Chronic diarrhea overview: Difference between revisions
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==Overview== | ==Overview== | ||
Chronic diarrhea is a common symptom of many conditions | Chronic [[diarrhea]] is a common [[symptom]] of many [[conditions]] and has an estimated [[prevalence]] of 5%. Although chronic [[diarrhea]] has multiple definitions, a current working definition is the production of [[loose stools]] for longer than 4 weeks. Frequent [[defecation]] with normal consistency is termed psuedodiarrhea. There are 3 basic categories of chronic [[diarrhea]]: [[Watery diarrhea|watery]], fatty ([[malabsorption]]), and [[inflammatory]] (with [[blood]] and [[pus]]). The fundamental [[pathophysiology]] of all [[diarrhea]] is altered intestinal water and [[electrolyte]] transport caused by several factors majorly dependent on the socioeconomic status of the [[population]]. If left untreated, [[patients]] with [[chronic diarrhea]] may progress to develop [[symptoms]] of [[Altered mental status|altered sensorium]] due to [[electrolyte imbalance]], [[dehydration]], and [[malnutrition]]. Common [[complications]] of [[chronic diarrhea]] include [[confusion]], perforated [[bowels]], [[sepsis]], and death. [[Prognosis]] is generally good when the underlying cause is identified and treated early. The laboratory findings in chronic [[diarrhea]] include [[complete blood count]] to evaluate for [[anemia]] and abnormal [[white blood cell count]], [[Electrolyte|electrolytes]], [[Thyroid function tests|thyroid function tests,]] [[Serological testing|serology testing]] for [[celiac disease]], and [[Stool examination|stool analysis]] for [[Fecal occult blood|fecal leukocytes]], fecal [[lactoferrin]], and [[Fecal occult blood|fecal occult blood.]] Treatment is targeted at treating the underlying cause of the diarrhea. | ||
==Historical Perspective== | ==Historical Perspective== | ||
The word diarrhea derived from the Greek term "to flow through | The word "[[diarrhea]]" was coined by Hippocrates. [[Diarrhea]] is derived from the Greek term "to flow through." Diarrhea is a common manifestation of [[Gastrointestinal diseases|gastrointestinal disease]]. | ||
==Classification== | ==Classification== | ||
Chronic diarrhea may be classified into 3 basic categories: watery, fatty([[malabsorption]]) and [[inflammatory]] (with [[blood]] and [[pus]]). It is important to note that not all chronic diarrhea falls into one category alone. | Chronic [[diarrhea]] may be classified into 3 basic categories: [[Watery diarrhea|watery]], fatty ([[malabsorption]]), and [[inflammatory]] (with [[blood]] and [[pus]]). It is important to note that not all [[chronic diarrhea]] falls into one category alone. Classifying a patient's [[chronic diarrhea]] into a subcategory helps to direct the [[diagnostic]] workup. | ||
==Pathophysiology== | ==Pathophysiology== | ||
The fundamental pathophysiology of all diarrhea is incomplete absorption of water from the [[lumen]] | The fundamental [[pathophysiology]] of all diarrhea is incomplete [[absorption]] of water from the [[lumen]] because of either a reduced rate of net water [[absorption]] or [[osmotic]] retention of water intraluminally. The causes of chronic diarrhea include [[inflammatory]], [[osmotic]], [[Secretory component|secretory]], [[iatrogenic]], [[motility]], and functional [[Disease|diseases]]. [[Osmotic]] chronic [[diarrhea]] involves an unabsorbed substance that draws water from the [[plasma]] into the [[intestinal]] lumen along [[osmotic]] gradients. If excessive amounts of unabsorbed substance are retained in the [[intestinal]] lumen, water will not be absorbed and [[diarrhea]] will result. Secretory chronic [[diarrhea]] on the other hand, results from disordered [[electrolyte]] transport and, despite the term, is more commonly caused by decreased [[absorption]] rather than net [[secretion]]. A disruption of the normal colonic [[epithelial]] barrier by microorganisms is mainly responsible for [[inflammatory]] chronic [[diarrhea]]. This disruption can lead to exudative, secretory, or malabsorptive components of inflammatory chronic [[diarrhea]]. Both rapid transit time and slow transit time are associated with motility [[disorders]] causing chronic [[diarrhea|diarrhea.]] Some [[iatrogenic]] causes of chronic diarrhea are seen after [[abdominal]] [[surgeries]] such as [[cholecystectomy]], where about 5%–10% of patients develop chronic diarrhea. In general, the causes of chronic [[diarrhea]] are multifactorial. | ||
==Causes== | ==Causes== | ||
Depending on the | Depending on the socioeconomic status of the [[population]], chronic [[diarrhea]] can be caused by several factors. In a developing nation, the most likely causes of chronic [[diarrhea]] are [[Mycobacterial infection|mycobacterial]] and [[parasitic infections]], while functional disorders such as [[malabsorption]] and [[Inflammatory bowel disease|inflammatory bowel diseases]] are less likely causes. In a developed nation, however, the most likely causes of [[diarrhea]] are [[irritable bowel syndrome]] (IBS), [[inflammatory bowel disease]], [[malabsorption]] syndromes (such as [[lactose intolerance]] and [[celiac disease]]), and chronic [[infections]] (particularly in patients who are [[immunocompromised]]). | ||
==Differentiating Chronic Diarrhea | ==Differentiating Chronic Diarrhea from other Conditions== | ||
The differential diagnosis for chronic diarrhea is enormous, with a large number of diagnostic tests available that can be used to evaluate these patients. Classifying | The [[differential diagnosis]] for [[chronic diarrhea]] is enormous, with a large number of diagnostic tests available that can be used to evaluate these patients. Classifying a patient's [[chronic diarrhea]] into a subcategory such as [[Watery diarrhea|watery]], fatty, and [[inflammatory]] helps to direct the [[diagnostic]] workup. Some [[Watery diarrhea|watery]] causes of chronic diarrhea which should be differentiated from one another include [[Crohn's disease]], [[hyperthyroidism]], [[VIPoma]], [[lactose intolerance]], [[celiac disease]], and [[irritable bowel syndrome]] (IBS). The causes of fatty diarrhea that should be differentiated from one another include [[celiac sprue]], [[pancreatic insufficiency]], [[bacterial overgrowth]], and [[maldigestion]] problems which results from [[Pancreatic insufficiency|pancreatic exocrine insufficiency]]<nowiki/>y. Finally, the [[inflammatory]] causes of chronic diarrhea such as [[diverticulitis]], [[ulcerative colitis]], and [[entamoeba histolytica]] must also be differentiated. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
In developed countries, the [[prevalence]] of [[chronic diarrhea]] is estimated to be about 300-500 per 100,000 persons. In any given year, about 3–5% of the population has diarrhea lasting more than 1 month. | |||
==Risk Factors== | ==Risk Factors== | ||
The risk factors of chronic diarrhea can be assessed based on | The [[risk factors]] of [[chronic diarrhea]] can be assessed based on [[epidemiological]] associations and the [[patient]]'s characteristics. Some of these factors can be classified based on travel history, [[epidemics]] and [[outbreaks]], [[patients]] with [[AIDS|acquired immune deficiency syndrome]], and whether the [[patients]] are institutionalized or hospitalized. | ||
==Natural History, | ==Natural History, Complications, and Prognosis== | ||
If left untreated, [[patients]] with [[chronic diarrhea]] may progress to develop [[symptoms]] of [[Altered mental status|altered sensorium]] due to [[electrolyte imbalance]], [[dehydration]], and [[malnutrition]]. Common [[complications]] of [[chronic diarrhea]] include [[confusion]], perforated [[bowels]], [[sepsis]], and death. [[Prognosis]] is generally good when the underlying cause is identified and treated early. | |||
== | ==Diagnosis== | ||
There are no criteria for the diagnosis of chronic diarrhea. However, in order to make an accurate diagnosis, it is important | There are no criteria for the [[diagnosis]] of [[chronic diarrhea]]. However, in order to make an accurate [[diagnosis]], it is important to take a detailed history and a [[Physical examination|physical exam]] from an expert's opinion and from experience in individual clinical centers. The use of these methods is subject to bias; however, a specific [[diagnosis]] can be achieved in more than 90% of [[patients]]. | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
Obtaining the history of a patient is the most important aspect of making a [[diagnosis]] of chronic [[diarrhea]]. Specific histories about the [[symptoms]] (duration, onset, progression), associated [[symptoms]], and [[drug]] usage have to be obtained. The hallmark of chronic [[diarrhea]] is [[loose stools]] lasting for 4 weeks or more. A positive history of foul smelling [[stools]] that are difficult to flush, bloody loose bowel movements, and cramping [[abdominal pain]] are suggestive of chronic [[diarrhea]]. The most common symptoms of chronic [[diarrhea]] include cramping [[abdominal pain]][[Body temperature|, elevation in body temperature]], and increased frequency of [[Diarrhea (patient information)|bowel movements]]. | |||
===Physical Examination=== | ===Physical Examination=== | ||
Some of the physical findings of chronic diarrhea are [[orthostatic hypotension]], [[dehydration]], [[neuropathy]], [[muscle wasting]], [[edema]], [[malnutrition]], [[urticaria]] pigmentosa, [[dermatographism]], pinch [[purpura]], [[macroglossia]], [[hyperpigmentation]], [[Addison's | Some of the physical findings of [[chronic diarrhea]] are [[orthostatic hypotension]], [[dehydration]], [[neuropathy]], [[muscle wasting]], [[edema]], [[malnutrition]], [[urticaria]] pigmentosa, [[dermatographism]], pinch [[purpura]], [[macroglossia]], [[hyperpigmentation]], [[Addison's disease]], and migratory necrotizing [[erythema]]. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
The laboratory findings in chronic diarrhea include [[complete blood count]] to evaluate for [[anemia]] | The laboratory findings in chronic [[diarrhea]] include [[complete blood count]] to evaluate for [[anemia]] and abnormal [[white blood cell count]], [[Electrolyte|electrolytes]], [[Thyroid function tests|thyroid function tests,]] [[Serological testing|serology testing]] for [[celiac disease]], and [[Stool examination|stool analysis]] for [[Fecal occult blood|fecal leukocytes]], fecal [[lactoferrin]], and [[Fecal occult blood|fecal occult blood.]] Some other diagnostic studies that have been adopted in the diagnosis of [[chronic diarrhea]] include [[flexible sigmoidoscopy]], [[colonoscopy]], [[esophagogastroduodenoscopy]], and [[capsule endoscopy]]. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
There are no electrocardiogram findings associated with chronic diarrhea. | There are no [[electrocardiogram]] findings associated with [[Chronic diarrhea|chronic diarrhea.]] | ||
===Chest X Ray=== | ===Chest X-Ray=== | ||
There are no chest | There are no chest [[x-ray]] findings associated with [[chronic diarrhea]]. | ||
===CT Scan=== | ===CT Scan=== | ||
There are no CT findings associated with chronic diarrhea. | There are no [[Computed tomography|CT]] findings associated with [[chronic diarrhea]]. | ||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
There are no additional | There are no additional [[imaging]] findings for [[chronic diarrhea]]. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
[[Medications]] are the mainstay of treatment; the treatment of chronic [[diarrhea]] is targeted at treating the underlying cause. [[Antidiarrheal]] drugs, which act by improving [[stool]] consistency, reducing [[stool]] frequency, or reducing [[stool]] weight, are mainly employed for [[symptomatic]] treatment. | |||
===Surgery=== | ===Surgery=== | ||
Surgical intervention is | [[Surgery]] is not the first-line treatment option for [[patients]] with chronic [[diarrhea]]. Surgical intervention is usually reserved for [[patients]] who have failed all medical therapy and when [[malignancy]] is suspected on [[biopsy]] as the cause of the chronic [[diarrhea]]. | ||
===Prevention=== | |||
The primary and secondary prevention methods of chronic diarrhea are the same. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Emergency medicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Gastroenterology]] | |||
[[Category:Pediatrics]] | |||
[[Category:Up-To-Date]] | |||
Latest revision as of 13:44, 15 January 2021
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Chronic diarrhea Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]
Overview
Chronic diarrhea is a common symptom of many conditions and has an estimated prevalence of 5%. Although chronic diarrhea has multiple definitions, a current working definition is the production of loose stools for longer than 4 weeks. Frequent defecation with normal consistency is termed psuedodiarrhea. There are 3 basic categories of chronic diarrhea: watery, fatty (malabsorption), and inflammatory (with blood and pus). The fundamental pathophysiology of all diarrhea is altered intestinal water and electrolyte transport caused by several factors majorly dependent on the socioeconomic status of the population. If left untreated, patients with chronic diarrhea may progress to develop symptoms of altered sensorium due to electrolyte imbalance, dehydration, and malnutrition. Common complications of chronic diarrhea include confusion, perforated bowels, sepsis, and death. Prognosis is generally good when the underlying cause is identified and treated early. The laboratory findings in chronic diarrhea include complete blood count to evaluate for anemia and abnormal white blood cell count, electrolytes, thyroid function tests, serology testing for celiac disease, and stool analysis for fecal leukocytes, fecal lactoferrin, and fecal occult blood. Treatment is targeted at treating the underlying cause of the diarrhea.
Historical Perspective
The word "diarrhea" was coined by Hippocrates. Diarrhea is derived from the Greek term "to flow through." Diarrhea is a common manifestation of gastrointestinal disease.
Classification
Chronic diarrhea may be classified into 3 basic categories: watery, fatty (malabsorption), and inflammatory (with blood and pus). It is important to note that not all chronic diarrhea falls into one category alone. Classifying a patient's chronic diarrhea into a subcategory helps to direct the diagnostic workup.
Pathophysiology
The fundamental pathophysiology of all diarrhea is incomplete absorption of water from the lumen because of either a reduced rate of net water absorption or osmotic retention of water intraluminally. The causes of chronic diarrhea include inflammatory, osmotic, secretory, iatrogenic, motility, and functional diseases. Osmotic chronic diarrhea involves an unabsorbed substance that draws water from the plasma into the intestinal lumen along osmotic gradients. If excessive amounts of unabsorbed substance are retained in the intestinal lumen, water will not be absorbed and diarrhea will result. Secretory chronic diarrhea on the other hand, results from disordered electrolyte transport and, despite the term, is more commonly caused by decreased absorption rather than net secretion. A disruption of the normal colonic epithelial barrier by microorganisms is mainly responsible for inflammatory chronic diarrhea. This disruption can lead to exudative, secretory, or malabsorptive components of inflammatory chronic diarrhea. Both rapid transit time and slow transit time are associated with motility disorders causing chronic diarrhea. Some iatrogenic causes of chronic diarrhea are seen after abdominal surgeries such as cholecystectomy, where about 5%–10% of patients develop chronic diarrhea. In general, the causes of chronic diarrhea are multifactorial.
Causes
Depending on the socioeconomic status of the population, chronic diarrhea can be caused by several factors. In a developing nation, the most likely causes of chronic diarrhea are mycobacterial and parasitic infections, while functional disorders such as malabsorption and inflammatory bowel diseases are less likely causes. In a developed nation, however, the most likely causes of diarrhea are irritable bowel syndrome (IBS), inflammatory bowel disease, malabsorption syndromes (such as lactose intolerance and celiac disease), and chronic infections (particularly in patients who are immunocompromised).
Differentiating Chronic Diarrhea from other Conditions
The differential diagnosis for chronic diarrhea is enormous, with a large number of diagnostic tests available that can be used to evaluate these patients. Classifying a patient's chronic diarrhea into a subcategory such as watery, fatty, and inflammatory helps to direct the diagnostic workup. Some watery causes of chronic diarrhea which should be differentiated from one another include Crohn's disease, hyperthyroidism, VIPoma, lactose intolerance, celiac disease, and irritable bowel syndrome (IBS). The causes of fatty diarrhea that should be differentiated from one another include celiac sprue, pancreatic insufficiency, bacterial overgrowth, and maldigestion problems which results from pancreatic exocrine insufficiencyy. Finally, the inflammatory causes of chronic diarrhea such as diverticulitis, ulcerative colitis, and entamoeba histolytica must also be differentiated.
Epidemiology and Demographics
In developed countries, the prevalence of chronic diarrhea is estimated to be about 300-500 per 100,000 persons. In any given year, about 3–5% of the population has diarrhea lasting more than 1 month.
Risk Factors
The risk factors of chronic diarrhea can be assessed based on epidemiological associations and the patient's characteristics. Some of these factors can be classified based on travel history, epidemics and outbreaks, patients with acquired immune deficiency syndrome, and whether the patients are institutionalized or hospitalized.
Natural History, Complications, and Prognosis
If left untreated, patients with chronic diarrhea may progress to develop symptoms of altered sensorium due to electrolyte imbalance, dehydration, and malnutrition. Common complications of chronic diarrhea include confusion, perforated bowels, sepsis, and death. Prognosis is generally good when the underlying cause is identified and treated early.
Diagnosis
There are no criteria for the diagnosis of chronic diarrhea. However, in order to make an accurate diagnosis, it is important to take a detailed history and a physical exam from an expert's opinion and from experience in individual clinical centers. The use of these methods is subject to bias; however, a specific diagnosis can be achieved in more than 90% of patients.
History and Symptoms
Obtaining the history of a patient is the most important aspect of making a diagnosis of chronic diarrhea. Specific histories about the symptoms (duration, onset, progression), associated symptoms, and drug usage have to be obtained. The hallmark of chronic diarrhea is loose stools lasting for 4 weeks or more. A positive history of foul smelling stools that are difficult to flush, bloody loose bowel movements, and cramping abdominal pain are suggestive of chronic diarrhea. The most common symptoms of chronic diarrhea include cramping abdominal pain, elevation in body temperature, and increased frequency of bowel movements.
Physical Examination
Some of the physical findings of chronic diarrhea are orthostatic hypotension, dehydration, neuropathy, muscle wasting, edema, malnutrition, urticaria pigmentosa, dermatographism, pinch purpura, macroglossia, hyperpigmentation, Addison's disease, and migratory necrotizing erythema.
Laboratory Findings
The laboratory findings in chronic diarrhea include complete blood count to evaluate for anemia and abnormal white blood cell count, electrolytes, thyroid function tests, serology testing for celiac disease, and stool analysis for fecal leukocytes, fecal lactoferrin, and fecal occult blood. Some other diagnostic studies that have been adopted in the diagnosis of chronic diarrhea include flexible sigmoidoscopy, colonoscopy, esophagogastroduodenoscopy, and capsule endoscopy.
Electrocardiogram
There are no electrocardiogram findings associated with chronic diarrhea.
Chest X-Ray
There are no chest x-ray findings associated with chronic diarrhea.
CT Scan
There are no CT findings associated with chronic diarrhea.
Other Imaging Findings
There are no additional imaging findings for chronic diarrhea.
Treatment
Medical Therapy
Medications are the mainstay of treatment; the treatment of chronic diarrhea is targeted at treating the underlying cause. Antidiarrheal drugs, which act by improving stool consistency, reducing stool frequency, or reducing stool weight, are mainly employed for symptomatic treatment.
Surgery
Surgery is not the first-line treatment option for patients with chronic diarrhea. Surgical intervention is usually reserved for patients who have failed all medical therapy and when malignancy is suspected on biopsy as the cause of the chronic diarrhea.
Prevention
The primary and secondary prevention methods of chronic diarrhea are the same.