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ACUTE AND CHRONIC DIARRHOEA

Prof. S.M. Bhatt, EBS, MBCh.B, M.Med, MPH (Hopkins), FRCP (Edin). Professor of Medicine.

OUTLINE

Introduction. Definitions. Classification of Diarrhea. Approach to a patient with diarrhea. Acute Diarrhea. Chronic Diarrhea.

Introduction

Diarrhea is a major health concern in developing countries. 4 billion global cases of diarrhea per year. It is one of the most common clinical signs of gastrointestinal disease, but also can reflect primary disorders outside of the digestive system Mainly affects <2 yr olds

Definitions

Diarrhea is best described as too frequent passage of too loose (unformed) stools. It is frequently accompanied by urgency, and occasionally incontinence. When considering a patient with diarrhea the following must be considered:

frequency (>3 movements/day), consistency (loose/watery), volume (>200 g/day) and whether the condition is continuous.

Definitions

Acute: Diarrhea lasting less than 2 weeks, Persistent: 2 to 4 weeks, and Chronic diarrhea lasting more than 4 weeks. Dysentery: diarrhea with visible blood in the stool. Pseudodiarrhea - frequent passage of small volumes of stool. Often associated with rectal urgency and accompanies the irritable bowel syndrome or anorectal disorders e.g. proctitis. Fecal incontinence - involuntary discharge of rectal contents, most often caused by neuromuscular disorders or structural anorectal problems

Classification

There are numerous causes of diarrhea though usually is a manifestation of one of the four basic mechanisms described below. It is common for more than one of the 4 mechanisms to be involved in the pathogenesis of a given case. 1. Osmotic Diarrhea: results if the osmotic pressure of intestinal contents is higher than that of the serum. Characteristically, osmotic diarrhea ceases when the patient fasts. E.g. lactose intolerance 2. Secretory diarrhea: occurs when there is a net secretion of water into the lumen. This may occur with bacterial toxins, such as those produced by E. coli or Vibrio cholerae, or with hormones, such as vasoactive intestinal polypeptide (VIP), which is produced by rare islet cell tumors of the pancreas.

Classification:
3. Inflammatory diarrhea: results from direct damage to the small or large intestinal mucosa. This interferes with the absorption of sodium salts and water and is complicated by exudation of serum proteins, blood and pus. Infectious or inflammatory disorders of the gut cause this kind of diarrhea. 4. Dysmotility diarrhea: Disorders in motility that accelerate transit time could decrease absorption, resulting in diarrhea even if the absorptive process per se was proceeding properly. NB: In most instances of diarrhea two or more of these four mechanisms are at work.

Causes of Diarrhea

Infective causes Bacterial, e.g. Campylobacter jejuni Salmonella sp. Shigella, Clostridium botulinum GI TB Viral, e.g. rotavirus Fungal, e.g. histoplasmosis Parasitic, e.g. amoebic dysentery (Entamoeba histolytica) schistosomiasis Giardia intestinalis Endocrine ZE syndrome Vipoma Carcinoid syndrome Thyrotoxicosis Medullary carcinoma of thyroid Diabetic autonomic neuropathy

Non-infective causes of diarrhoea Inflammatory bowel disease Pseudomembranous colitis Radiation proctitis or colitis Behet's disease Diverticular disease Ischaemic colitis Malabsorption Drugs - many, including laxatives metformin antica ncer drugs Irritable bowel syndrome and functional diarrhoea Factitious diarrhoea Purgative abuse Dilutional diarrhoea

Approach to a patient with Diarrhea.

History:

Is it truly diarrhea? Duration? The stool: consistency?, frequency?, volume? any visible blood?. Any systemic symptoms :Fever, tachycardia, weight loss? Underlying Risk factors: Age, immune status, recent travel, medications, known food allergy? Presence and location of abdominal pain?

Approach to Diarrhea

Physical examination: Always look for signs of dehydration and malnutrition.


Vital signs: tachycardia, hypotension, tachypnea. Skins turgor and tonus. Systemic features of any underlying disaese e.g. stigmata of HIV. Abdominal exam: distension, bowel sounds, tenderness, masses and rectal examination

Approach to diarrhea patient.


Laboratory and diagnostic studies: chosen on the history, acute vs. chronic diarrhea. Stool analysis: Microscopy: for features of intestinal inflammation. Ova and Cyst. Toxins like C.deficile Culture. Quantitative and qualitative fat analysis. FHG, LFTs and U/E/CR Imaging as per the clinical presentation of the patient.

Acute Diarrhea

More than 90% of cases of acute diarrhea are caused by infectious agents; these cases are often accompanied by vomiting, fever, and abdominal pain. The remaining 10% or so are caused by medications, toxic ingestions, ischemia, and other conditions. In immunocompetent patients it is usually self limiting and intervention may be limited to oral rehydration if there are no signs of significant fluid loss.

Acute diarrhea: Presence or absence of blood in stool


Acute diarrhea with blood

Acute dirrrhea without blood


Bacillary dysentery (shigellosis) Enterohemorrhagic EC Campylobacter Salmonella Yersinia Amebic dysentery Pseudomembranous colitis.

Viruses(Rotavirus etc) Bacteria: Cholera; E.Coli except EHEC; Clostridia Protozoa: Giardia; cryptosporidia. Others: Food toxins, strongloides; malaria

Acute diarrhea: site involved


Small bowel

Large bowel

Include toxigenic bacteria like vibrio and ETEC; viruses and Giardia. Produce large volume watery diarrhea and mid abdominal pain. Blood and fecal leucocytes are rare.

Usually invasive oerganisms like Shigella, campylobacter and EIEC, EHEC. They produce low volume, mucoid or bloody diarrhea. Associated with low abdominal or rectal pain (tenesmus). There is inflamed rectal mucosa and the diarrhea has fecal leucocytes

Acute diarrhea: management

Fluid replacement: Oral rehydration is preferred route but if patient vomiting or intravascularly depleted (resting tachycardia with postural hypotension) IV fluid is necessary. Diet: Not benefit to fasting but avoid the following: Dairy products Alcohol caffeine

Acute diarrhea: management

Drugs:

Antimoility agents:

Can be very useful but should not be used if there is an acute severe colitis. LOPERAMIDE is the drug of choice. Pathogens: shigella; V.cholera, S.typhi; C.deficile. Acute diarrhea with pain, vomiting, fever and myalgia. Laboratory proven cases of G.intstinalis. Travellers diarrhea in adults.

Antibiotics: Indications

Chronic diarrhea

History To distinguish: Acute from chronic diarrhea Organic (<3months; weight loss; nocturnal symptoms; continuous symptoms) from functional(absence of organic symptoms and longstanding history) Malabsorptive diarrhea ( bulky, malodorous, difficult to flush, pale stools) from other causes(liquid/loose stools with blood or mucus) Stool character and associated symptoms. Family history of IBD Sytemic dideseases e.g DM and hyperthyroidsm Evidence of chronic pancreatitis. Diet and stres as aggreveating factors

Chronic diarrhea

Physical exam:

General exam: extent of fluid depletion; nutritional status. Skin and mucus membranes: Rashesmouth ulcers etc Thyroid gland exam Per Abdomen: Ascites, masses Anorectal exam for abscesses, masses etc.

Chronic Diarrhea

Investigations: Blood tests: FHG/ESR; Fe and B12, TFT, RBS, LFTS, U/E/CR Stool: m/c/s For fat analysis Stool volume and osmotic gap response to fasting Sigmoidoscopy and/or colonoscopy Radiological imaging. Others: Pancreatic function test. Small bowel biopsy Serology for coeliac disease.

Chronic diarrhea: treatment

Treatment of chronic diarrhea depends on the specific etiology and may be: Curative: If the cause can be eradicated, treatment is curative as with antibiotic administration for Whipple's disease, or discontinuation of a drug. Suppressive: For many chronic conditions, diarrhea can be controlled by suppression of the underlying mechanism. Examples include elimination of dietary lactose for lactase deficiency or gluten for celiac sprue, use of glucocorticoids or other antiinflammatory agents for idiopathic IBDs or Empirical: When the specific cause or mechanism of chronic diarrhea evades diagnosis, empirical therapy may be beneficial. Mild opiates, such as diphenoxylate or loperamide, are often helpful in mild or moderate watery diarrhea.