chronic diarrhea approach and evaluation

2. • Diarrhea is conventionally defined as more than three stools,
which are of abnormal liquidity per day.1
• Daily fecal weight (200 g daily)
• 1. Jeejeebhoy KN. Symposium on diarrhea. 1. Definition and mechanisms of diarrhea. Can Med Assoc J
1977;116:737-9

3. These definitions has problem Indian population
9% of healthy Indian population pass 3 or more stools per day
and 90% pass 1-2 stools per day.2
Average stool weight in healthy Indian adults is 311 g/d.2
• 3. Tandon RK, Prasad N, Gupta MC, Tandon BN. Stool weights and transit time in north Indians. Jr Asso Phys Ind
1976;24:807-10
• 2 Ghoshal U et al. Epidemiological and clinical profile of irritable bowel syndrome in India: Report of the Indian Society of
Gastroenterology Task Force. Indian J Gastroenterol 2008;27:22-8

4. • Acute if <2 weeks
• Persistent if 2–4 weeks
• Chronic if >4 weeks

5.  Volume (large vs. small)
Pathophysiology (secretory vs. osmotic)
 Stool characteristics(watery vs. fatty vs. inflammatory)
Epidemiology

6. Mayo Clin Proc. June2012;87(6):596-602

9. • Normal recto sigmoid colon functions as a storage reservoir.
• Frequent small volume stools- inflammatory or motility
disorders involving the left colon
• Bowel movements are less frequent and larger- right colonic or
small bowel source

11. • Intestinal malabsorption of ingested nonelectrolytes (osmotic
diarrhea)
• Diarrhea that results from malabsorption or secretion of electrolytes
(secretory diarrhea)
• In secretory diarrhea, sodium, potassium, and accompanying anions
account almost entirely for stool osmolality
• In osmotic diarrhea poorly absorbable solutes within the lumen of
the intestine account for much of the osmotic activity of stool water
• Abates with fasting- osmotic diarrhea.

13. • Watery diarrhea implies a defect primarily in water absorption
as a result of increased electrolyte secretion or reduced
electrolyte absorption (secretory diarrhea) or ingestion of a
poorly absorbed substance (osmotic diarrhea).
• Fatty diarrhea implies defective absorption of fat and perhaps
other nutrients in the small intestine.
• Inflammatory diarrhea – Presence of white blood cells or blood
in the stool are classified as having inflammatory diarrhea

17. APPROACH

19. Mastocytosis (urticaria pigmentosa)
Amyloidosis (macroglossia, waxy papules, pinch purpura)
 Addison’s disease (increased pigmentation)
Glucagonoma(migratory necrotizing erythema)
 Carcinoid syndrome (flushing)

20. • Celiac disease (dermatitis herpetiformis).
• Tremor and other systemic signs should lead to consideration
of hyperthyroidism.
• Right-sided heart murmurs, as well as an enlarged hard liver,
may be present with carcinoid syndrome.

21. • Occult blood
• White blood cells
• Sudan stain for fat.
• Fecal cultures
• pH, electrolytes and minerals, and laxatives
• Osmotic gap

22. • Tests for the neutrophil products, calprotectin and lactoferrin,
are sensitive and specific for the detection of neutrophils in
stool and may be a useful alternative to microscopy.
• Routine stool cultures are of little use
• C. difficile toxin

23. • Osmotic gap is calculated by subtracting twice the sum of the sodium
and potassium concentrations from 290 mOsm/kg, the osmolality of
stool in the body.
• A small osmotic gap (<50 mOsm/ kg), which signifies that the
osmolality of stool water is attributable mostly to incompletely
absorbed electrolytes, is characteristic of secretory diarrhea
• A large osmotic gap (>100 mOsm/kg) indicates that much of the
stool osmolality is composed of nonelectrolytes
• A large gap is characteristic of an osmotic diarrhea, usually resulting
from ingestion of some poorly absorbed substance, such as
magnesium salts.

24. • The diagnostic yield of colonoscopy or sigmoidoscopy with biopsy in
patients referred for chronic diarrhea is approximately 15% to 30%.
• Chronic disorders that can be diagnosed by inspection of the colonic
mucosa
 Melanosis coli
 Ulcerations
 Polyps,
 Tumors,
 IBD
 Amebiasis.
• Surawicz CM, Meisel JL, Ylvisaker T, Saunders DR, Rubin CE. Rectal biopsy in the diagnosis of Crohn’s disease: value of multiple biopsies and serial sectioning. Gastroenterology 1981;
• 80:66–71.
• Candreviotis N. The pathology of chronic amebic colitis in Greece studied by colon biopsy. Am J Proctol 1966;17:39–47.
• Nostrant TT, Kumar NB, Appleman HD. Histopathology differentiates acute self-limited colitis from ulcerative colitis. Gastroenterology 1987;92:318–328.

25. • Diseases in which the mucosa appears normal endoscopically
but that can be diagnosed histologically
 Microscopic colitis (lymphocytic and collagenous colitis),
Amyloidosis
Whipple’s disease
Granulomatous infections
 Schistosomiasis

26. Diseases that may be diagnosed by small intestinal biopsy
 Crohn’s disease
 Giardiasis
 Celiac sprue
 Intestinal lymphoma
 Eosinophilic gastroenteritis,
 Hypogammaglobulinemic sprue
 Whipple’s disease
 Lymphangiectasia,
 Abetalipoproteinemia
 Amyloidosis, mastocytosis,
 Various mycobacterial, fungal, protozoal, and parasitic infections.
Rubin CE, Dobbins WO. Peroral biopsy of the small intestine. Gastroenterology 1965;49:676–697.
• .Perera DR, Weinstein WM, Rubin CE. Small intestinal biopsy. Hum Pathol 1975;6:157–217. Whitehead R. Jejunal biopsy In: Whitehead R, ed.
Mucosal biopsy of the gastrointestinal tract. 3rd ed. London: Saunders, 1985:139–164.

31. THANK YOU