APPROACH to DIARRHEA

DR.Bilal Natiq Nuaman,MD

C.A.B.M. , F.I.B.M.S. , D.I.M. , M.B.Ch.B.

Lecturer in Al-Iraqia Medical College

2017

Normal bowel motions :

3stools by 1day

(> 3 STOOLS /DAY DIARRHEA)

1stool by 3days (1 STOOL

/ >3DAYS CONSTIPATION )

DIARRHEADiarrheal diseases represent one of the

five leading causes of death worldwide.

Diarrhea is both a symptom and a sign.

As a symptom, diarrhea is most often reported as a decrease in stool consistency and an increase in stool volume.

As a sign, diarrhea is defined as a stool weight (i.e., water content) that exceeds 200 g in 24 hours.

classifications of diarrhea

Acute diarrhea vs.

Chronic diarrhea

ACUTE DIARRHEA

Diarrhea lasting < 2 weeks• Acute diarrhea is an extremely common

presenting problem, and mostly due to infectious causes.

• It is self-limited, No evaluation is necessary unless the stools are bloody and fever or infection is suspected (e.g., from travel history or a common source outbreak). If these conditions exist, do not treat with antimotility agents.

• Begin the evaluation with stool studies for bacterial pathogens, ova, and parasites and proctosigmoidoscopy.

Acute diarrhea

Classified into:

1- watery diarrhea Vs. bloody diarrhea

2-Infectious diarrhea Vs. non infectious diarrhea

Food poisoning• Symptoms that begin within six hours

suggest ingestion of a preformed toxin of Staphylococcus aureus or Bacillus cereus

• Symptoms that begin at 8 to 16 hours suggest infection with Clostridium perfringens

• Symptoms that begin at more than 16 hours can result from viral or bacterial infection (eg, E. coli).

Infectious acute diarrhea is usually associated with abdominal colicky pain, urgency, tenesmus,nausea and vomiting, watery stools, with or without blood or mucus.

Systemic symptoms such as fever and myalgia may be present.

In severe cases of diarrhea, urgency of defecation and fecal incontinence is a common event.

Tenesmus :

A sensation of incomplete evacuation often accompanied by abnormally frequent desire to defecate with involuntary painful straining , but little bowel movement.

• Causes of tenesmus

1-inflammatory bowel disease

2-colorecteal cancer

3-amebiasis

4- shigellosis

5-diverticular disease

(dysentery)

Fecal urgency:

the sudden, almost uncontrollable, need to

defecate.

Fecal incontinence :

complete inability to control the bowel

movements, resulting in the involuntary passage of stool.

History should include recent consumption

of unsanitary food or water (raw or poorly

cooked foods such as eggs, meat, shellfish,

dairy products, fruits and vegetables, or foods that may have been improperly handled or stored)

EXCLUDE FOOD POISONING

Important features in history of acute diarrhea:

• Stool characteristics-frequency, consistency, quantity, bloody, mucus-filled , purulent.

• Presence of dysentery—fever, tenesmus , blood, mucus, or both;

• Symptoms of dehydration—thirst , lethargy, postural giddiness, decreased urination; and

• Presence of associated symptoms—nausea, vomiting, abdominal cramps, and significant upper or lower gastrointestinal bleeding (coffee ground hematemesis,melena, hematochezia).

• Cholera may present very suddenly with vomiting and acute watery diarrhea with a “rice-water” appearance of stool; but cholera not associated with frank abdominal pain, tenesmus, or Fever.

• shigellosis is typically characterized by acute bloody diarrhea with or without mucous associated with abdominal cramps and tenesmus along with fever and anorexia.

Indications for diagnostic evaluation  • Profuse watery diarrhea with signs of hypovolemia• Passage of many small volume stools containing 

blood and mucus• Bloody diarrhea• Temperature ≥38.5ºC (101.3ºF)• Passage of ≥6 unformed stools per 24 hours or a 

duration of illness >48 hours• Severe abdominal pain• Hospitalized patients or recent use of antibiotics• Diarrhea in the elderly (≥70 years of age)• Systemic illness with diarrhea, especially in 

pregnant women

Complications of acute diarrheal diseases

1-Hypovolemia and electrolyte imbalances (cholera). 

2-Bacteremia (Non typhoidal Salmonella  )

3-Hemolytic-uremic syndrome- triad of acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia (enterohemorrhagic Escherichia coli (EHEC))

4-Guillain-Barré syndrome-ascending symmetrical paralysis (Campylobacter)

5-Reactive arthritis (formerly Reiter syndrome).

6-  Rectal prolapse, toxic megacolon (Shigella)

treatment• Watery diarrhea  — Antimicrobial therapy 

is not typically indicated for the treatment of acute watery diarrhea in adults, as most cases resolve spontaneously. An important exception is the treatment of severe cholera (doxycyclin,azithromycin, ciprofloxacin)

• Bloody diarrhea  — adults with bloody diarrhea should be treated promptly with an antimicrobial that is effective against Shigella.(ciprofloxacin)

Chronic diarrhea

Diarrhea lasting >4 weeks

•  most cases of chronic diarrhea are 

noninfectious—IBS being the leading

cause of chronic diarrhea

• Differentiate organic diarrhea from functional diarrhea.

• IBS (Irritable Bowel Syndrome)-

Recurrent abdominal pain associated with chronic diarrhea and improved with defecation

• Large volume diarrhea, bloody stools, nocturnal diarrhea, and greasy stools are not associated with IBS and suggest an organic disease.

• Functional diarrhea  —  continuous or recurrent passage of watery stools without abdominal pain or discomfort 

Medical history: 

AIDS, diabetes, cirrhosis, sickle cell disease,

cancer, endocrine – thyroid disease.previous surgery (surgery for peptic ulcer, 

cholecystectomy, and ileal resection), irradiation, 

Typical features of chronic diarrhea :

• Nocturnal diarrhea—autonomic neuropathy, e.g. diabetes mellitus;

• Diarrhea alternating with constipation -TB abdomen, laxative abuse, diverticulosis, carcinoma of colon;

• Chronic bloody or melanotic stools with weight loss - IBD, colonic malignancy;

• Pale, bulky, greasy, frothy, foul-smelling stools, which float in toilet, and associated with nutritional deficiency, weight loss- malabsorption syndrome.

Chronic diarrhea classified into:

1-Organic vs. Functional diarrhea

2-Small bowel (right sided) vs. Colonic diarrhea (left sided)

3-Osmotic vs. Secretory

• Osmotic diarrhea small volume , responds to fasting

• Secretory diarrhea large volume ,not responds to fasting