2. 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.
11. SMALL BOWEL/LARGE
BOWEL
Small
intestine or proximal colon involved
– Large stool Diarrhea
– Abdominal cramping persists after
Defecation
Distal
colon involved
– Small stool Diarrhea
– Abdominal cramping relieved by
Defecation
12. DIURNAL VARIATION
No relationship to time of day: Infectious Diarrhea
Morning Diarrhea and after meals
– Gastric cause
– Functional bowel disorder (e.g. irritable bowel)
– Inflammatory Bowel Disease
Nocturnal Diarrhea (always organic)
– Diabetic Neuropathy
– Inflammatory Bowel Disease
13. 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
18. PAST MEDICAL HISTORY
Childhood
diarrhea-resolves-reemergence in adulthood– celiac
disease
Uncontrolled
Pelvic
diabetes
radiotherapy
19. PAST SURGICAL HISTORY
Jejunoileal
bypass
Gastrectomy
Bowel
with vagotomy
resection
Cholecystectomy
20. 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
35. No
good evidence to support use of
bulking agents
Bismuth
Bismol )
opioids
subsalicylate (i.e., Pepto-
and opioid agonists
– Loperamide- first line therapy
– diphenoxylate-atropine (Lomotil )
– Codeine and other narcotics – for
refractory cases
36. SPECIFIC THERAPIES
Clonidine-
– Diabetic diarrhea
– moderate and severe diarrhea-predominant IBS
Somatostatin
– refractory diarrhea
•
•
•
•
AIDS,
post chemotherapy,
GVHD,
and hormone secreting tumors.
38. 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.
39. The most clinically useful definition of
diarrhea for this patient would rely on:
A-
Symptom description
B-An
increase in daily stool weight (> 200
g/day)
C-Laboratory
D-Report
tests
of loose or watery stools
40. 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
41. How would you assess illness
severity?
A-Length
of time since symptoms first
appeared
B-Impact
of diarrhea on daily function
C-Physical
D-
examination
Stool frequency
42. Initial empirical therapy of chronic
diarrhea for this patient should include:
A- Psyllium
B-Bismuth subsalicylate
C-Loperamide
D-Codeine
43. 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