Chronic watery diarrhea differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2], Seyedmahdi Pahlavani, M.D. [3]

Differential Diagnosis of Chronic watery Diarrhea from other diseases

The following table outlines the major differential diagnoses of chronic watery diarrhea.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]

Abbreviations: GI: Gastrointestinal, CBC: Complete blood count, WBC: White blood cell, RBC: Red blood cell, Plt: Platelet, Hgb: Hemoglobin, ESR: Erythrocyte sedimentation rate, CRP: C–reactive protein, IgE: Immunoglobulin E, IgA: Immunoglobulin A, ETEC: Escherichia coli enteritis, EPEC: Enteropathogenic Escherichia coli, EIEC: Enteroinvasive Escherichia coli, EHEC: Enterohemorrhagic Escherichia coli, EAEC: Enteroaggregative Escherichia coli, Nl: Normal, ASCA: Anti saccharomyces cerevisiae antibodies, ANCA: Anti–neutrophil cytoplasmic antibody, DNA: Deoxyribonucleic acid, CFTR: Cystic fibrosis transmembrane conductance regulator, SLC10A2: Solute carrier family 10 member 2, SeHCAT: Selenium homocholic acid taurine or tauroselcholic acid, IEL: Intraepithelial lymphocytes, MRCP: Magnetic resonance cholangiopancreatography, ANA: Antinuclear antibodies, AMA: Anti-mitochondrial antibody, LDH: Lactate dehydrogenase, CPK: Creatine phosphokinasePCR: Polymerase chain reaction, ELISA: Enzyme–linked immunosorbent assay, LT: Heat–labile enterotoxin, ST: Heat–stable enterotoxin, RT-PCR: Reverse–transcriptase polymerase chain reaction, CD4: Cluster of differentiation 4, HIV: Human immunodeficiency virus, RUQ: Right-upper quadrant, VIP: Vasoactive intestinal peptide, GI: Gastrointestinal, FAP: Familial adenomatous polyposis, HNPCC: Hereditary nonpolyposis colorectal cancer, MTP: Microsomal triglyceride transfer protein, Scl‑70: Anti–topoisomerase I, TSH: Thyroid-stimulating hormone, T4: Thyroxine, T3: Triiodothyronine, DTR: Deep tendon reflex, RNA: Ribonucleic acid

Cause Clinical manifestation Lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Symptoms GI signs
Duration Diarrhea Fever Abdominal pain Weight loss
Stool exam CBC Other lab findings
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Crohn's disease + + + + ± + + + + Nl
  • Abnormal immune response to self antigens
Ulcerative colitis + + + + ± + + + + Nl
  • Abnormal immune response to self antigens
Celiac disease + ± ± + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Chronic pancreatitis + + + + + Nl Nl Nl Nl
Bile acid malabsorption + + + + Nl Nl Nl Nl
Microscopic colitis + + + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Infective colitis + + + + + + + + + Nl
Ischemic colitis + + + + + + + + + Nl
Lactose intolerance + + + + Nl Nl Nl
  • Lactose tolerance test
  • Genetic testing
  • Reduction of lactase enzyme activity or inability to produce persistent lactase
  • Congenital lactase deficiency
  • Secondary lactose malabsorption
Irritable bowel syndrome + ± ± ± Nl Nl Nl Nl Nl
  • Unknown
  • Diagnosis of exclusion
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Whipple's disease + + + ± + + Nl ↓/↑
Tropical sprue + + + + + + + + Nl Nl Nl
  • Diagnosis of exclusion
Small bowel bacterial overgrowth + + + + + + Nl Nl Nl
  • Diagnosis of exclusion
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Salmonellosis + + + + + + + + Nl Nl
Escherichia coli enteritis EPEC + + + + + + + + + Nl Nl Nl
EAEC + + + + + + + Nl
Aeromonas + + + + + + + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Mycobacterium avium complex + + + + + + + + Nl Nl
HIV + + + + + + Nl Nl
  • HIV virologic (viral load) test
  • Immunoassay 
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Entamoeba histolytica + + + + + + + + + Nl Nl Nl
  • Antigen testing
  • Serology 
Giardia + + + + + + Nl Nl Nl Nl
  • Antigen detection assays
Cryptosporidium + + + + + Nl
  • Positive stool microscopy
Nl Nl Nl
  • Polymerase chain reaction
Microsporidia + + + + + + Nl
  • Positive stool microscopy
Nl Nl Nl
  • Decreased CD4 count
  • Antigen detection assays
Isospora + + + + + + + + + + Nl Nl Nl
  • Detecting oocysts in the feces
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Carcinoid tumor + + + + + + Nl Nl Nl
VIPoma + + + + + + Nl Nl Nl
  • Primary secretory tumor
  • Blood VIP levels
  • Followed by imaging
Zollinger–Ellison syndrome + + + + + + Nl Nl
Somatostatinoma + + + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Lymphoma + + + + + + + Nl Nl Nl
  • Primary tumor of GI tract
Colorectal cancer + + + + + + + Nl Nl Nl
Medications + + + ± ± + + ↑/↓ Nl Nl
  • Elevated plasma level of drug
  • Clinical evaluation after discontinuation of the drugs
Factitious diarrhea + + + + + ↑/↓ Nl Nl Nl
  • Clinical evaluation after discontinuation of the drugs
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Heavy metal ingestion + + + + Nl Nl Nl Nl
  • Elevated plasma heavy metal level
  • Plasma level of heavy metal
Organophosphate poisoning + + + + Nl Nl Nl Nl
  • Clinical diagnosis
Opium withdrawal + + + + Nl Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Short bowel syndrome + + + + + Nl Nl
Radiation enteritis + + + + + + + + + Nl Nl Nl
Dumping syndrome + + + + Nl Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Abetalipoproteinemia + + + + + Nl Nl Nl Nl
Hyperthyroidism + + ± + + Nl Nl Nl Nl
Diabetic neuropathy + + + + + Nl Nl Nl
Systemic sclerosis + + ± + + + + Nl Nl Nl
  • Clinical diagnosis
  • Followed by serologic tests

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