CHRONIC DIARRHEA (>4WKS)

Scenario: 32M with 2 week hx of bloody BM’s, fever, anorexia, malaise. Now very sick
Approach:

 My approach to chronic diarrhea is infectious vs inflammatory vs neoplastic vs drugs vs malabsorption vs secretory vs

motility

Chronic Diarrhea
Infectious  HIV and related infections

Inflammatory  Inflammatory bowel disease

 Bowel ischemia
 Radiation enteritis

Neoplastic  Colon cancer

Drugs  Antacids, antibiotics, Mg, lactulose, sorbitol, colchicine

Malabsorption Bile salt deficiency:

 Cirrhosis

Pancreatic insufficiency:
 Chronic pancreatitis

Mucosal abnormalities:
 Bacterial overgrowth
 Lactose intolerance
 Celiac disease, Tropical sprue, Whipple’s disease

Secretory  Gastrinoma (Zollinger-Ellison syndrome)

 Carcinoid tumor
 VIPoma
 Laxative abuse
 Short bowel syndrome
 Post-cholecystectomy

Motility  Irritable bowel syndrome

 Systemic sclerosis
 Diabetic autonomic neuropathy

ABC’S, VITAL SIGNS

 ABC’s (+ vital signs)
 Is the patient stable?
 Establish IV Access, Monitors, Initial investigations

CLINICAL MANIFESTATIONS
Historical features
 Symptoms:
 Diarrhea (duration, frequency, volume, blood, floating in toilet bowl, aggravating factors,  w/ fasting)
 Abdominal pain (characterize), fever, jaundice, nausea, vomiting, weight loss, chills, sweats
 Nocturnal symptoms (pain, stooling)
 Urgency, tenesmus, fecal incontinence, change of bowel pattern
 Previous episodes of the same  cause, diagnosis, treatment (including procedures)
 Complications of Diarrhea:
 Volume depletion, Nutritional Deficiency, Anemia, Osteoporosis, Electrolyte Abnormality
 Infectious: Sick Contacts, Exposures, HIV, Recent Abx, Contaminated foods/water, Constitutional symptoms

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  Inflammatory:
 Radiation, family history of Cancer or IBD
 IBD: Extra-intestinal manifestations Pain, bleeding, constitutional symptoms, complications (fistula, obstruction)
 Osmotic: Relation to lactose, laxatives or antacids
 Secretory: Laxatives, prior bowel surgery or cancer
 Malabsorptive: History for Celiacs; Biliary or pancreatic disease
 Motility: DM, Hyperthyroid, scleroderma, IBS
 Past Medical/Surgical history
 Medications: Recent laxatives or antibiotic use, colchicine, SSRI, Chemo, Caffeine, PPI/H2RA
 Allergies
 Social history – EtOH, drugs

PHYSICAL EXAMINATION (including body weight)

 General
o Vitals
o Capillary refill time, skin turgor, orthostatic vitals (signs of volume depletion)
o Extra-intestinal manifestations of IBD
o Examine for malnutrition
 Head & Neck
o Lymphadenopathy
Remember epitrochlear, supra/infra-clavicular, Vichow’s/Sister Mary Joseph’s node
o Eyes/Ear/Nose/Oropharynx
 Respiratory
o Work of breathing, oxygenation (w/o supplemental O2)
 Cardiovasular
o JVP, murmurs, signs of ischemia
 Abdominal
o Inspection (observe patient breath at rest, maximal inspiration)
 General level of comfort and health
 Abdominal scars
 Asymmetry, obesity
o Palpation
 Tenderness
 Organomegaly
 Peritoneal findings (perforation)
o Percussion
 Resonance vs. Dullness
 Presence of Ascites
o Auscultation
 Bowel sounds
 Friction rub (hepatic/splenic)
o DRE
 Bleeding (FOBT), masses, stool color/consistency

Investigations
 CBC ( diff), electrolytes + renal function tests, INR/PTT, liver enzymes + liver function tests (Albumin)
 TSH, ferritin (Fe deficiency), serum B12, RBC folate
 If appropriate: Chromogranin A, serum gastrin, serum VIP concentration (>75 pg/mL in VIPoma)
 Anti-tTG Ab (also check serum IgA level)
 Stool C&S / O&P / C. dificile toxin assay, stool for giardia toxin
 Fecal WBC, 72hr fecal fat test (pancreatic insufficiency), stool for phenothalin (laxative abuse)
 Fecal electrolytes & osmolality (calculate osmotic gap usually based on estimated stool osmolality of 290)

 The fecal osmotic gap is best calculated as 290 – 2 ([Na+] + [K+]). Osmotic diarrheas are characterized by osmotic gaps >125
mOsm/kg, whereas secretory diarrheas typically have osmotic gaps <50 mOsm/kg.
 Stool pH may be assessed, with values of <5.6 are consistent with carbohydrate malabsorption

EGD/Colonoscopy
 With Bx IBD, lymphocytic/collagenous colitis, celiac disease, Whipple’s Disease

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  Small bowel aspirate (bacterial overgrowth)

Breath testing (H2–lactulose breath test)

 For bacterial overgrowth

D-xylose test
 Measures the absorptive capacity of the proximal small intestine

SBFT/CT Abdomen + Pelvis

 To rule out structural abnormalities (post-op) and assess the pancreas

Treatment:

ABC’s
 Oxygen, IV access, Monitors
 Hemodynamics

Supportive Rx
 IV fluids
 Analgesia
 Nutritional support
 Anti-diarrheal medications (if NOT inflammatory) – Bismuth subsalicylate 2 tabs po q1h prn OR Loperamide (Imodium)
4mg po, then 2mg po prn (Maximum dose 16mg/day)

Specific Rx

Celiac Disease
 prevalence ~1 in 200, T-cell mediated
 Sensitivity to gluten in Barley, Rye, Oats, Wheat (BROW)
 Anti-tTG or anti-Endomysial Ab (sensitivity 94%, specificity 99%) - ensure pt is not IgA deficient (false –ve);
confirm positive test with small bowel biopsy
 Villous atrophy and crypt hyperplasia on Biopsy
 Associated with DM1, dermatitis herpetiformis, Small Bowel lymphoma, IgA deficiency
 Clinical features include weight loss, Fe deficiency anemia, osteoporosis, diarrhea
 Treat with a gluten free diet (refer to RD), Vitamin D/calcium (assess BMD), screen family members (10% +ve)

Irritable Bowel Syndrome

 Affects 10-15% of adults
 Rome III Criteria: Recurrent abdominal pain > 3days/month for > 3 months PLUS one of:
 Improvement with defecation
 Onset with alteration of stool frequency
 Onset with change of form of stool
 Non-Pharmacological Rx: Fiber, avoidance of carbonated beverages, cook vegetables, avoid chewing gum
 Pharmacological Rx: Loperamide for diarrhea, TCA/SSRI for pain, Probiotics for bloating

Whipple’s Disease
 T. whipplei infection
 LAN, Arthritis, Fever, CNS changes, AI + MS murmurs, eye oscillations and mastication contractures
 Bowel Biopsy for diagnosis
 Rx: PCN+Streptomycin OR 3rd Gen Cephalosporin x 2 weeks then Bactrim X 1 year

Bile salt malabsorption

 May be seen post-cholecystectomy
 Treat with cholestyramine 2-4g po bid-qid
 Pancreatic insufficiency
 Treat with a low fat diet and administration of exogenous pancreatic enzymes (ViokaseR 1 g po with meals)

Lactose intolerance

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  Elimination of milk and milk products from the diet leads to improvement in primary lactase deficiency. In acquired
forms of lactose intolerance due to small intestinal disease, treatment of the underlying disease or its complications
may improve lactose tolerance without requiring dietary modification.

Inflammatory Bowel Disease

Crohn’s Disease Ulcerative Colitis

Pathology: Pathology:
- Involves GI tract with skip lesions - Involves rectum with proximal contiguous spread
- Small bowel (47%), Ileocolonic (21%), Colonic (28%) - Proctitis (30%), Left-Sided Colitis (50%), Pancolitis
- Cobblestoning, aphthous ulcers and fissuring (20%)
- Transmural inflammation with non-caseating granulomas - Ulcerated and friable mucosa
on biopsy - Mucosal inflammation with Pseudopolyps and crypt
abscesses on biopsy

Presentation: Presentation:
- Abdominal pain, constitutional symptoms and diarrhea - Bloody diarrhea with urgency and tenesmus

Extra-Intestinal Manifestations:
OPHTHALMOLOGIC
 Episcleritis: scleral injection, asymptomatic, 3-4%
 Uveitis (Iritis): blurred vision, HA, eye pain, risk scar/blindness, steroids to Rx

ORAL
 Aphthous ulcers

HPB
 PSC (especially UC: 70% w/ PSC)
 Chronic active hepatitis, Fatty Liver, Cirrhosis, Gallstones

GU
 Calcium Oxalate Stones (esp Crohn’s)

MSK
 Seronegative Peripheral arthritis:
- Type 1: Nondeforming, affects knees, ankles and wrist - Migratory, Typically correlates w/ IBD activity
- Type 2: Polyarticular deforming arthritis involving particularly MCP joints
 Spondyloarthropathy: Sacroilitis & Ankylosing Spondylitis - NOT related to disease activity
 Hypertrophic Osteoarthropathy: Clubbing and painful periostosis
 Osteopenia/Osteoporosis

DERMATOLOGIC
 common w/ colonic disease, severity correlates w/ IBD activity
 Erythema Nodosum: red, raised, tender nodules, extensors/shins, most common skin (15%)
 Pyoderma Gangrenosum: erythematous plaques, ulceration w/ necrotic centre (5% UC, 2% CD)

HEMATOLOGIC
 Anemia, Thromboembolism

Complications: Complications:
- Perianal Disease (fistula, abscess) - Toxic Megacolon (> 6cm on KUB AXR)
- Strictures (small bowel obstruction) - Colon Cancer (require colonoscopy with random biopsies
- Fistula beginning 8 years after diagnosis for screening and
- Malabsorption secondary to bowel resection (Vit D subsequent colonoscopy Q1-3Years)
deficiency, gallstones, calcium oxalate renal stones)

Non-Pharmacologic Management:
- GI Consult
- Referral to Crohn’s Colitis Foundation
- Avoidance of NSAIDS
- Exclude infection (TB screening) before immunosuppressive therapy
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 Pharmacologic Management: Pharmacologic Management:
 Oral lesions: topical hydrocortisone for local relief  Mild proctitis or protosigmoiditis
 Active ileitis, ileocolitis, colitis o Topical 5-ASA enema or suppository
o Oral 5-ASA (Pentasa or Asacol) o Hydrocortisone enema in acute flare (to splenic
o Antibiotics: cipro and flagyl flexure)
o Corticosteroids (budesonide, prednisone), o Cortifoam enema (to mid-sigmoid)
immunomodulating (MTX, azathioprine, 6-  Moderate proctosignmoiditis or left-sided colitis
MP), biologics (infliximab, adalimumab) o Oral 5-ASA or sulfasalazine (can give as
 Localized peritonitis: usually secondary to microperforation suppositories)
o Bowel rest + broad spectrum antibiotics: o Oral corticosteroids for flares (but not for
ceftriaxone + flagyl maintenance)
o Steroids controversial (may mask symptoms) o Immunomodulatory meds (take 2-4 months to
 Perianal disease treated best with antibiotics and Anti-TNF take effect)
 Steroids – used to induce remission in any severity of disease  Severe
 Anti-TNF can be used for steroid failure or to induce o Hospitalize, iv fluids, bowel rest and parenteral
remission early on. Infliximab + AZA induces remission of nutrition
60% without steroids o IV steroids and steroid enemas
o Cylosporine infusion x 24hr for severe flare
o Infliximab
o Consider surgery (curative) for intractable
disease, severe complications (toxic
megacolon, perforation, hemorrhage), cancer,
strictures, fistulae
Medication Counseling:
1. Anti-TNF: Screen for TB first as can cause reactivation. Exclude viral hepatitis if elevated LFTs. Lupus/psoriasis like
reaction possible with infusion.
2. 6MP/AZA: Can cause BM suppression, lymphoma, hepatitis. Can check TPMT genotype prior to start to reduce toxicity
3. 5-ASA: Diarrhea, Pancreatitis

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