Diarrhea

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Diarrhea

• Definition
• increase in the frequency of bowel movements
• increase in stool liquidity
• in some cases increase in daily stool weight
  (gt200g/d)

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Pathophysiological mechanisms

• secretory diarrhea (increased intestinal
  secretion)
• Osmotic diarrhea
• Decreased intestinal surface area and/or
  intestinal absorption
• Inflammatary diarrhea
• Rapid transit of intestinal contents (shortened
  transit time)

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Pathophysiological mechanisms

• secretory diarrhea (increased intestinal
  secretion)

Adenylate cyclase
cAMP system
activate
NaCl?
secretory diarrhea
agents

• infections (cholera toxin, E-col, salmonella,
  staphylococcal)
• Hormonal (Gut Hormones, ZES, VIP), cancer
  (calcitonin, Prostaglandins)
• miscellaneous (laxatives abuse, villous adenoma
  of the rectum)

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secretory diarrhoea

• infection
• cholera
• hormonal
• Verner-Morrison syndrome (VIP associated)
• carcinoid syndrome
• gastrinoma
• medullary thyroid cancer
• phenolphthalein abuse
• bile salt malabsorption

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Cholera the simplified version
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Verner-Morrison syndrome (VIP associated)

• a profuse, watery diarrhoea that results in
  massive intestinal loss of water, potassium,
  sodium and bicarbonate, leading to hypovolaemia,
  hypokalaemia and reduced total body potassium,
  and achlorhydria (metabolic acidosis).

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carcinoid syndrome

• paroxysmal flushing - for example, following
  coffee, alcohol, certain foods and drugs
• bronchoconstrictive episodes, similar to asthma
• right-sided heart failure
• episodes of explosive watery diarrhoea
• abdominal pain
• pellagra-like lesions of the skin and oral mucosa

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gastrinoma

• The Zollinger-Ellison syndrome describes the
  association of
• gastrin-producing tumours
• gastric hypersecretion
• severe peptic ulcer disease

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gastrinoma

• high fasting plasma gastrin
• high gastric acid secretion
• diminished response to pentagastrin
• demonstrable pancreatic or gastrointestinal
  tumour - by CT or venous sampling for gastrin
• more than 90 of gastrinomas have somatostatin
  receptors, and somatostatin receptor scintigraphy
  has been reported to be a especially sensitive
  method to image gastrinomas

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• Pathophysiological mechanisms
• Osmotic diarrhea
• It caused by accumulation of the followings in
  the gut lumen

being osmotically active
poorly absorble solutes maldigestion of
ingested food failure to transport an
osmotically active dietary nonelectrolyte (E
glucose)
water salts
diarrhea
intestinal Lumen
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osmotic diarrhoea

• disaccharidase deficiency
• primarily lactase deficiency
• laxative abuse(about 20 of patients

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Causes of diarrhea in
enteral nutrition
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Calculation of osmotic gap
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• Pathophysiological mechanisms
• Decreased intestinal surface area and/or
  intestinal absorption
• E surgical removal malabsorption syndrome

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• Pathophysiological mechanisms
• Rapid transit of intestinal contents (shortened
  transit time)

increase in intestinal motility (intestinal hurry)
contents
reduce
volume liquidity
stool
contact time? increase
small bowel mucosa
E irritable bowel syndrome Functional
diarrhea laxatives abuse post vagotomy
diarrhea post gastrectomy dumbing syndrome
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Etiology

• Acute Diarrhea
• infection
• Food poisoning
• Systematic diseases (influenza, sepsis, etc)
• Miscellanous

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Etiology

• Acute Diarrhea
• infection
• 1.viral
• 2. bacterial
• campylobacteria
• Shigella
• E. Coli
• Salmoneila
• etc
• 3.fungal
• 4.parasitic (amebic Trophozoites, Giardia)

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• Acute Diarrhea
• Food poisoning
• bacterial, plants, chemical poison(arsenic,...)
• Systematic diseases (influenza, sepsis, measle,
  etc)
• Miscellanous
• Allergic diseases
• Allergic purpura, enteropathy..
• endocronic diseases (ZES, etc.)
• Drugs laxatives, 5-Fu, etc.

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food poisoning

• bacterial
• intrinsically poisonous food, for example deadly
  nightshade, red kidney beans
• parasites in the meat, for example Taenia,
  Trichinella
• chemicals
• heavy metals, e.g. mercury, zinc
• pesticides, e.g. rodenticides, insecticides
• allergies
• paralytic shell fish poisoning
• scombrotoxin histamine intoxication
• viral food poisonining
• chinese restaurant syndrome - monosodium
  glutamate

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chinese restaurant syndrome

• Excess ingestion of monosodium glutamate results
  in a syndrome that includes a burning sensation
  over the neck, chest and arms, with tightness
  over the face and chest. There may also be
  headache, flushing, weakness, nausea and
  abdominal cramps.

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Etiology

• Chronic Diarrhea
• Intestinal
• Gastric(chronic gastritis,subtotal gastrectomy ,
  etc.)
• Pancreatic (Chronic Pancreatitis, Pancreatic
  Cancer, etc.)
• Hepatobiliary(liver cirrhosis, obstructive
  jaundice)
• functional causes
• Endocronic (Hyperthyroids crisis, ZES,
  Carcinoids)
• Drugs (Reserpin, Ismelin, Laxatives, etc.)
• Others (uremia, hypogammaglobulemia, etc.)

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Chronic Diarrhea

• Intestinal
• infections(T.B., Chronic bacteria dysentery,
  etc.)
• parasitics (Amebia dysentery, Giardiasis, etc.)
• IBD (ulcerative colitis, Chrons, etc.)
• malabsorption synd. (lactase deficiency, etc.)
• tumors

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Endoscopic image infectious colitis in
7-year-old girl
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lower small bowel disease

• Crohn's disease
• tuberculosis
• Yersinia enterocolitica
• Complications of lower small bowel disease
  causing diarrhoea include
• B12 deficiency
• bile acid wasting

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upper small bowel disease

• coeliac disease
• Giardiasis
• Whipple's disease
• There may be steatorrhoea or a watery stool.
• Other complications include
• iron deficiency
• folate deficiency
• calcium deficiency

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large intestine causes

• dysentery
• worms
• inflammatory bowel disease
• colonic carcinoma
• irritable bowel syndrome
• faecal impaction with overflow
• radiation enteritis
• diverticular disease
• mesenteric ischaemia

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gastric causes

• post gastrectomy
• post vagotomy
• gastrocolic fistula

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pancreatic causes

• cystic fibrosis
• chronic pancreatitis
• pancreatic carcinoma

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endocrine related

• uraemia
• thyrotoxicosis
• carcinoid syndrome
• Zollinger-Ellison syndrome
• medullary carcinoma of the thyroid
• hypoparathyroidism
• diabetes mellitus, which may cause autonomic
  diabetic neuropathy, presenting with nocturnal
  diarrhoea
• Verner-Morrison syndrome

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functional causes irritable bowel syndrome

• more than three motions per day
• less than three motions per week
• hard or lumpy stools
• loose or watery stools
• straining during a bowel movement
• urgency
• feeling of incomplete emptying
• passing mucus during a bowel movement
• abdominal fullness, bloating or swelling

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classification of diarrhoeal disease by
time-course

• acute
• chronic

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• Symptoms
• Acute diarrhea
• duration less than 2 weeks

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Acute diarrhea Symptoms

• onset
• Abrupt frequent, small fecal discharge
• Cramping abdominal pain, tenesmuse
• stool increased
• Routin Ex
• severe cases dehydration, electrolyte
  disturbances, metabolic acidosis, collapse
  hypovolumia, tetany.

volume liquidity
flecks of blood, mucus WBC, RBC, pus,
destroyed epithelium
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Symptoms

• Chronic diarrhea
• duration more than 2 months

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• Chronic diarrhea
• Symptoms
• Onset
• gradual/insidious
• Diarrhea of variable severity
• Diarrhea alternate with constipation
• Colicky abdominal pain, distention

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intestinal causes

• in small bowel pathology
• abdominal pain, when present, is periumbilical or
  right iliac fossa
• the frequency of defecation is often reduced
• the stool may be well formed but it is bulky,
  offensive, and may be pale in colour
• there may be signs and symptoms of malabsorption

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intestinal causes

• in large bowel pathology
• there is often a defect in the reabsorption of
  water from the faeces
• stools may be profuse and watery and/or mixed
  with blood and mucus
• there may be lower abdominal pain with tenesmus
  and urgency

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• stool
• watery, bloody, steatorrhea
• contains
• inflammatory cells/mucus/pus/indigested food
• severe/long-standing cases
• weight loss, malnutrition, edema, multy vits
  deficiency, malabsorption, wasting, edema, bone
  pain

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Accompanied Symptoms

• severe dehydration
• (cholera, pancreatic cholera-WDHA, etc.)
• fever
• (Acute bacillery dysentery, Typhoid, TB
  enteritis, etc.)
• tenesmus (Acute dysentery, proctitis, etc.)
• markedly weight loss
• (cancer of gut, malabsorption, etc.)
• Arthralgia/Arthritis
• (IBD, connective tissue diseases, etc.)
• masses (malignant cancer of GI, TB, peritonitis,
  etc.)

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Diagnostic Procedures

• Information
• P.E. Findings
• fever, dehydration, malnutrion, anemia,
  ulticaria, jaundice, arthralgia, abdominal
  masses, Tenesmus, digital rectal examination.
• Lab findings

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Diagnostic Procedures

• information
• in epidemics (Dysentery, v. Cholerae, Typhoid,
  food poisonning, enteritis)
• food allergy
• past illness(antibiotic related diarrhea, etc.)
• medication take(corticosteroids, laxatives, etc.)
• predisposing conditions (surgical resection,
  parasitic infection, etc.)

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Lab findings

• Blood
• Urine
• Stool
• Microscopy
• Tolerance tests
• Breath tests
• Culture of Jejunal aspirates
• 5 HIAA (urinary excretion)
• Vit B12 absorption test
• X-ray Barium
• Endoscopy
• Suction biopsy technique (Jejunal mucosa histology

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investigations of diarrhoea

• digital rectal examination, to exclude overflow
  diarrhoea due to constipation and a low rectal
  carcinoma
• blood tests include
• full blood count, ESR
• creatinine and electrolytes, glucose
• C reactive protein
• clotting screen
• B12 and folate
• TIBC
• thyroxine
• immunoglobulins
• fasting gut hormones - if other tests(-)

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• Lab findings
• Urine
• Protein
• cast
• Stool
• appearance
• (watery, bloody, bulky, sticky, malodorous,
  steaterrhea,
• foul-smelling)

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• Lab findings
• Microscopy
• RBC, WBC
• polymorphonuclear (PMN)Shigella, solmonella,
• E coli
• mononuclear (M)
• motile amebic trophozoites
• Grams stain () staphylococcal enteritis
• Culture salmonolla, shigella, v. cholera
• Fat determination

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investigations of diarrhoea

• radiology
• especially important when the abdomen is
  distended or tender
• a plain abdominal film may reveal fluid levels,
  gas- filled loops or loss of gas in parts where
  the loops are inflamed
• barium enema
• sigmoidoscopy /- biopsy
• colonoscopy /- biopsy
• stool microbiology, including microscopy, culture
  and antibiotic sensitivitydetermine
• stool for faecal fat estimation to exclude
  steatorrhoea

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• Lab findings
• Tolerance tests
• (d-xylose Glucose/lactose/sucrose)
• Breath tests
• 14C Glycine-cholate, xylose
• Culture of Jejunal aspirates
• (Bacterial overgrowth)
• (increased Bile and deconjugation)
• 5 HIAA (urinary excretion)
• Vit B12 absorption test

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differential diagnosis of diarrhoea

• copious watery diarrhoea suggests an organic
  aetiology
• nocturnal diarrhoea suggests an organic aetiology
  - patient wakes up in the night needing to open
  bowels
• frequent passage of small amounts of faeces
  suggests functional bowel disease, e.g. irritable
  bowel syndrome
• bloody diarrhoea implies colonic disease, often
  inflammatory bowel disease or carcinoma, or an
  invasive infective diarrhoea, e.g. Campylobacter
  jejuni
• acute diarrhoea often has an infective aetiology

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CASE REPORT

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