Management of chronic diarrhea
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Transcript of Management of chronic diarrhea
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MANAGEMENT OF CHRONIC DIARRHEA
SPEAKER: ANGAN KARMAKAR
CHAIRPERSON: DR. K D BISWAS(DEPT. OF GASTROENTEROLOGY)
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Definition
• Increased stool weight > 200 gm/d• 3 or more bowel movements• Increased fluidity of stool• > 4 weeks
Among Indians• Average stool weight 311 g/d
• Bowel movement >3/d (9% of population)
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Initial Evaluation:HISTORY
• Duration, pattern, epidemiology
• Severity, dehydration
• Stool volume & frequency
• Stool characteristics
• Nocturnal symptoms
• Fecal urgency, incontinence
• Associated symptoms (abdpain, cramps, bloating, fever, weight loss, etc)
• Extra-intestinal symptoms
• Relationship to meals, specific foods, fasting, & stress
• Medical, surgical, travel, water exposure history
• Recent hospitalizations, antibiotics
• History of radiation
• Current/recent medications
• Diet (including excessive fructose, sugar alcohols, caffeine)
• Laxative abuse
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Stool characteristics
• Blood in stool – IBD, malignancy
• Watery stool – osmotic,secretory
• Oily stool – malabsorption,maldigestion
• Relationship with fasting –secretory diarrhea
• Nocturnal diarrhoea – organic
• Excess flatus - malabsorption
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Initial Evaluation:PHYSICAL EXAMINATION
Fever
Bowel sounds
Anemia, edema
Abdominal distention, tenderness, masses
Hepatomegaly, lymphadenopathy
DRE
Skin, joints, thyroid, peripheral neuropathy,
murmur
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• CBC (Hb%,Hct, MCV, WBC count),ESR
• electrolytes, BUN /Cr, glucose, LFTs, Ca, albumin
• HIV serology, CRP, INR/PTT, TSH, B12, folate, Vit D, iron
• anti-transglutaminase IgA Ab, anti-endomyseal IgA Ab
• Stool studies– OPC: Giardia , Microsporidia, Cryptosporidiosis
– Fecal leukocytes
– occult blood: inflammatory, malignancy
Initial Evaluation:TESTING
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– Stool electrolytes for osmotic gap = 290 – 2[Na + K]
Small gap(<50)= secretory
Large gap(>100)= osmotic
Measured osmolality <290= addition of water, urine
– Stool pH (<6 suggests carbohydrate malabsorption)
– Fat content (48h or 72h quantitative or Sudan stain)
>7gm/9% of fat intake for 24 hrs= steatorrhoea
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CHRONIC OSMOTIC DIARRHEA
• CLUES:
Osmotic gap >100
Stool volume: decreases with fasting
Bloating
Stool analysis: stool pH(low)
laxative screen(Mg)
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• CARBOHYDRATE MALABSORPTION
Dietary review
Breath hydrogen test using lactose, mucosal
lactase assay
Therapeutic trial: elimination diet
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CHRONIC SECRETORY DIARRHEA
• CLUES:
Large volume(>1 litre)
Little change with fasting (except bile salt diarrhea)
Normal osmotic gap
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Further approach
• stool culture
• Microscopy for OPC
• Antigen testing
• CT/MRI of abdomen,pelvis
• Sigmoidoscopy/colonoscopy + mucosal biopsy
• Enteroscopy + mucosal biopsy & aspirate
• Capsule enteroscopy
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• Selective testing
plasma peptides- gastrin, VIP
Urine autacoids & metabolites
Others – TSH, cortisol, SPEP, Ig
• Therapeutic trial
Bile acid binding agent
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• 25% of all cases: undiagnosed
• Idiopathic secretory diarrhea
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CHRONIC INFLAMMATORY DIARRHEA
• CLUES:
Fever
Hematochezia
Abdominal pain
Weight loss
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Further approach
• Sigmoidoscopy or colonoscopy + mucosal biopsy
• CT/MRI – abdomen, pelvis
• Enteroscopy + mucosal biopsy
• Exclude infection : biopsy, serology, culture
(TB, parasite, virus)
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CHRONIC FATTY DIARRHEA
• CLUES:
Weight loss
Fecal fat >7-10gm/24 hr
Anemia
Hypoalbuminemia
Vitamin deficiency
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Further approach
• Exclude structural disease
CT abdomen, enteroscopy + small intestinal biopsy & aspirate
• Exclude bile acid deficiency
empiric trial of bile acid
duodenal aspirate for bile acid conc
• Exclude pancreatic exocrine deficiency
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Pancreatic exocrine insufficiency
• Smaller stool volume, higher fat content
>9.5 gm fat/100 gm stool- pancreatic/biliarydysfunction
• Oil in stool
• Less hypocalcemia( w.r.t mucosal disaease)
• TESTS: therapeutic trial: pancreatic enzymes
stool elastase/chymotrypsin conc
secretin test
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FACTITIOUS DIARRHEA
• Laxative abuse
• Munchausen’s syndrome
• Polle’s syndrome
• Addition of water, urine
• Treatment
counseling
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MICROSCOPIC COLITIS
• Elderly female
• Normal colonoscopy
• two types – collagenous colitis and lymphocytic colitis
• Treatment:
Bismuth, mesalamine
Steroid, immunosuppressive
Anti TNF-α
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BILE ACID INDUCED DIARRHEA
• Causes:
Chronic cholestatic liver disease
ileal resection
• Diagnosis:
1. Therapeutic trial
2. Measuring conjugated bile acid in
duodenal aspirate
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Empiric therapy for chronic diarrhea
INDICATIONS:
• initial therapy prior to diagnostic testing
• diagnostic tests fail to confirm a diagnosis
• diagnosis established, but no specific treatment available or it fails to provide any benefit
American Gastroenterological Association (AGA) guidelines
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Empiric therapy for chronic diarrhea
• Antibiotics
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TREATMENT OF IBS-D
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MAS – Indian persrpective
• Tropical sprue: broad spectrum antibiotic
folate, vit B12
• Coeliac disease: Gluten free diet
• Giardia infection: antibiotic
• Intestinal tuberculosis: ATD (9-12 months)
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MEDICAL MANAGEMENT OF IBD
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DRUGS FOR CHRONIC DIARRHEA IN AIDS
BOVINE COLOSTRUM
Cryptosporidium Nitazoxanide
Microsporidia Albendazole
Isospora TMP/SMX
CMV Ganciclovir/ Foscarnet
MAC Macrolide + Ethambutol
AIDS enteropathy
GI lymphoma
ART induced Crofelemer
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TAKE HOME MESSAGES
• History, examination and assesment of stool characteristics : MOST IMPORTANT
• Stepwise approach for finding etiology
• Judicious application of empiric therapy
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THANK YOU