Chronic diarrhea

1. Chronic Diarrhea
• Abdul Waris Khan
• Soepel: 5th
• Dept: Internal medicine

2. SOEPEL
• Subjective: a 44 years old female presented to ER
wit complains of loose stools for the past 1 month.
• H/O presenting illness: she complains of loose stools
for 1 month associated with blood in stools. She is a
known case of IBD

3. • Objective: appropritae history and P.E
• Evaluation: haemorrhoids, bleeding per rectum,
infective diarrhea, inflammatory diarrhea
• Plan: stool culture
• Elaporation: rehydration, antiobiotics if infective
cause and elemination of the cause.

4. Definition
Diarrhea is loosely defined as passage of abnormally
liquid or unformed stools at an increased frequency.
For adults on a typical Western diet, stool weight >200
g/d can generally be considered diarrheal.
Acute if <2 weeks
Persistent if 2–4 weeks
Chronic if >4 weeks in duration.

5. • In contrast to acute diarrhea, most of the
causes of chronic diarrhea are
noninfectious.

6. Slide Title
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• • Feature 1
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7. • Secretory Causes:-
o Due to derangements in fluid and electrolyte
transport across the enterocolonic mucosa.
• They are characterized clinically by watery, large-volume
fecal outputs that are typically painless and
persist with fasting.
o Medications (e.g, laxatives ,nsaids)
o Bowel Resection, Mucosal Disease, or Enterocolic Fistula (e,g. ileal resection,
bile acid mal absorbtion)
o Defects in Ion Absorption (addison’s disease)

8. • Osmotic Causes:-
o occurs when ingested, poorly absorbable, osmotically active solutes draw
enough fluid into the lumen to exceed the reabsorptive capacity of the
colon. Osmotic diarrhea characteristically ceases with fasting or with
discontinuation of the causative agent.
o Osmotic Laxatives
o Carbohydrate Malabsorption (e,g. lactase deficiency)

9. • Steatorrheal Causes:-
o Fat malabsorption may lead to greasy, foul-smelling, difficult-to-flush
diarrhea often associated with weight loss and nutritional
deficiencies due to concomitant malabsorption of amino acids
and vitamins.
o Intraluminal maldigestion
o Mucosal malabsorption (celiac disease)
o Lymphatic obstruction

10. • Inflammatory Causes:-
o Inflammatory diarrheas are generally accompanied by pain,
fever, bleeding, or other manifestations of inflammation.
o Depending on lesion site, may include fat malabsorption,
disrupted fluid/electrolyte absorption, and hypersecretion or
hypermotility from release of cytokines and other inflammatory
mediators.
o The unifying feature on stool analysis is the presence of leukocytes
or leukocyte-derived proteins such as calprotectin.
o Inflammatory Bowel Disease

11. • Dysmotility Causes:-
• IBS, hyperthyroidism, carcinoid syndrome,
and certain drugs (e.g., prokinetic agents)
may produce hypermotility with resultant
diarrhea.

12. • Factitial Causes:-
o Factitial diarrhea accounts for up to 15% of
unexplained diarrheas referred to tertiary care
centers.
o Munchausen syndrome

13. Approach to the Patientwith Chronic Diarrhea
• The history, physical examination and routine blood
studies should attempt to characterize the
mechanism of diarrhea.
• Patients should be questioned about the onset,
duration, pattern, aggravating (especially diet) and
relieving factors, and stool characteristics of their
diarrhea.
• The presence or absence of fecal incontinence,
fever, weight loss, pain, and common extraintestinal
manifestations (skin changes, arthralgias, oral
aphthous ulcers) should be noted. E,g in IBD

14. • Peripheral blood leukocytosis, elevated
sedimentation rate, or C-reactive protein suggests
inflammation
• Anemia reflects blood loss or nutritional deficiencies
• Blood chemistries may demonstrate electrolyte,
hepatic, or other metabolic disturbances
• Measuring tissue transglutaminase antibodies may
help detect celiac disease

17. Management
• Treat causes.
• Rehydration
• If severely dehydrated, give 0.9% saline + 20mmol K+/L IVI.
• Codeine phosphate or loperamide reduces stool frequency.
• If dehydrated and bloody diarrhea for >2 weeks administer IV
fluids as well.
• Avoid antibiotics except in infective causes, as this can cause
antibiotic resistance.

18. References
Harrison internal medicine
Kumar and cark clinical emdicine
Oxford handbook of clinical medicine