1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Approach to the patient with chronic diarrhea Presented By: Yusra Alkabab Medical Student May 2008

3. Definition the frequency, volume, and consistency of stools. the relationship between these features and patients' perception of diarrhea is variable. As a result, a consensus statement issued by the American Gastroenterological Association suggests that chronic diarrhea should be defined as a decrease in fecal consistency lasting for 4 or more weeks.

4. Onset Congenital Chloridorrhea, Na+ malabsorption Abrupt Infections, idiopathic secretory diarrhea Gradual Everything else Family history Congenital absorptive defects, IBD, celiac disease, multiple endocrine neoplasia Dietary history "Sugar-free" foods Sorbitol, mannitol ingestion Raw milk Exposure to potentially impure water source Chronic bacterial infections (eg, Aeromonas), giardiasis, cryptosporidiosis

5. Travel history Infectious diarrhea, chronic idiopathic secretory diarrhea Weight loss Malabsorption, pancreatic exocrine insufficiency, neoplasm, anorexia Previous therapeutic interventions (drugs, radiation, surgery, antibiotics) Drug side effects, radiation enteritis, postsurgical status, pseudomembranous colitis, post- cholecystectomy diarrhea Secondary gain from illness Laxative abuse

6. Systemic illness symptoms Hyperthyroidism, diabetes, vasculitis tumors, Whipple's disease, inflammatory bowel syndrome, tuberculosis, mastocytosis Intravenous drug abuse, sexual promiscuity AIDS Immune problems AIDS, immunoglobulin deficiencies Abdominal pain Mesenteric vascular insufficiency, obstruction, irritable bowel syndrome

7. Excessive flatus Carbohydrate malabsorption Leakage of stool Fecal incontinence Stool characteristics Blood Malignancy: inflammatory bowel disease Oil/food particles: Malabsorption, maldigestion White/tan color :Celiac disease, absence of bile Nocturnal diarrhea: Organic etiology

11. Mg, PO4, SO4 ingestion Carbohydrate malabsorption

12. Malabsorption syndromes Mucosal diseases Short bowel syndrome Postresection diarrhea Small bowel bacterial overgrowth Mesenteric ischemia Maldigestion Pancreatic exocrine insufficiency,Inadequate luminal bile acid

13. Inflammatory bowel disease UC, Crohn, Diverticulitis Ulcerative jejunoileitis Infectious diseases Pseudomembranous colitis, Invasive bacterial infections TB, yersinosis, others Ulcerating viral infections CMV,HSV Amebiasis/other invasive parasites Ischemic colitis Radiation colitis Neoplasia Colon cancer Lymphoma

14. Ileal bile acid malabsorption Inflammatory bowel disease Microscopic (lymphocytic) colitis Collagenous colitis Diverticulitis Vasculitis Drugs and poisons Laxative abuse (nonosmotic laxatives) Post-cholecystectomy (from bile salts) Congenital syndromes (chloridorrhea) Bacterial toxins

15. Disordered motility Postvagotomy,sympathectomy,Diabetic autonomic neuropathy, thyroidism,IBS Neuroendocrine tumors Gastrinoma,VIPoma, Somatostatinoma,Mastocytosis Carcinoid syndrome, Medullary ca of thyroid Neoplasia Colon ca, Lymphoma,Villous adenoma, Addison's disease Epidemic secretory diarrhea Idiopathic secretory diarrhea