Presentation on theme: "APPROACH TO A PATIENT WITH CHRONIC DIARRHOEA DR. SHIRIN MIRZA HOUSE PHYSICIAN MEDICAL UNIT-I, HFH."— Presentation transcript:
APPROACH TO A PATIENT WITH CHRONIC DIARRHOEA DR. SHIRIN MIRZA HOUSE PHYSICIAN MEDICAL UNIT-I, HFH
DEFINITION ► Traditionally, diarrhea has been defined as an increase in daily stool weight (> 200 g/day). --- impractical ► Diarrhea can be considered an increase in stool frequency (3 or more stools/day) and/or the presence of loose or liquid stools.
CLASSIFICATION ► Acute diarrhea ► Chronic diarrhea ► 4 weeks– cut off point
PAST MEDICAL HISTORY ► Childhood diarrhea-resolves-re-emergence in adulthood– celiac disease ► Uncontrolled diabetes ► Pelvic radiotherapy
PAST SURGICAL HISTORY ► Jejunoileal bypass ► Gastrectomy with vagotomy ► Bowel resection ► Cholecystectomy
RED FLAGS-suggestive of organic causes ► Painless diarrhea ► Recent onset in an older patient ► Nocturnal diarrhea (especially if wakes patient) ► Weight loss ► Blood in stool ► Large stool volumes: >400 grams stool per day ► Anemia ► Hypoalbuminemia ► increased ESR
GPE ► General appearance and mental status ► Vital signs ► Body weight ► Orthostasis- volume depletion,autonomic dysfunction
► exophthalmos (hyperthyroidism) ► aphthous ulcers (IBD and celiac disease) ► lymphadenopathy (malignancy, infection or Whipple's disease) ► enlarged or tender thyroid (thyroiditis, medullary carcinoma of the thyroid) ► clubbing (liver disease, IBD, laxative abuse, malignancy)
► Fecal fat (abnormal if >14 grams/24 hours) ► Stool ova and parasites (2-3 samples) ► Giardia lamblia antigen Indicated for diarrhea >7 days and >10 stools/day ► Clostridium difficle toxin Indicated if recent antibiotics or hospitalization ► Consider testing stools for laxative abuse
ENDOSCOPY ► PROCTOSIGMOIDOSCOPY
NON-SPECIFIC THERAPIES ► Dietary modifications Smaller, more frequent meals Dec. carbohydrates Dec. fat intake Avoidance of milk Avoid sorbitol and mannitol
► No good evidence to support use of bulking agents ► Bismuth subsalicylate (i.e., Pepto-Bismol ) ► opioids and opioid agonists Loperamide- first line therapy diphenoxylate-atropine (Lomotil ) Codeine and other narcotics – for refractory cases
SPECIFIC THERAPIES ► Clonidine- Diabetic diarrhea moderate and severe diarrhea-predominant IBS ► Somatostatin refractory diarrhea ► AIDS, ► post chemotherapy, ► GVHD, ► and hormone secreting tumors.
Case Presentation: ► A 60-year-old woman ► diarrhea for the past 3 months ► denies nausea, vomiting, or fever ► Her appetite is poor. ► She initially attributed the diarrhea to travel, ► but her symptoms have not resolved over several weeks. ► traveled to Singapore prior to the onset of symptoms.
The most clinically useful definition of diarrhea for this patient would rely on: ► A- Symptom description ► A- Symptom description ► B-An increase in daily stool weight (> 200 g/day) ► B-An increase in daily stool weight (> 200 g/day) ► C-Laboratory tests ► C-Laboratory tests ► D-Report of loose or watery stools
How would you begin to diagnose this patient's complaint? ► A-History and physical examination ► B-History, physical examination, and laboratory studies ► C-History, physical examination, laboratory studies, and colonoscopy with biopsy ► D-History, physical examination, laboratory studies, and sigmoidoscopy with biopsy
How would you assess illness severity? ► A-Length of time since symptoms first appeared ► A-Length of time since symptoms first appeared ► B-Impact of diarrhea on daily function ► C-Physical examination ► D- Stool frequency
Initial empirical therapy of chronic diarrhea for this patient should include: ► A- Psyllium ► B-Bismuth subsalicylate ► B-Bismuth subsalicylate ► C-Loperamide ► D-Codeine ► D-Codeine
ROME II CRITERIA FOR IBS ► At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features: Relieved with defecation; and/or Onset associated with a change in frequency of stool; and/or Onset associated with a change in form (appearance) of stool
Evaluation of Patient There is a long list of investigations for the diagnostic of etiology of ch. diarrhea. SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA Large stool volume Small amount of stool Increased frequency with large volume stool Increased frequency with small volume stool No urgency urgency No tenesmus Tenesmus present No mucus Mucus in stool No blood Blood may be present Central abdominal pain Pain in left iliac fossa relived by defecation