Kembara Xta - Medicine - Chronic Diarrhea
Introduction The most important defining characteristic of chronic diarrhea is abnormal stool form; frequent defecation with normal consistency is referred to as pseudo diarrhea. The etiologies of chronic diarrhea can be divided into the following categories: osmotic, secretory, malabsorptive, inflammatory, infectious, and hypermotility. Infectious causes of chronic diarrhea are uncommon in immunocompetent individuals. Epidemiology ( Incidence and Prevalence) Incidence Estimation is challenging because definitions differ. Prevalence according to etiology. The prevalence is 20% globally . The prevalence in the US is 6.6%. Pathophysiology and Etiology Increased water volume in the stool results from disturbances in luminal water and electrolyte balance. A fecal osmotic gap more than 100 mOsm/kg is osmotic. resolves through a trial swiftly - Malabsorptive of carbohydrates Consumption of magnesium, phosphate, and sulfate as well as disaccharides (like lactose), monosaccharides (like fructose), and polyols (popular sugar substitutes). Secretory (fecal osmotic gap less than 50 mOsm/kg) (1), (6). a fasting trial will not address the issue (2) - Consumption of stimulants and laxatives - Bacterial enterotoxins (cholera, for example) - Disordered motility - Postvagotomy, autonomic neuropathy - Postcholecystectomy/ileal resection 100 cm - Excessive intestinal bile salts induce choleretic diarrhea; resolves in 6 to 12 months - Neuroendocrine tumors and hyperthyroidism The VIPoma Metastatic medullary thyroid carcinoma, carcinoid syndrome, gastrinoma, and somatostatin-producing tumors - Insufficiency of the adrenals - Microscopic colitis - Non-invasive infections such giardiasis and cryptosporidiosis - Protein-losing enteropathy Malabsorptive conditions include lymphatic blockage, chronic mesenteric ischemia, Whipple illness, tropical sprue, and giardiasis. - Short bowel syndrome: Ileal excision of more than 100 cm results in inadequate bile salts in the small bowel. - Microscopic colitis - Diverticulitis - Vasculitis - Radiation enterocolitis - Small intestine bacterial overgrowth (SIBO) - Pancreatic exocrine insufficiency - Inflammatory - IBD—ulcerative colitis; Crohn disease - - Infections: TB, CMV, Entamoeba histolytica, Clostridium difficile, - Neoplasms: lymphoma and colon cancer Hypermotility (50–100 mOsm/kg, normal fecal osmotic gap) (1) Pain distinguishes functional diarrhea from irritable bowel syndrome (IBS), and vice versa. Drugs. Adverse effects of more than 700 drugs are most frequently associated with NSAIDs, PPIs, colchicine, metformin, digoxin, ACE inhibitors, -blockers, newer gliptins, theophyllines, antibiotics, SSRIs, and anti-cancer agents. The disappearance of symptoms after stopping a drug confirms drug-induced diarrhea (3). - Excessive laxative use causes factitious diarrhea Herbal remedies including St. John's wort, echinacea, saw palmetto, ginseng, and garlic. Bacterial infections like C. difficile and M. avium intracellulare. - Parasitic: Giardia lamblia, Cryptosporidium, Isospora, and E. histolytica - Viral: Cytomegalovirus - Strongyloides, a helminth Genetics Major Histocompatibility Complex (MHC) class II HLA-DQ2 and HLA-DQ8 haplotypes are linked to Celiac disease. It is polygenic to have inflammatory bowel disease (IBD). First-degree relatives of IBD patients are 10 times more likely to develop the disease. The CF transmembrane conductance regulator (CFTR) anion channel mutation, which results in aberrant chloride exocrine gland secretions, is the cause of CF. Risk Elements Overconsumption of nonabsorbable carbs, such as artificial sweeteners, is referred to as osmotic. - Antacids that contain magnesium - Celiac illness and lactose intolerance Postsurgical secretory complications include bile acid malabsorption, vagotomy, and significant small bowel resection/ileal surgery. - Abuse of stimulant laxatives or neuroendocrine diseases in the past Dysmotility disorders - CF; long-term alcohol misuse; celiac illness; medications (e.g., NSAIDs, caffeine, metformin, colchicine, and carbamazepine) that are malabsorptive - Fat malabsorption due to chronic pancreatitis or pancreatic insufficiency - Drugs (such as orlistat and acarbose) Radiation - HIV/AIDS, NSAID usage, and inflammatory - IBD - The use of antibiotics, most frequently cephalosporins, amoxicillin, and clindamycin. (3) - Anticancer medications (5-fluorouracil, methotrexate, irinotecan, etc.) (3) Hypermotility - Psychosocial stress - Prior infection - Stimulant drugs (such as macrolides, metoclopramide, and senna) - Immunosuppressive therapy Predisposition genetic Caution Both secretory and osmotic diarrhea can be brought on by diabetes mellitus and cholecystectomy. Prevention Depending on the etiology, treat the root cause. Accompanying Conditions Arthralgias, aphthous stomatitis, uveitis/episcleritis, erythema nodosum, pyoderma gangrenosum, perianal fistulas, rectal fissures, ankylosing spondylitis, and PSC are examples of extraintestinal symptoms of IBD. IgA deficiency, T1DM, and dermatitis herpetiformis are all linked to celiac disease. Behavioral comorbidities are common in IBS patients. Associated allergies to latex and banana, avocado, kiwi, and walnut are referred to as "latex-food allergy syndrome." A thorough history of symptoms is presented. - Stooling's onset, pattern, and frequency, as well as any aggravating or resolving factors - The quantity and quality of the stools, including any blood or mucous. - Travel history, use of antibiotics, and dietary habits - Current drugs and dietary supplements - A history of IBD, colorectal cancer, or CF in the family. Alarming symptoms such nocturnal symptoms, fevers, unexpected weight loss, or rectal bleeding/melena Alcohol consumption, arthritis, eye issues, heat intolerance, polyuria/polydipsia, headache, fever, skin changes (rashes, hives), Food allergies are uncommon, affecting about 1% to 2% of individuals. Think about patients who have hives. The two most common symptoms of carbohydrate malabsorption are flatus and bloating. Prior radiation or surgery Endocrine or immunologic systemic disease Functional diarrhea or IBS by Rome IV standards: - IBS: recurring stomach pain occurring at least once per week for the last three months (symptoms lasting longer than six months); and 2 of: Functional diarrhea: 25% loose or watery stools without noticeable stomach pain or bloating for >3 months (symptoms >6 months). Related to defecation. Change in frequency. Change in form. clinical assessment General: anasarca, recent weight loss, nutritional state, volume depletion, Ecchymoses (vitamin K deficiency), dermatitis herpetiformis (celiac disease), erythema nodosum (IBD), pyoderma gangrenosum (IBD), and hyperpigmentation (Addison disease) are all skin-related conditions. HEENT: IBD-related iritis/uveitis, hyperthyroidism-related lid lag Neck: lymphadenopathy (Whipple disease) with goiter (hyperthyroidism) Cardiovascular symptoms include cardiac murmurs and tachycardia (hyperthyroidism). Pulmonary: carcinoid wheeze Abdomen: distension, widespread discomfort, or hyperactive bowel noises (IBD/IBS) Anorectal: fecal impaction (overflow incontinence), anorectal fistulas, or anal fissures (IBD) Neurological: tremor (hyperthyroidism) in the extremities Laboratory Results Patients who exhibit alarm symptoms or chronic symptoms without a known reason undergo first tests (lab, imaging). Blood tests include the complete blood count (CBC), electrolytes (Mg, P, Ca), total protein, albumin, thyroid-stimulating hormone, free T4, erythrocyte sedimentation rate, C-reactive protein (CRP), IgA anti-tissue transglutaminase (TTG), and iron studies. For patients who meet Rome IV diagnostic criteria for IBS without warning characteristics, a normal CRP (10 mg/L) or fecal calprotectin (50 g/g) level effectively excludes out IBD. Stool: qualitative fecal fat (Sudan stain), occult blood, lactoferrin/calprotectin (preferred), culture, ova and parasite, Giardia antigen, C. difficile toxin (1) - The fecal osmotic gap is equal to 290 mOsm/kg 2(Na+Kfeces). - Only tested for C. difficile in diarrheal feces A CT or MRI to assess the GI tract's anatomy (for IBD, cancer, or chronic pancreatitis, for example) Tests in the Future & Special Considerations Antiendomysial antibody IgA, anti-TTG IgA (sensitivity and specificity >90%) in patients without IgA deficit, antigliadin antibodies (AGA), serum IgA level (10% of celiac patients have IgA deficiency—may result in false-negative results), and serum IgA level are all indicators of the condition. - A duodenal biopsy should be performed to confirm an IgA TTG positive result. Fecal elastase and chymotrypsin for chronic pancreatic insufficiency; fecal 1-antitrypsin for protein-losing enteropathy; normal-appearing mucosal biopsy from the colon for microscopic colitis; hydrogen breath test and proximal jejunal aspirate with >105 colony-forming units per milliliter coliform bacteria for SIBO; C. difficile toxin for carbohydrate ma Laxative abuse: stool osmotic gap Allergy tests Serum: chromogranin A, VIP, gastrin, calcitonin; neuroendocrine tumor - 5-HIAA, histamine in the urine - Abdominal CT or MRI imaging Other/Diagnostic Procedures Flexible sigmoidoscopy: if pregnant, with comorbidities, or if left-sided symptoms (tenesmus and urgency) predominate; Esophagogastroduodenoscopy (EGD) with biopsies if malabsorption is suspected; CT or magnetic resonance enterography. Ileocolonoscopy with biopsies for IBD, microscopic colitis, CMV colitis, and colorectal neoplasia. Test interpretation for Celiac disease includes intraepithelial lymphocytosis, crypt hyperplasia, and villous atrophy. For Crohn's disease, cobblestoning, linear ulcerations, skip lesions, and noncaseating granulomas are present. For Ulcerative colitis, crypt abscesses, superficial inflammation, and continuous rectal lesions are present. For Lymphocytic colitis, high intraepithelial lymphocytes and high inflammatory Treatment includes volume resuscitation and electrolyte replacement. If the patient is stable, outpatient care is usually used. First Line of Medicine Depending on the underlying cause: - Postcholecystectomy or ileal resection: cholestyramine or colestipol 2 to 16 g/day PO split BID - Lactose intolerance: lactose-free diet Diabetes: glucose management - Methimazole 5 to 20 mg orally daily, split with propylthiouracil (PTU) 100 to 150 mg daily, and thyroid ablation - Vancomycin 125 mg PO every six hours, metronidazole (Flagyl) 500 mg PO every eight hours, or fidaxomicin 200 mg PO every day for ten days. G. lamblia: 250 mg PO every 8 hours for five to seven days; 500 mg PO every 12 hours for three days (1).[A] - Ceftriaxone 2 g IV for 14 days, followed by Bactrim DS 160/800 mg PO BID for a year to two years. Fluoroquinolones 250 to 750 mg PO BID, metronidazole 500 mg PO q6-8h, and rifaximin 550 mg PO BID are all used for SIBO. Pancrelipase is prescribed for pancreatic insufficiency. Antiretroviral therapy (HAART) for HIV/AIDS IBD treatment options include 5-ASA, brief courses of corticosteroids and/or antibiotics, immunomodulators, and anti-TNF medication. - Microscopic colitis: budesonide 9 mg/day PO, mesalamine 800 mg PO TID, and bismuth subsalicylate (Pepto-Bismol) 786 mg PO TID - Neuroendocrine tumor: 100–600 g/day SC octreotide[C] IBS diarrhea: rifaximin 550 mg PO TID 14 days, alosetron 0.5 to 1.0 mg PO BID, peppermint oil, eluxadoline 100 mg PO BID; TCAs may also be taken into consideration. Celiac disease: gluten-free diet. IBS diarrhea: rifaximin 550 mg PO TID 14 days. Loperamide 4 to 8 mg/day PO divided; only use in the event that an infectious etiology has been ruled out. - 1–2 tabs of diphenoxylate-atropine BID–QID - Bismuth subsalicylate 525 to 1,050 mg every 0.5 to 1 hour; maximum dose 4.2 g/day; fiber supplements Referral Referral to gastroenterology for suspected cases of inflammatory diarrhea or suspected cases needing an endoscopy or biopsy (such as celiac disease or microscopic colitis). Resection of neuroendocrine tumors, intestinal resection for refractory IBD, and fecal transplant for recurrent Clostridium difficile are all surgical procedures. Admissions If the patient is hemodynamically unstable, has significant electrolyte imbalances, dehydration, malnutrition, AKI, or is unable to accept oral food, inpatient hospitalization should be considered. Diet Elimination diet: Steer clear of foods containing gluten, non-digestible carbohydrates, lactose, and food allergies. Up to 75% of IBS patients report symptom relief with a low FODMAP diet. Chronic diarrhea is commonly characterized as three or more loose bowel motions per day for more than four weeks. High carbohydrate intake and obesity have been associated to chronic diarrhea. The wide range of "normal" bowel behaviors Limit the use of colon stimulants. The prognosis varies depending on the etiology Complications Malnutrition, anemia, and weight loss Fluid and electrolyte imbalances, AKI Cancer (small bowel [celiac, Crohn's]), lymphoma, and colon cancer (IBD treatments), all of which are malignancies. IBD immunosuppressive therapy-related infection
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