Approach to the patient with diarrhea

1. Definition Diarrhea

2. Diarrhea 3. Diarrhea 4.

Definition of Diarrhea

Pathophysiology :- Stool weight > 200 g/day (infant stool weight > 10 g/kg/day) Clinical : Frequency , Liquidity, Changing character

Form

water
mucous - bloody

Frequency of bowel movement in general population

Mean number of bowel movement /day

Daily intake and endogenous secretion and absorption

Oral intake 2000 Salivary 1500 Glands Stomach 2500

Net balance 2000-200=1800

Endogenous secretions 7000 ml

Bile 500
Pancreas 1500 Intestine 1000 9000 - 8800 Stool 200

% absorbed 8800/9000=98%

The amount of fluid absorbed differs throughout the intestine

Duodenum / jejunum ~5.5 L

Ileum ~2L

Colon Rectum ~ 1.3 L

Intake 2 liter

Stool <200 ml

Mechanism of Diarrhea
1. Osmotic diarrhea 2. Secretory diarrhea 3. Inflammatory diarrhea 4. Abnormal gastrointestinal motility

Osmotic Diarrhea

1. Unabsorbable osmotic load

2. Malabsorption or maldigestion

1. Unabsorbable solute load ---> more fluid transport to lumen

Osmotic Diarrhea

Raised CI Secretion

Clinical approach to diarrhea

Diarrhea

Pseudodiarrhea

Acute

Chronic

Acute Diarrhea

Infectious

Non infectious

Non infectious acute diarrhea

Drug induced

Diet
Poisoning

Acute Infective Diarrhea

Clinical Evaluation

Severity of illness Underlying disease

Special Consideration and management

Clinical setting Diagnosis + treatment

Parasite

Viruses

Bacteria Parasites Enteroadherant E.coli Giardia Cryptosporidia Bacteria Helminths

Etiology of infectious diarrhea

Bacterial
Shigella Sp. Aeromonas Shigelloides Salmonella Sp. Vibrio Sp. Compylobactor Sp. Clostridium difficile E.coli (ETEC, EPEC, EIEC, EAEC and EHEC)

 Viral
Norwalk Rotavirus Enteric adenovirus Cytomegalovirus Herpes simple virus

Fungal
Candida Sp. Histoplasma Sp.

Parasite
Entamoeba histolytica Giardia lamblia Strongyloides Cryptosporidium Cyclospora Cayetanensis

Severity of Diarrhea
Sunken eyeballs
Poor skin turgor

Orthostatic hypotension
Tachycardia

Oliguria or Anuria
Alteration of consciousness

Underlying diseases
AIDS Hyperthyroidism

History of Diet

, , Botulism Lactose deficiency Samonella Campylobacter Bacillus cereus Vibrio cholerae Vibiro pararhemolyticus Vibrio non-O-group I Norwalk virus

diarrhea
Amanita phelloides

History of Diet
,

diarrhea
Samonella , Campylobacter Salmonella , S aureus Giardia , Aeromonas Shigilla , Salmonella E histolytica E coli (EHEC) V. cholera , E coli Norwalk Virus

Antacid Lactose containing drugs Cancer chemotherapy Neomycin Cadiovascular drugs : digitalis , quinidine , ganglionic - blocking agent Antibiotics

diarrhea Magnesium induce osmotic diarrhea Osmotic diarrhea Mucosal Injury Malabsorption Increase motility

Antibiotic associated enterocolitis (Clostridium difficile)

Clinical Setting
Food poisoning
(entero/neuro toxin producing) Fever Incubation Peroid Mucous-bloody stool Nausea vomiting Tenesmus Voluminous stool Etiology Rare < 6 hours Non ++ + Staphylococcus aureus, C.perfringens B, ceceus Salmonella

Water Diarrhea
(non-Invasive Organism) Non or Low Grade 6 hours-3 days Non + ++ EPEC, ETEC, EAEC Aeromonas, Vibrio Cholerae Giardia, Cryptospodium Salmonella virus

Dysentery (Invasive organism) Common 1-3 days Common + + + Shigella P.shigelloides EIEC EHEC Salmonella Campylobactor C.difficile, E.Histolytica V.Parahemolyticus

Stool Leukocyte
Present stool leukocyte
HSV CMV Aeromonas Campylobacter EIEC, EHEC Shigella Salmonella V.parahemolyticus Plesiomenas Shigiloides E.Histolytica Microsporidium Strongyloides

Absent stool leukocyte

Adenovirus Norwalk virus Rotavirus Bacillus cereus Staphylococcus aureus ETEC, EPEC, EAEC Giardia lamblia Cryptosporidium V. cholerae Cyclospora sp.

Treatment
1. Supportive 2. Symptomatic 3. Specific

Antimicrobial treatment
Fecal WBC
Severe volume depletion Community out break

Impaired host

Shigella sp. Areomonas sp.

Drug of choice

Alternative
Ciprofloxacin, ceftriaxone TMP/SMX, loramphenical Ciprofloxacin Bacitacin Doxycycline , TMP/SMX Emitine Quinacrine hydrochloride Albendazole

Norfloxacin , ofloxacin Amlnoglycoside Ceftriaxone Campylobacter Erythromycin Norfloxacin Clostridium difficile Metronidazole Vancomycin Vibrio cholerae Tetracycline E. histolytica Metronidazole Giardia lamblia Metronidazole Strongyloides Thiabendazole

Chronic Diarrhea

Functional

Organic

HIV

Non-HIV

Causes of chronic diarrhea in Thai-AIDS

29/45 Found causative organism Cryptosporidium TB Salmomella spp. CMV MAC Strongyloidiasis Giardiasis Cryptococcus Histoplasma carsulatum Campylobacter Cyclospora % 20 17.8 15.5 11.1 6.6 4.4 4.4 2.2 2.2 2.2 2.2

Manatsathit S. et al. J Gastroenterol.1996;31(4):533-7.

Chronic organic diarrhea (Non HIV)

Inflammatory

Secretory

Malabsorption

Chronic Inflammatory Diarrhea

Infection

Inflammatory bowel Radiation Ischemic

Malabsorption syndrome

Diarrhea Malnutrition

Intestinal epithelial cells are continually renewed

Cell death And sloughing
Turn over time ~ 48 72hr

Villus Region

Crypt Region

Diving cells Paneth cells

Normally : # Cells entering villus = # Cells dying

The intestine has a very large surface area for absorption

Type of surface Amplification factor
1
3 10 20

Surface area (cm2)

3,300
10,000 100,000 2,000,000

Mucosal cylinder
Fold of Kerkring Villi Microvilli

Malabsorption syndrome
Strongyloidiasis

Giardiasis Capillariasis Lymphoma

Chronic secretory diarrhea

Vipoma

Carcinoid syndrome
ZE syndrome

Constipation

Definition Constipation

Definition Acute Chronic Patient review Clinical review

Rome II Criteria for chronic constipation (At least 2 of following)

Fever than 3 bowel movement/week Hard stool in more than 25% of BM A sense incomplete evaluation in more than 25% of BM Excessive staining in more than 25% of BM The necessity of digital manipulation to facilitate evaluation Any 12 week period in the least 12 months

Pathogenesis

Drugs (opiates, phenothiazines)

Obstruction Pseudo-obstruction

Cause of constipation
Extrinsic
Structural

Systemic
Neurological

Drugs

Extrinsic
Inadequate dietary fiber, fluid Ignoring urge to defecate

Structural
Colorectal : neoplasms, stricture, ischemia , volvulus, diverticular disease Anorectal : inflammations,

prolapse, rectocele,fissure, stricture

Systemic
Hypokalemia Hypercalcemia Hyperparathyroidism Hypothyroidism Hyperthyroidism Diabetes mellitus

Neurological
CNS : Parkinsons disease, multiple

sclerosis, trauma, ischemia, tumor

Sacral nerves : trauma, tumor

Autonomic neuropathy
Aganglionosis (Hirschsprungs disease)

Drugs
Analgesics
Opiates, non-steroidal antiinflammatory

Anticholinergics
Atropine agent,

antidepressants, neuroleptics

Drugs
Metal ions
Aluminum (antacids, sucralfate),
barium sulfate , bismuth, calcium, iron, heavy metals (arsenic, mercury)

Resins
Cholestyramine, polystyrene

Diagnosis and differential

History taking

Physical examination
Diagnostic techniques

History taking
How many stools per week?

Chronic constipation or not?

Is there concomitant abdominal pain?

Dietary history
Lifestyle

Use of laxative
Use of other drugs

Physical examination
Percussion (check for gas)

Palpable feces (loaded colon)

Rectal palpation
Consistency / impaction Presence of non fecal masses pr abnormalities (tumor, hemorrhoid, fissures, fistulas, prolapse, neoplasms) Presence of blood Sphincter tone

Diagnostic techniques
Stool analysis (assess seriousness)
weighing 3 days ; < 100 g average means constipation Abdominal Xray (assess seriousness) Radiological or Endoscopic investigation (to assess/exclude obstructions) :

megacolon
redundant sigmoid colon pattern of haustral folds IBS patients ---> normal length haustral colon Colon inertia ---> longer length less haustral colon

Major Alarm symptoms especially in patients > 50 yr

New onset constipation
Anemia Weight loss Anal blood loss Positive occult blood test

Sudden change in defecation pattern and appearance of stool

Stepped Treatment of Constipation

change lifestyle and diet

Stop medications which cause constipation

Bulk-forming agent

Osmotic laxatives Pelvic floor physiotherapy

Contact laxatives

Enema

Prokinetics

Laxatives
Bulk laxative
Psyllium Polycarbophil Methylcellulose

Lubricating agents
Mineral oil

Laxatives
Osmotic agents
Magnesium and phosphate salts Lactulose Sorbitol Polyethylene glycol

Glycerin suppositories

Laxatives
Stimulant laxatives
Surface acting agents
Ducusate
Bile acids

Diphenymethane derivates
Phenolphtalein

Bisacodyl
Sodium picosulfate

Ricinoleic acid Anthraquinones

Senna Cascara sagrada Aloe Rhubarb