvan S. Sagvan S. khamokhamo

Supervised by:Supervised by: Dr. Wala Dr. Wala yousifyousif

Definition:Definition:

• Diarrhea is a loose or Diarrhea is a loose or watery stool, excessively watery stool, excessively frequent, or stools that are frequent, or stools that are large in volume.large in volume.

• Chronic diarrhea is the Chronic diarrhea is the diarrhea that lasts for more diarrhea that lasts for more than 2 weeks.than 2 weeks.

Classification:Classification:

• Physiological mechanismsPhysiological mechanisms1.1. SecretarySecretary2.2. OsmoticOsmotic3.3. ExudativeExudative4.4. Motility Motility

• Etiological agentsEtiological agentsViruses, bacteria or their toxins, chemicals, Viruses, bacteria or their toxins, chemicals,

parasites, mal absorbed substances, and parasites, mal absorbed substances, and inflammation.inflammation.

Secretary diarrhea:Secretary diarrhea:• This occurs when the intestinal mucosa This occurs when the intestinal mucosa

directly secretes fluid and electrolytes directly secretes fluid and electrolytes into the stool. This secretion may be into the stool. This secretion may be the result of inflammation (IBD), or a the result of inflammation (IBD), or a chemical stimulus.chemical stimulus.

• Cholera is a secretary diarrhea Cholera is a secretary diarrhea stimulated by the enterotoxin of vibrio stimulated by the enterotoxin of vibrio cholera. This toxin causes increased cholera. This toxin causes increased levels of cAMP within enterocytes, levels of cAMP within enterocytes, leading to secretion into the small leading to secretion into the small bowel lumen.bowel lumen.

• Secretion also is stimulated by Secretion also is stimulated by mediators of inflammation and by mediators of inflammation and by various hormones, such as VIP various hormones, such as VIP secreted by a neuroendocrine tumor secreted by a neuroendocrine tumor (neuroblastoma).(neuroblastoma).

Features:Features:

• Characterized by watery, large-volume Characterized by watery, large-volume fecal outputs that are typically painless fecal outputs that are typically painless and persist with fasting,and persist with fasting,

• one may do a 24 hr stool quant.-should one may do a 24 hr stool quant.-should exceed one liter and not decrease with exceed one liter and not decrease with fastingfasting

• Usually stool pH is neutral, and fecal fat Usually stool pH is neutral, and fecal fat test is negativetest is negative

• If secretary diarrhea confirmed, If secretary diarrhea confirmed, recommend checking serum should recommend checking serum should be sent for:be sent for:

• Gastrin (gastrinoma), VIP(VIPOMA), Gastrin (gastrinoma), VIP(VIPOMA), glucagons (glucogonoma), serotonin glucagons (glucogonoma), serotonin (carcinoid), calcitonin, histamine, and (carcinoid), calcitonin, histamine, and prostaglandinsprostaglandins

• -if overproduction of one of these -if overproduction of one of these mediators is documented, mediators is documented, abdominal CT scan is abdominal CT scan is recommendedrecommended

• Carcinoid present with watery Carcinoid present with watery diarrhea, flushing, skin changes, diarrhea, flushing, skin changes, bronchospasm, and cardiac murmurs bronchospasm, and cardiac murmurs which are all symptoms caused by which are all symptoms caused by secretion of serotonin, histamine, secretion of serotonin, histamine, catecholamine, kinins, and catecholamine, kinins, and prostaglandins by the tumor massesprostaglandins by the tumor masses

• 1/3 pts with carcinoid present with 1/3 pts with carcinoid present with diarrhea alonediarrhea alone

• Medullary carcinomas of thyroid Medullary carcinomas of thyroid (spontaneous or part of MENIIA) (spontaneous or part of MENIIA) cause secretary diarrhea because of cause secretary diarrhea because of the release of calcitoninthe release of calcitonin

Osmotic diarrhea:Osmotic diarrhea:

• Occurs after malabsorption of ingested Occurs after malabsorption of ingested substances, which pull water into the bowel substances, which pull water into the bowel lumen.lumen.

• A classical example is lactose intolerance. A classical example is lactose intolerance. When dairy products are ingested in the When dairy products are ingested in the absence of sufficient lactase activity in the absence of sufficient lactase activity in the small intestinal brush border, malabsorption small intestinal brush border, malabsorption of the undigested lactose creates an osmotic of the undigested lactose creates an osmotic effect.effect.

• Osmotic diarrhea also can result from Osmotic diarrhea also can result from mal- digestion, such as that seen with mal- digestion, such as that seen with pancreatic insufficiency, or with pancreatic insufficiency, or with malabsorption caused by intestinal malabsorption caused by intestinal injury.injury.

• Certain non absorbable laxatives, such Certain non absorbable laxatives, such as polyethylene glycol and magnesium as polyethylene glycol and magnesium hydroxide (milk of magnesia) also cause hydroxide (milk of magnesia) also cause osmotic diarrhea.osmotic diarrhea.

• The end result is osmotically active The end result is osmotically active solute in the stool with excessive solute in the stool with excessive fecal water content. fecal water content.

• Fermentation of some of these mal- Fermentation of some of these mal- absorbed substances (e.g. lactose) absorbed substances (e.g. lactose) often can occur in the colon, often can occur in the colon, resulting in gas production, cramps, resulting in gas production, cramps, and acidic stools.and acidic stools.

Exudative DiarrheaExudative Diarrhea

• GI tract inflammation change induce GI tract inflammation change induce exudationexudation– Pus or blood contents in stoolPus or blood contents in stool– Microscopic RBC, WBCMicroscopic RBC, WBC– Systemic toxic sign, e.g.. FeverSystemic toxic sign, e.g.. Fever– Ulcerated colitis, Crohn disease, Eosinophilic Ulcerated colitis, Crohn disease, Eosinophilic

gastroenteritisgastroenteritis– Salmonella, ShigellaSalmonella, Shigella– Radiation enterocolitisRadiation enterocolitis

• Diarrhea “partially” improve with NPODiarrhea “partially” improve with NPO

• Life-threateningLife-threatening

Motility DisturbanceMotility Disturbance

• Peristalsis increasePeristalsis increase– Hyperthyroidism, Irritable bowel Hyperthyroidism, Irritable bowel

syndromesyndrome

• Peristalsis decreasePeristalsis decrease– DM, ConstipationDM, Constipation

Toddler's diarrhea:Toddler's diarrhea:

• The most common cause of loose stools in The most common cause of loose stools in early childhood. Also known as chronic early childhood. Also known as chronic nonspecific diarrhea.nonspecific diarrhea.

• This condition is defined by frequent This condition is defined by frequent watery stools in the setting of normal watery stools in the setting of normal growth and weight gain and is caused by growth and weight gain and is caused by excessive intake of fruit juices that contain excessive intake of fruit juices that contain non-digestible carbohydrates.non-digestible carbohydrates.

• Diarrhea typically improves tremendously Diarrhea typically improves tremendously when the child’s beverage intake is when the child’s beverage intake is reduced or changed.reduced or changed.

Causes of chronic Causes of chronic diarrheadiarrhea

Differential diagnosis Differential diagnosis according to the age:according to the age:

• Infancy:Infancy:

1.1. Post infectious secondary lactase Post infectious secondary lactase deficiencydeficiency

2.2. Cow milk-soy protein intoleranceCow milk-soy protein intolerance

3.3. Chronic non specific diarrhea of infancyChronic non specific diarrhea of infancy

4.4. Celiac diseaseCeliac disease

5.5. Cystic fibrosisCystic fibrosis

6.6. AIDS enteropathyAIDS enteropathy

Child:Child:

1.1. Post infectious secondary lactase Post infectious secondary lactase deficiencydeficiency

2.2. IBSIBS3.3. IBDIBD4.4. Celiac diseaseCeliac disease5.5. GiardiasisGiardiasis6.6. Acquired immune defectAcquired immune defect7.7. Secretary tumorsSecretary tumors8.8. Pseudo-obstructionPseudo-obstruction9.9. Factitious Factitious

Adolescent:Adolescent:

1.1. IBSIBS

2.2. IBDIBD

3.3. Lactose intoleranceLactose intolerance

4.4. GiardiasisGiardiasis

5.5. Laxative abuse (anorexia nervosa)Laxative abuse (anorexia nervosa)

Distinguishing features:Distinguishing features:

1. Osmotic gap = 290 - 2 (Na+K)1. Osmotic gap = 290 - 2 (Na+K)

• If less than 50 it is secretary If less than 50 it is secretary diarrhea.diarrhea.

• A number significantly higher than A number significantly higher than 50 is osmotic.50 is osmotic.

2. 2. NPO trial:NPO trial: is stoppage of all is stoppage of all feedings and observation of feedings and observation of hospitalized patient rather than IV hospitalized patient rather than IV fluid to prevent dehydration.fluid to prevent dehydration.

• If diarrhea stops, means osmotic If diarrhea stops, means osmotic diarrhea, but if it continues, means diarrhea, but if it continues, means secretary one.secretary one.

EvaluationEvaluation

History:History:• Bowel pattern: get an idea of the volume, Bowel pattern: get an idea of the volume,

appearance and consistency of the stool. appearance and consistency of the stool. Is there blood or mucus.Is there blood or mucus.

• Precipitating factors: lactose intolerance is Precipitating factors: lactose intolerance is precipitated by acute diarrhea, are certain precipitated by acute diarrhea, are certain foods trouble some, are others affected in foods trouble some, are others affected in the family or in child care.the family or in child care.

• Associated symptoms: weight loss or Associated symptoms: weight loss or abdominal pain are particularly important.abdominal pain are particularly important.

• Review of symptoms: non GI disease often Review of symptoms: non GI disease often cause diarrhea and failure to thrive.cause diarrhea and failure to thrive.

Physical examination:Physical examination:

• Growth: obtain height, weight, OFC and Growth: obtain height, weight, OFC and compare with earlier measurements. compare with earlier measurements. Chronic disease affects growth. Chronic disease affects growth.

• Other features: hydration, pallor, abdominal Other features: hydration, pallor, abdominal distension, tenderness, finger clubbing.distension, tenderness, finger clubbing.

• General examination: does the child looks ill, General examination: does the child looks ill, look for non GI disease that cause diarrhea.look for non GI disease that cause diarrhea.

• Anorectal examination is not routinely Anorectal examination is not routinely indicated.indicated.

Investigations:Investigations:

• These are rarely necessary if the These are rarely necessary if the child is thriving and there are no child is thriving and there are no accompanying symptoms and signs.accompanying symptoms and signs.

• Investigations are done for stool, Investigations are done for stool, blood, and others according to the blood, and others according to the suspicion of the physician.suspicion of the physician.

Stool:Stool:

• Occult blood: in cow milk intolerance and IBDOccult blood: in cow milk intolerance and IBD

• Ova and parasites (3 samples): parasitic Ova and parasites (3 samples): parasitic infectioninfection

• Reducing substances and low PH: lactose Reducing substances and low PH: lactose intoleranceintolerance

• Chymotrypsin: low in pancreatic insufficiencyChymotrypsin: low in pancreatic insufficiency

• Microscopy: fat globules seen in fat Microscopy: fat globules seen in fat malabsorption e.g. pancreatic insufficiency.malabsorption e.g. pancreatic insufficiency.

Blood:Blood:

• Full blood count: anemia indicate Full blood count: anemia indicate blood loss, malabsorption, poor diet. blood loss, malabsorption, poor diet. Eosinophilia suggests parasites or Eosinophilia suggests parasites or atopy.atopy.

• Plasma viscosity/ESR: high in IBDPlasma viscosity/ESR: high in IBD

• Celiac antibodies: celiac diseaseCeliac antibodies: celiac disease

Others:Others:

• Urine culture: UTIUrine culture: UTI• Sweat test: cystic fibrosisSweat test: cystic fibrosis• Breath hydrogen test: high H2 in Breath hydrogen test: high H2 in

lactose intolerance.lactose intolerance.• Jejunal biopsy: flattened vilii in celiac Jejunal biopsy: flattened vilii in celiac

disease.disease.• Barium meal and enema: IBDBarium meal and enema: IBD• Endoscopes: IBDEndoscopes: IBD

Management:Management:

• IVF and electrolyte ?IVF and electrolyte ?

• NPO try ?NPO try ?

• Nonspecific anti diarrheals ?Nonspecific anti diarrheals ?

• Antibiotic ?Antibiotic ?

• Looking for underlying etiology ?Looking for underlying etiology ?

Non specific Non specific antidiarrheals:antidiarrheals:

• AbsorbentsAbsorbents– tannalbin, kaopectin, Al(OH)tannalbin, kaopectin, Al(OH)33 (ulcerin-p) (ulcerin-p)

• Anti-cholinergicsAnti-cholinergics– buscopan, bentyl (kolantyl), trancolon, buscopan, bentyl (kolantyl), trancolon,

duspatalin, delibs, atropinduspatalin, delibs, atropin

• Opiate derivativesOpiate derivatives– loperamide (immodium),loperamide (immodium), codeine, codeine,

morphinemorphine

Specific antidiarrheals:Specific antidiarrheals:

• AntibioticsAntibiotics– Anti-G(-), such as E.ColiAnti-G(-), such as E.Coli– EmpiricEmpiric

• ampicillin, unasyn, augmentinampicillin, unasyn, augmentin• Trimethoprim160/sulfamethoxazole800 (Baktar)Trimethoprim160/sulfamethoxazole800 (Baktar)• Ciproxin / RocephinCiproxin / Rocephin

• Ulcerated colitis/ Crohn disease --- steroidUlcerated colitis/ Crohn disease --- steroid• Pseudomembrane colitis --- Pseudomembrane colitis ---

metronidazole/vancomycinmetronidazole/vancomycin• Eosinophilic gastroenteritis --- steroidEosinophilic gastroenteritis --- steroid• AIDS-related --- metronidazoleAIDS-related --- metronidazole

• Carcinoid syndromeCarcinoid syndrome– octreotide (sandostatinoctreotide (sandostatin))

• Zollinger-Ellison syndromeZollinger-Ellison syndrome– proton pump inhibitorproton pump inhibitor

• Ileal bile salt malabsorptionIleal bile salt malabsorption– cholestyramine (Questrancholestyramine (Questran))

• Thyroid medullary carcinoma / Colon Thyroid medullary carcinoma / Colon villous adenomavillous adenoma– indomethacinindomethacin

• Opiate withdrawal / DM diarrheaOpiate withdrawal / DM diarrhea– clonidine clonidine ((22-adrenergic agonist)-adrenergic agonist)

ThaThanknk youyou