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Dr. HSAR Lelosutan, Sp.PD-KGEH, MARS
Sub SMF Gastroentero-Hepatologi Dep Peny Dalam RSPAD Gatot Soebroto Ditkesad Jakarta, 2010

Interpretation of findings 5. History 2. Osmotic load 2. Physical examination 3. Red flags 4. Increased secretions 3. Reduced contact time/surface area • Evaluation : 1.Diarrhea • Complications • Etiology : 1. Testing • Treatment • Key Points .

. Stool is 60 to 90% water. Stool amount is 100 to 200 g/day in healthy depending on the amount of unabsorbable dietary material (mainly carbohydrates). • Diarrhea is defined as stool weight > 200 g/day. • However.Approach of Diarrhea • • • • Malabsorption Syndromes Inflammatory Bowel Disease (IBD). many people consider any increased stool fluidity to be diarrhea. • Alternatively. many people who ingest fiber have bulkier but formed stools but do not consider themselves to have diarrhea.

electrolyte loss (Na. 3 • Hypokalemia can occur in severe or chronic diarrhea or if the stool contains excess mucus.Complications: • Complications may result from diarrhea of any etiology. very young. • Vascular collapse :  develop rapidly in patients who have : 1. . HCO loss can cause metabolic acidosis. • Hypomagnesemia after prolonged diarrhea can cause tetany. Cl). patients with cholera) or 2. very old. Mg. severe diarrhea (eg. • Fluid loss :  dehydration. K. . or debilitated.

There are a number of causes of diarrhea (see Table : Approach to the Patient With Lower GI Complaints: Some Causes of Diarrhea*). exudation into the lumen. increased secretions. decreased contact time/surface area. Thus. even small reductions (ie.Etiology • • • Normally. 2. and from multiple secretagogues and bacterial toxins that affect enterocyte function . 1%) in intestinal water absorption or increases in secretion can increase water content enough to cause diarrhea. Diarrhea in inflammatory bowel disease (IBD): mucosal destruction. • Several basic mechanisms for most significant diarrheas: 1.  ex. the small intestine and colon absorb 99% of fluid resulting from oral intake and GI tract secretions—a total fluid load of about 9 of 10 L daily. and 3. increased osmotic load.

Endocrine tumors : 9. Endocrine : Numerous causes exist. mastocytosis. Celiac sprue. Crohn's disease ex. Carbohydrate intolerance ex. lactose) in elixirs See Acute ex. Staphylococcus. Whipple's disease. Surgery : 6. Parasitic infection 4. caffeine. antineoplastic drugs.Some Causes of Diarrhea* • Acute 1. Laxatives. Tumors : 8. Mg-containing antacids. Vipoma. Food poisoning 5. rotavirus ex. colchicine. villous adenoma of the colon ex. Malabsorption syndr. medullary carcinoma of the thyroid ex. lymphoma. Hyperthyroidism • Chronic 1. quinine / quinidine. Drugs : : : : : ex. Shigella. Diet : 4. Infl. Cryptosporidia ex. carcinoid. Functional : 3. excipients (eg. gastrinoma. Viral infection 2. Colon carcinoma. bowel disease : 5. Irritable bowel syndrome ex. Escherichia coli. : 7. Entamoeba histolytica. Giardia. Clostridium difficile ex. many antibiotics. Clostridium perfringens ex. Ulcerative colitis. pancreatic insufficiency ex. Drugs : 2. Norovirus. Campylobacter. Bacterial infection 3. prostaglandin analogues. Some not mentioned may be likely causes in particular subgroups . Bacillus cereus. Intestinal or gastric bypass or resection ex. Salmonella.

used with permission. 15. prunes Sugar-free gum. Mg Adapted from Bayless T: Chronic diarrhea. sorbitol. Hospital Practice Jan. Caffeine 2. cola. tea. nuts. figs. pear juice. grapes. p 131. ice cream.Dietary Factors That May Worsen Diarrhea Dietary Factor 1. Lactose 5. . 1989. Fructose (in quantities surpassing the gut's absorptive capacity) Source Coffee. dates. prunes Milk. frozen yogurt. yogurt. mints. soft cheeses Mg-containing antacids 3. OTC headache remedies Apple juice. soft drinks (especially fruit flavored). honey. Hexitols. sweet cherries. and mannitol 4.

xylitol) or high fructose corn syrups. • Lactulose.Osmotic load: • Diarrhea occurs when unabsorbable. causes osmotic diarrhea because hexitols are poorly absorbed. Mg salts (hydroxide and sulfate). which is used as a laxative. • Osmotic diarrhea occurs with sugar intolerance (eg. which are used as sugar substitutes in candy. lactose intolerance caused by lactase deficiency). • Ingesting large amounts of hexitols (eg. gum. mannitol. causes diarrhea by a similar mechanism. and Na phosphate. sorbitol. and fruit juices. • Overingesting certain foodstuffs can produce osmotic diarrhea . which are used as laxatives. • Such solutes include polyethylene glycol. water-soluble solutes remain in the bowel and retain water.

intestinal peptide). which is an important driving force for fluid absorption in the small bowel and colon. mastocytosis (histamine). quinidine. prostaglandins) or indirectly by impairing fat absorption (eg. including vipomas (vasoactive • Some of these mediators (eg. medullary carcinoma of the thyroid ( calcitonin and prostaglandins). related compounds) also . • Infections (eg. and polypeptides). • Causes of increased secretions include infections. • Unabsorbed dietary fat and bile acids (as in malabsorption syndromes and after ileal resection) can stimulate colonic secretion and cause diarrhea. or both. colchicine. • Drugs may stimulate intestinal secretions directly (eg. • Various endocrine tumors produce secretagogues. gastrinomas (gastrin). castor oil. orlistat :XENICAL). Most enterotoxins block Na+-H+ exchange. accelerate intestinal transit. and carcinoid tumors (histamine. and various intrinsic and extrinsic secretagogues. certain drugs. colonic transit. quinine. prostaglandins.Increased secretions: • Diarrhea occurs when the bowels secrete more electrolytes and water than they absorb. anthraquinone cathartics. serotonin. serotonin. discussed in Gastroenteritis) are the most common causes of secretory diarrhea. unabsorbed fats. Infections combined with food poisoning are the most common causes of acute diarrhea (< 4 days in duration). gastroenteritis.

SSRIs) or humoral agents (eg. laxatives. • Other causes include microscopic colitis (collagenous or lymphocytic colitis) and celiac sprue. gastric resection. and inflammatory bowel disease. serotonin) also can speed transit . Mg-containing antacids. cholinesterase inhibitors. • Stimulation of intestinal smooth muscle by drugs (eg.Reduced contact time/surface area: • Rapid intestinal transit and diminished surface area impair fluid absorption and cause diarrhea. prostaglandins. • Common causes include small-bowel or large-bowel resection or bypass.

circumstances of onset (including recent travel. associated changes in weight or appetite. examination with attention to the abdomen and a digital rectal examination for sphincter competence and occult blood testing are important. presence of blood. diarrhea. Simultaneous occurrence of diarrhea in close contacts should be ascertained. drug use (including any antibiotics within the previous 3 mo). evidence of steatorrhea). pus. – – – – – • Physical examination: Fluid and hydration status should be evaluated.Evaluation • History: Duration and severity of diarrhea. and rectal urgency or tenesmus should be noted. changes in color or consistency. food ingested. source of water). or mucus. changes in stool characteristics (eg. A full • Red flags: Certain findings raise suspicion of an organic or more serious etiology of Blood or pus Fever Signs of dehydration Chronic diarrhea Weight loss . frequency and timing of bowel movements. abdominal pain or vomiting.

Interpretation of findings: • Acute. lymphadenopathy (lymphoma. abdominal discomfort is relieved by defecation. celiac disease). In colonic diseases. these symptoms alone do not discriminate IBS from other diseases. mucus. in small-bowel diseases. • • • watery diarrhea in an otherwise healthy person is likely to be of infectious etiology. and small. However. Recurrent bouts of bloody diarrhea in a younger person suggest inflammatory bowel disease. large-volume diarrhea (eg. and abdominal discomfort. thyroid nodules (medullary carcinoma of the thyroid). Diarrhea that consistently follows ingestion of certain foods (eg. possibly tainted food. Extra-abdominal findings that suggest an etiology include skin lesions or flushing (mastocytosis). or both. sometimes small in volume. and possibly accompanied by blood. pus. A history of oil droplets in stool. In irritable bowel syndrome (IBS). fats) suggests food intolerance. inflammatory bowel disease. AIDS). associated with more loose or frequent stools. particularly if associated with weight loss. • • • . stools are voluminous and watery or fatty. Recent antibiotic use should raise suspicion for antibiotic-associated diarrhea. Acute bloody diarrhea with or without hemodynamic instability in an otherwise healthy person suggests an enteroinvasive infection. Generally. daily stool volume > 1 liter/day) strongly suggests an endocrine cause in patients with normal GI anatomy. including Clostridium difficile colitis. right-sided heart murmur (carcinoid). The symptoms can help identify the affected part of the bowel. In the absence of laxative use. frequent stools (see Irritable Bowel Syndrome (IBS): Symptoms and Signs). particularly when travel. stools are frequent. tenesmus. or an outbreak with a point-source is involved. Patients with IBS or rectal mucosal involvement often have marked urgency. and arthritis (inflammatory bowel disease. Diverticular bleeding and ischemic colitis also present with acute bloody diarrhea. eg. suggests malabsorption.

• • • Undiagnosed secretory diarrhea requires testing (eg. urinary 5-hydroxyindole acetic acid [5-HIAA]) for endocrine-related causes. Assessment of pancreatic structure and function Capsule endoscopy may uncover lesions. and dietary review). coccidia. (> 4 wk) • Chronic diarrhea • • • • • • • • • stool testing should include culture. calcitonin. Stool samples C. Plesiomonas. Patients with osmotic diarrhea may have covert Mg laxative ingestion (detectable by stool Mg levels) or carbohydrate malabsorption (diagnosed by hydrogen breath test. Stool osmotic gap. fecal leukocytes (detected by smear or measurement of fecal lactoferrin). vasoactive intestinal peptide levels. and electrolytes (Na and K). pH (bacterial fermentation of unabsorbed carbohydrate lowers stool pH < 6. indicates whether diarrhea is secretory or osmotic. not identified by other modalities. and creatinine. BUN. Surreptitious laxative abuse must be considered. small-bowel enteroclysis or CT enterography (structural disease) and endoscopic small-bowel biopsy (mucosal disease). A review for symptoms and signs of thyroid disease and adrenal insufficiency should be done.electrolytes. lactase assay. plasma gastrin. An osmotic gap < 50 mEq/L indicates secretory diarrhea. histamine. and microsporidia Sigmoidoscopy or colonoscopy with biopsies should follow to look for inflammatory causes. difficile toxin assay. a larger gap suggests osmotic diarrhea. microscopic examination for ova and parasites. it can be ruled out by a fecal laxative assay . predominantly Crohn's disease or NSAID enteropathy. which is calculated 290 − 2 × (stool Na + stool K).0). fat (by Sudan stain). Specific tests for Giardia antigen and Aeromonas.Testing: • Acute diarrhea • • • Initial (< 4 days) CBC .

KCl. . Parenteral fluids containing NaCl. Although usually prescribed for constipation. and acidosis. codeine phosphate 15 to 30 mg bid or tid. – Diarrhea is a symptom. Psyllium or methylcellulose compounds provide bulk. but symptomatic – – – treatment is often necessary. acetate. or paregoric (camphorated opium tincture) 5 to 10 mL once/day to qid. Diarrhea may be decreased by oral loperamide 2 to 4 mg tid or qid (preferably given 30 min before meals). diphenoxylate 2. bulking agents given in small doses decrease the fluidity of liquid stools. electrolyte imbalance. Osmotically active dietary substances (see Table : Approach to the Patient With Lower GI Complaints: Dietary Factors That May Worsen Diarrhea) and stimulatory drugs should be avoided.5 to 5 mg (tablets or liquid) tid or qid. When possible. Kaolin. An oral glucose-electrolyte solution can be given if diarrhea is not severe and nausea and vomiting are minimal (see Dehydration and Fluid Therapy: Solutions). and activated attapulgite adsorb fluid.Treatment • Fluid and electrolytes for dehydration • Possibly antidiarrheals for nonbloody diarrhea in patients without systemic toxicity – Severe diarrhea • • • • to correct dehydration. in cholera). HCO 3) may be indicated if serum HCO3 is < 15 mEq/L. Oral and parenteral fluids are sometimes given simultaneously when water and electrolytes must be replaced in massive amounts (eg. Salts to counteract acidosis (Na lactate. and glucose are generally required. the underlying disorder should be treated. pectin.

 stool examination (cultures.Key Points • In patients with acute diarrhea. MBBS. or red flag symptoms. MD Content last modified October 2007 . difficile cytotoxin) is only necessary for patients who have prolonged symptoms (ie. Bharucha. difficile. more than 1 wk). or shigellosis. ova and parasites. C. Last full review/revision October 2007 by Adil E. Salmonella. • Beware using antidiarrheals if there is a possibility of C.