Chronic Diarrhea

Chronic Diarrhea: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Altered Intestinal Motility

❑ Irritable bowel syndrome

❑ Diabetic enteropathy

Inflammatory

❑ Inflammatory bowel disease

❑ Giardiasis

❑ Cryptosporidiosis

Osmotic

❑ Lactase deficiency

❑ Drugs

❑ Pancreatic insufficiency

❑ Post-gastrectomy

❑ Celiac sprue

❑ Small bowel lymphoma

Secretory

❑ Villous adenoma

❑ Pancreatic cholera

❑ Carcinoid

❑ Zollinger-Ellison syndrome

❑ Medullary carcinoma of the thyroid

Diagnostic Approach

Symptoms of inflammatory diarrhea are fever, abdominal tenderness, blood in the stool, or extraintestinal manifestations such as arthritis, erythema nodosum, pyoderma gangrenosum, or iritis. Osmotic diarrhea is suggested by steatorrhea or carbohydrate malabsorption. It improves with fasting. Secretory diarrhea is evidenced by large volume and watery stools, which persist at night and with fasting. Voluminous watery diarrhea is more likely with small bowel disorders, while small-volume frequent diarrhea occurs with colon disorders.

Fat malabsorption is characterized by increased stool bulk with foul-smelling stools. Stools are difficult to flush and leave oil in the bowl. Weight loss occurs despite adequate appetite and intake. Increased flatulence occurs with carbohydrate malabsorption. Protein-losing enteropathy is associated with peripheral edema and ascites. Malabsorption of fat-soluble vitamins may cause specific deficiencies, such as vitamin A (night blindness and dry eyes), vitamin D (paresthesias and cramps), or vitamin K (easy bruising) deficiencies.

Clinical Findings

Irritable bowel syndrome  Constipation and low-volume diarrhea with mucous stools wax and wane over years without worsening. Cramping abdominal discomfort, usually in the left lower quadrant, is relieved by defecation. Exacerbations often correspond to psychological stress.

Diabetic enteropathy  Nocturnal diarrhea occurs with diabetic autonomic neuropathy, along with orthostatic hypotension and erectile dysfunction.

Inflammatory bowel disease  Active inflammation causes frequent loose, bloody or purulent stools, abdominal pain, fever, and tenesmus. Extraintes-tinal manifestations such as axial or monoarticular arthritis, pyoderma gangrenosum, iritis, or hepatitis provide further clues when present.

Giardiasis  Diarrhea is mild with prominent gas and cramps. A history of ingestion of a ground water source (e.g., from a stream) is common.

Cryptosporidiosis  Watery diarrhea in children attending day care or in adults with AIDS is the typical presentation.

Lactase deficiency  Bloating, cramps, and diarrhea occur after eating milk products. Lactase deficiency may be acquired in adulthood or occur transiently as a sequela to a viral gastroenteritis.

Drugs  Laxative abuse may be hidden in patients with bulimia. Antibiotics, caffeine, digitalis, quinidine, sorbitol (sugar-free gums), and NSAIDs also cause diarrhea.

Pancreatic insufficiency  Stools are malodorous, bulky, and greasy. Often, two flushes are necessary to completely clear the toilet. In adults, there is usually a preceding history of recurrent acute pancreatitis, or of cystic fibrosis with recurrent URIs and small size for age.

Post-gastrectomy  Patients may have diarrhea because of “dumping syndrome” or “blind loop syndrome.” The former is caused by carbohydrate-rich foods, and the diarrhea is associated with orthostatic lightheadedness, sweating, and tachycardia. The latter produces fat malabsorption with the bulky, malodorous stools previously described.

Celiac sprue  Stools have an appearance similar to those from patients with pancreatic insufficiency. In addition, weight loss and symptoms of vitamin deficiency such as ecchymoses, glossitis, and peripheral neuropathy are prominent. Dermatitis herpetiformis (grouped vesicles on extensor surfaces) occur in a minority of patients with gluten-sensitive enteropathy.

Small bowel lymphoma  It presents insidiously with abdominal pain, weight loss, clubbing, peripheral edema, and abdominal mass.

Villous adenoma  Watery diarrhea occurs independent of food or fluid intake and often with excessive mucous secretion. Hypokalemia results.

Pancreatic cholera  Vasoactive intestinal peptide (VIP) causes watery, massive diarrhea, which leads to electrolyte abnormalities. Myopathy, flushing, or neuropathy may also occur.

Carcinoid  Episodic diarrhea coincides with flushing. Telangiectasias, cyanosis, pellagra-like skin lesions, bronchospasm, and right-sided valvular lesions are useful clues.

Zollinger-Ellison syndrome  Although patients may present with diarrhea, refractory or unusually located gastric ulcers are the more typical manifestations.

Medullary carcinoma of the thyroid  Diarrhea is associated with metastases and a poorer prognosis.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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