1. Diarrhea

2. Case Presentation 48 yo woman c/o diarrhea
2-3 large volume, watery BMs since her 20s
associated abdominal pain (localized to the epigastrum and periumbilical area)
no fevers,chills significant weight loss, blood or mucus in the stool
rare noctural diarrhea
PMH 1. Hypertension 2. Osteopenia
PSH: TAH-BSO

3. Case Presentation
SH: 3rd generation Mexican-American, married with 3 adult children, No tobacco, alcohol or illicit drug use. No blood transfusion
Meds: Accupril, Premarin, Calcium/Vit D
PE: thin, well appearing woman
VS: afebrile, BP 105/60, HR 72, wt 105, ht 5’1”
Heent: pale conjunctiva
Abdomen: NABS, soft NT, no massess, well healed scar in RUQ

4. Case Presentation Labs: Stool: Bloods
nl electrolyes, BUN, creatinine and glucose, Hgb 10.2 g/dl, MCV 77, Platelets 400K
Stool:
Culture: normal fecal flora, no leukocytes, neg 0+P, neg Sudan fat

5. Definition
Increased liquidity, frequency or decreased consistency of stools

6. Mechanisms Osmotic Diarrhea Secretory Diarrhea Deranged Motility
Exudation

7. Osmotic Diarrhea
results from poorly absorbable osmotically active solutes in the gut lumen
stops when the patient is fasting
stool analysis - Inc osmotic gap 290 mosm/kgH2O-2(Na+K)mmol/l

8. Some Causes of Osmotic Diarrhea
Carbohydrate malab
gluc-galact malab
fructose malab
disaccaridase def
ingestion (poorly absorbable carbs)
lactulose
sorbitol
fructose
fiber
Magnesium-Induced
Nutritional supplemts
antacids
laxatives
GI Lavage solutions
Laxative
sodium citrate
sodium phophate
sodium sulfate

9. Secretory Diarrhea
Results from abnormal ion transport in intestinal epithelial cells
Main categories of secretory diarrhea
congenital defects of ion absorptive process
intestinal resection
diffuse mucosal disease
abnormal mediators

10. Secretory Diarrhea Diarrhea persist during a fast
stool Na, K and the accompany anions account for the stool osmolality (small osmotic gap)

11. Some Causes of Secretory Diarrhea
Laxatives
Phenolophthalein, aloe
Medications
diuretics
Toxins
coffee, tea, cola, ETOH
Bacterial Toxins
S.aureus, C.perf +bot, B.cereus
Congenital
Bacterial entertoxins
V. cholera, C.diff, Y.enterocol, toxigenic E. coli
Endogenous laxatives
bile acids, LCFA
Hormone producing tumors

12. Deranged Motility
Enhanced Motility (Intestinal Hurry) - decrease contact time of the stool to the absorptive surface
Abnormally slow motility may results in bacterial overgrowth and resultant diarrhea

13. Exudation
Results from disruption of the intestinal mucosa from inflammation or ulceration
blood, mucus and serum proteins in gut lumen
bacillary dysnentery
Inflammatory bowel disease

14. Approach to Patients with Diarrhea
History
Characteristics of the onset of diarrhea should be precisely noted (congenital, abrupt, gradual)
Pattern of diarrhea should be recorded (continuous or intermittent)
Duration of the symptoms
Epidemiological factors (travel, exposure to contaminated food or water, illness in other contacts)

15. History
Stool characteristics should be investigated (watery, bloody, fatty)
Presence of fecal incontinence
Presence of abdominal pain
Presence of weight loss
Aggravating factors (diet or stress)
Mitigating factors (alteration of diet, OTC meds)
Previous evaluations

16. History
Iatrogenic causes (medication history, surgical history, radiation history)
Factitious diarrhea (history of eating disorders, secondary gain and malingering)
Careful ROS (hyperthyroidism, diabetes mellitus, CVD, AIDS, etc)

17. Approach to Patients with Diarrhea
Physical Exam
Presence of rashes or flushing
mouth ulcers
thyroid masses
wheezing
arthritis
anal rectal examination

18. Erythema Nodosum

19. Acute Diarrhea Less than 2-3 weeks duration
Majority of cases are mild and self limiting
4 million deaths world-wide per year in children under 5 years
Categories
infectious
noninfectious
drugs, fecal impaction, elixir diarrhea, enteral feedings, chemotherapy or radiation therapy, runner’s diarrhea

20. Who Needs Evaluation? High fever (>102F)
orthostatic symptoms or presyncope
bloody diarrhea
severe abdominal pain
immunocompromised persons

21. Diagnostic Tests for Acute Diarrhea
Spot Stool Sample
Culture, Ova and Parasite, C.diff toxin, fecal leukocytes
Blood Tests
CBC, electrolytes, SMA 7, blood culture
Plain X-rays
Endoscopy
flex sig

22. Treatment for Acute Diarrhea
Symptomatic
fluid replacement
Oral replacemet solutions or IV fluids
antidiarrheals
Bismuth subsalicylate
Antimicrobial therapy
quinolones
metronidazole
Bactrim
Rifaximin

23. Antidiarrheals and Infectious Acute Diarrheas
Bismuth Subsalicylates (Pepto-Bismol)
safe and efficacious
antidiarrheal effects, antibacterial, antiinflammatory
Loperamide
safe in traveler’s diarrhea
Kaolin-pectin, opiates, anticholingerics
not effective

24. Antibiotics in Acute Diarrheas
Recommended
Shigellosis
Cholera
Traveler’s diarrhea
Pseudomembranous enterocolitis
parasites
STDs
Not Recommended
E.coli 0157:H7

25. Antibiotics First Line Second Line
Ciprofloxacin - effective against most enteric infections
Metronidazole - if symptoms suggest Giardia
Second Line
Bactrim - effective second line therapy for most infectious diarrheas

26. Rifaximin (Xifaxan) Nonabsorbed
Broad-spectrum antibacterial activity invitro
No known drug interactions
200 mg PO TID or 400 mg PO BID comparable to cipro

27. Nosocomial Acute Diarrheas
Fecal impaction
Drugs
Elixir Diarrhea
Enteral Feedings
Infectious Nosocomial Diarrhea
Chemotherapy/Radiation Therapy

28. Infectious Nosocomial Diarrheas
Usually from C.difficile
Salmonella, Shigella, 0+P extremely rare if diarrhea develops after 3-4 days in hospital
In the immunosuppressed, viral infections are an important cause

29. Runner’s Diarrhea 20-40% of runner’s (more common in women) Mechanism
release of GI hormones
release of inflammatory mediators
?ischemia

30. Algorithm for Acute Diarrhea
Noninfectious
Infectious
Assess severity, duration
immocompetence of host
Eval and Rx of
underlying cause
Rehydration
and wu
Symptomatic therapy
resolves
Continues
Possible abx
antidiarrheal agents

31. Chronic Diarrhea At least 3 to 4 weeks duration
accounts for 30% of patients in GI practices
Categories
Organic
malabsorpitive, secretory, exudative (inflammatory)
Functional

32. Diagnostic Test for Chronic Diarrhea
Blood tests
CBC, SMA, ESR, Thyroid function
Stool studies
Spot
WBCs, occult blood, O+P, culture, giardia Ag
Quantitative
volume/weight, electrolytes, osmolality, fat, pH
fecal osm gap: ([Na] + [K])

33. Diagnostic Tests Endoscopy Radiology
Flex sig or colonoscopy with biopsies
Upper endoscopy
biopsies
aspiration for bacterial counts and parasites
Radiology
Plain Radiographs
UGI/Small Bowel Series

34. Malabsorptive Diarrhea
Fat Malabsorption
intraluminal maldigestion
mucosal malabsorption
postmucosal malabsorption
intestinal lymphangiectasia, vasuclitis
Carbohydrate Malabsorption
Protein Malabsorption (Azotorrhea)

35. Malabsorptive Diarrheas (Fat)
Intraluminal Phase
Cirhosis
Bile duct obstruction
Bacterial overgrowth
Pacreatic exocrine insufficiencyl
Mucosal Phase
Drugs
Infectious disease
Immune system dz
Tropical sprue
Celiac sprue
Whipple’s dz
Abetalipoproteinemia

36. Celiac Sprue
Normal small bowel

37. Schilling Test Vitamin B 12 deficiency 1. Intrinsic factor deficiency
2. Pancreatic insufficiency
3. Bacterial overgrowth
4. Extensive Ileal disease or resection

38. Schilling Test 1. Ingestion of labeled Vit B12 and Non- labeled
IM Vit B12
2. Urine labeled
Vit B12 <8%/24 hr=
malabsorption
(Corrects)
Intrinsic factor
IF def (PA)
Pancreatic enzymes
Panc exoc def
Antibiotic therapy
Bact overgrowth
Ileal disease or resection

39. Malabsoprtive Diarrhea (Carbs)
Sorbitol diarrhea
Fructose diarrhea
Glucose-galactose deficiency
Diasaccharidase deficiency

40. Lactose/Hydrogen Breath Test
Step 1 - measure baseline end-expiratory breath hydrogen levels
Step 2 - ingestion of lactose 50 gm
Step 3 - measure breath Hydrogen levels at 30, 60, 90, 120 min
rise >20 ppm suggest lactose malabsorption

41. D-Xylose Test Step 1 - 25 gm dose of D-xylose ingestion
Step 2 - urine collected for next 5 hours
Step 3 - at 1 hour, a blood sample taken (optional)
<4gm (16% excretion) in urine or serum conc <20mg/dl of d-xylose = abnormal intestinal absorption

42. Secretory Diarrheas Carcinoid Syndrome Gastrinoma (ZE syndrome)
Vipoma or Watery Diarrhea-Hypokalemia Achlorhydria Syndrome
Medullary Carcinoma of the Thyroid
Glucagnoma
Villous Adenomas
Systemic Mastocytosis

43. Inflammatory Diarrheas
Inflammatory Bowel Disease
Eosinophilic Gastroenteritis
Protein-Losing Enteropathy

44. Inflammatory bowel disease
Crohn’s disease
Granuloma

45. Treatment for Chronic Diarrhea
Antidiarrheal therapy
Mild to Moderate Diarrhea
Bismuth subsalicylates, opiates, bulk-forming agents, silicates, anticholingerics, cholestyramine
Secretory Diarrhea
octreotide, clonidine, Ca++ channel blockers, H2blockers, PPIs, H1 blockers, serotonin antagonist, indomethacin, glucocorticoids