Approach to a Patient With Chronic Diarrhoea Www.gr.Dentistbd.com

8/2/2019 Approach to a Patient With Chronic Diarrhoea Www.gr.Dentistbd.com

1/47

APPROACH TO A

PATIENT WITHCHRONIC DIARRHOEA


2/47

DEFINITION

Traditionally, diarrhea has been defined asan increase in daily stool weight (> 200g/day). --- impractical

Diarrhea can be considered an increase instool frequency (3 or more stools/day)and/or the presence of loose or liquidstools.


3/47

CLASSIFICATION

Acute diarrhea

Chronic diarrhea

4 weeks cut off point


4/47

CAUSES

Chronic Fatty Diarrheamalabsorptionsyndromes

Chronic Inflammatory Diarrhea

Chronic Watery Diarrhea Secretory Diarrhea

Osmotic Diarrhea

Drug-Induced Diarrhea
http://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI18.htm


5/47

Infectious Diarrhea

Endocrine diarrhea

Functional Diarrhea (diagnosis of exclusion)

Irritable Bowel Syndrome
http://www.fpnotebook.com/GI21.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI2.htmhttp://www.fpnotebook.com/GI2.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI21.htm


6/47

HISTORY


7/47

AGE

Young patients

Inflammatory Bowel Disease

Tuberculosis

Functional bowel disorder (Irritable bowel)

Older patients

Colon Cancer

Diverticulitis
http://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/GI82.htm


8/47

DIARRHEA PATTERN

Diarrhea alternates with Constipation

Colon Cancer

Laxative abuse

Diverticulitis

http://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI8.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/GI182.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI182.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/GI8.htmhttp://www.fpnotebook.com/GI16.htm


9/47

Intermittent Diarrhea

Diverticulitis


Malabsorption
http://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI16.htm


10/47

Persistent Diarrhea


Laxative abuse
http://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI182.htmhttp://www.fpnotebook.com/GI182.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htm


11/47

SMALL BOWEL/LARGEBOWEL

Small intestine or proximal coloninvolved

Large stool Diarrhea

Abdominal cramping persists after Defecation

Distal colon involved Small stool Diarrhea

Abdominal cramping relieved by Defecation
http://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI43.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI43.htmhttp://www.fpnotebook.com/GI43.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI43.htmhttp://www.fpnotebook.com/GI16.htm


12/47

DIURNAL VARIATION

No relationship to time of day: Infectious Diarrhea

Morning Diarrhea and after meals Gastric cause

Functional bowel disorder (e.g. irritable bowel)


Nocturnal Diarrhea (always organic)

Diabetic Neuropathy Inflammatory Bowel Disease
http://www.fpnotebook.com/GI21.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/END111.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/END111.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI21.htm


13/47

WEIGHT LOSS

Despite normal appetite Hyperthyroidism Malabsorption

Associated with fever Inflammatory Bowel Disease

Weight loss prior to Diarrhea onset Pancreatic Cancer

Tuberculosis Diabetes Mellitus Hyperthyroidism Malabsorption
http://www.fpnotebook.com/END230.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI65.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/END12.htmhttp://www.fpnotebook.com/END230.htmhttp://www.fpnotebook.com/END230.htmhttp://www.fpnotebook.com/END12.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/GI65.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/END230.htm


14/47

STOOL CHARACTERISTICS

Water:Chronic Watery Diarrhea

Blood, pus or mucus:ChronicInflammatory Diarrhea

Foul, bulky, greasy stools:Chronic FattyDiarrhea
http://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI20.htm


15/47

MEDICATION AND DIETARYINTAKE

drug induced diarrhea

Food borne illness

waterborne illnessHigh fructose corn syrup

Excessive sorbitol or mannitol

Excessive coffee or other caffeine


16/47

TRAVEL

Travelers diarrhea

Infectious diarrhea


17/47

ASSOCIATED SYMPTOMSAbdominal pain

Alternating constipation

Tenesmus

Unintentional wt. loss

Fever


18/47

PAST MEDICAL HISTORY

Childhood diarrhea-resolves-re-emergencein adulthood celiac disease

Uncontrolled diabetes

Pelvic radiotherapy


19/47

PAST SURGICAL HISTORY

Jejunoileal bypass

Gastrectomy with vagotomy

Bowel resection

Cholecystectomy


20/47

RED FLAGS-suggestive oforganic 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


21/47

PHYSICAL EXAMINATION


22/47

GPE

General appearance and mental status

Vital signs

Body weight

Orthostasis- volume depletion,autonomicdysfunction


23/47

exophthalmos (hyperthyroidism)

aphthous ulcers (IBD and celiac disease)

lymphadenopathy (malignancy, infection or

Whipple's disease)

enlarged or tender thyroid (thyroiditis, medullarycarcinoma of the thyroid)

clubbing (liver disease, IBD, laxative abuse,malignancy)


24/47

SKIN LESIONS

dermatitis herpetiformis (celiac disease)

erythema nodosum and pyoderma gangrenosum(IBD)

hyperpigmentation (Addison's disease)

flushing (carcinoid syndrome)

migratory necrotizing erythema (glucagonoma).


25/47

ABDOMINAL EXAMINATION

Surgical scars

abdominal tenderness

Masses

Hepatosplenomegaly

Borborygmus on auscultation malabsorption

bacterial overgrowth

obstruction, or rapid intestinaltransit.


26/47

PERINEAL AND RECTALEXAMINATION

Signs of incontinence skin changes from chronic irritation,

gaping anus,

weak sphincter tone.Crohn's disease

perianal skin tags

Ulcers

fissures abscesses

Fistulas

stenoses.

Fecal impaction or masses might be noted.


27/47

SYSTEMIC EXAMINATION

wheezing and right-sided heart murmurs(carcinoid syndrome)

arthritis (IBD, Whipple's disease)


28/47

INVESTIGATIONS


29/47

BLOOD TESTS

CBC

TSH

Serum electrolytes Serum albumin


30/47

STOOL EVALUATION

Stool pH (


31/47

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


32/47

ENDOSCOPY

PROCTOSIGMOIDOSCOPY


33/47

TREATMENT


34/47

NON-SPECIFIC THERAPIES

Dietary modifications

Smaller, more frequent meals

Dec. carbohydrates

Dec. fat intake

Avoidance of milk

Avoid sorbitol and mannitol


35/47

No good evidence to support use ofbulking agents

Bismuth subsalicylate(i.e., Pepto-Bismol)

opioids and opioid agonists Loperamide- first line therapy

diphenoxylate-atropine (Lomotil)

Codeine and other narcotics for refractorycases


36/47

SPECIFIC THERAPIES

Clonidine-

Diabetic diarrhea

moderate and severe diarrhea-predominant IBS

Somatostatin

refractory diarrhea

AIDS,

post chemotherapy,

GVHD,

and hormone secreting tumors.


37/47

bile acid binders (ie, cholestyramine)

pancreatic enzyme supplementation

antimicrobialsempiric fluoroquinolonestherapy


38/47

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.

e mos c n ca y use u e n on


39/47

e mos c n ca y use u e n onof diarrhea for this patient would

rely on:

A- Symptom description

B-An increase in daily stool weight (> 200g/day)

C-Laboratory tests

D-Report of loose or watery stools


40/47

How would you begin todiagnose this patient's complaint?

A-History and physical examination

B-History, physical examination, andlaboratory studies

C-History, physical examination, laboratorystudies, and colonoscopy with biopsy

D-History, physical examination, laboratorystudies, and sigmoidoscopy with biopsy

H ld ill


41/47

How would you assess illnessseverity?

A-Length of time since symptoms first appeared

B-Impact of diarrhea on daily function

C-Physical examination

D- Stool frequency

n a emp r ca erapy o c ron c


42/47

n a emp r ca erapy o c ron cdiarrhea for this patient should

include:A- Psyllium

B-Bismuth subsalicylate

C-Loperamide

D-Codeine


43/47

ROME II CRITERIA FOR IBS

At least 12 weeks, which need not beconsecutive, in the preceding 12 months ofabdominal discomfort or pain that has 2 of 3

features:

Relieved with defecation; and/or

Onset associated with a change in frequency ofstool; and/or

Onset associated with a change in form(appearance) of stool


44/47


45/47

Evaluation of PatientThere is a long list of investigations for the

diagnostic of etiology of ch. diarrhea .

SMALL BOWELDIARRHEA

LARGE BOWELDIARRHEA

Large stool volume Small amount of stoolIncreased frequencywith large volumestool

Increased frequencywith small volumestool

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


46/47


47/47

THANX

Documents

Approach to a Patient With Chronic Diarrhoea Www.gr.Dentistbd.com