1 / 74

Effective Management of Chronic Diarrhea

Learn to diagnose and treat chronic diarrhea cases effectively, understanding causes, endoscopy guidelines, and treatment options.

britten
Download Presentation

Effective Management of Chronic Diarrhea

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Evaluation and Management of Chronic Diarrhea Joe Harkins, PA-C Gastroenterology Center of Maine EMMC Bangor, ME

  2. OBJECTIVES • Understand definition of Chronic Diarrhea and recognize difference between osmotic and secretory types. • Identify various causes of Chronic diarrhea. • Evaluate cases of Chronic Diarrhea including history, exam, and testing. • Understand endoscopy guidelines including EGD, Colonoscopy, and Capsule endoscopy. • Determine appropriate work-up on basis of whether feces is watery, fatty, or bloody. • Choose effective treatments for respective cases of chronic diarrhea.

  3. 1st - RULE OUT CONSTIPATION • Sometimes patient thinks it is diarrhea when actually it is overflow from constipation. • Pelvic Floor Dysfunction can happen if trouble with IAS, HX abdominal/pelvic surgery, Connective tissue disorder, DM, adverse drug effects, dehydration. • Check upright KUB for fecal loading.

  4. RED FLAGS • Fever • Blood Loss • Unexplained weight loss • Abdominal Pain • Nocturnal episodes • REFER TO ER OR call GI.

  5. DEFINITION of diarrhea • Loose stools • More than 3 BM per day • Stool output weight>200 gram/day

  6. Definition • CHRONIC diarrhea: duration > 4 weeks. • Functional Diarrhea , ROME III criteria: daytime painless diarrhea > 3months.

  7. Pathophysiology of Diarrhea Normal: fluid input to S.I. 10 L/day absorption out of S.I. 9 L /day absorption out of Colon 0.9L /day Normal Stool: 100ml per day Input comes from: food, drinks, salivary, gastric, pancreatic, biliary, small intestine, colon. Water flows through ion transporter channels, iecAMP

  8. Digestive Input Signals • G-cell: gastrin signals release of HCl into stomach • Enteroendocrine cells: CCK stimulates Gallbladder, pancreas, and S.I. motility. • Duodenal S-cells: Secretin stimulates release of Bicarbonate from pancreas with H20 into duodenum. • D-cell: VIP stimulates motility and pancreas. • Vagal Nerve: cholinergic GI stimulation. • T4: stimulates GI motility.

  9. IC Valve

  10. Types of Diarrhea • Osmotic • Secretory • In Practice: Watery Fatty Bloody

  11. Osmotic Diarrhea • Unmeasured osmotic substances hold water in lumen of colon. • Improves with FASTING or elimination. • Fecal Osmolar Gradient will be >125. • If lactose intolerant, low stool pH. • Can be watery or fatty stool. • KEY here is history of lactose intolerance or laxatives.

  12. Osmotic Diarrhea • Laxatives like PEG, Lactulose, or Magnesium salts • Fructose in our diet • Lactose ( if lactase deficient) • Sorbitol, Mannitol ( sugar free gums, drinks)

  13. FOGFECAL OSMOLAR GRADIENT FOG= 290 – 2 {fecal Na + K} mmol/l • If <50 secretory • If > 125 osmotic • If between 50-125 overlap osmotic/secretory

  14. Secretory Diarrhea • Amount of fluid input exceeds absorption • Not affected by fasting and can continue at night • Related to excess secretion or inadequate absorption • Related to abnormal GI motility • Stool Na and Cl will be high and FOG<50 • Can be Fatty, Watery, Bloody, Mixed

  15. Causes of Secretory Diarrhea • Infection • Alteration of intestinal surface area • Inflammation • Dysregulation/dysmotility • Neuroendocrine tumor (NET) Note - Infections, IBD, and NET not covered in depth here

  16. Infection • C .Diff produces enterotoxins which kill enterocytes • Cholera type infections induces cGMP ion-transporters to increase Chloride secretion • Parasites- always consider this one • Viral CMV, HIV, and HSV affect colon if immunocompromised

  17. Altered Surface Area • Ileal resection: reduces bile salt absorption • Ileocecal resection: altered bacterial concentrations reach small bowel • Surgical scar/strictures: cause stasis • Celiac disease:reduces SI surface absorption • Inflammation: increased cytokines leads to increased wall-thickening with leakage and decreased absorption

  18. Dysregulation • diabetic autonomic dysfunction • post-vagotomy • sympathectomy • scleroderma, associated SI diverticulosis • hyperthyroidism

  19. Secretory Causes Watery IBS Neuroendocrine Infection IBD SIBO Microscopic Celiac DM Non-osmotic laxative Short Gut Villous adenoma Alcohol (sugar) Fatty Chronic pancreatitis EPI Celiac SIBO Cirrhosis Cholestasis Bile Salt Depletion Bloody IBD Infection Radiation Ischemia Cancer

  20. Steatorrhea Decreased fat solubilization: inadequate bile salts micelles • Intestinal stasis: SIBO and lower duodenal pH • CP/ ZES: pancrease enzyme insufficiency or enzyme deactivation by HCL • Cholestasis decreases bile salt secretion • Cholecystectomy: increases BS secretion • Ileal resection leads to BS depletion or malabsorption

  21. Length of Ileal resectiondetermines if fatty or watery • <100cm resected : compensated with reduced BS returned to Liver. Unabsorbed BS pull water through colon wall into lumen get watery diarrhea. OK to use cholestyramine. • >100cm resected: decompensated with no BS return to liver leading to reduced BS secretion; decreased micelle formation. May not be OK to use cholestyramine. Will get mixed fatty/watery diarrhea. Tx with low fat diet.

  22. Inflammation • Wall-thickening • Leaky wall • Impaired absorptive transporters

  23. Evaluation of Diarrhea • History • Medication • Physical Exam • Labs/tests • Imaging • Endoscopy

  24. History • Stool: Duration, Frequency,Intermittent vs. continuous, affected by fasting, blood, greasy, watery, mucus, Nocturnal, incontinence. • Physical Symptoms reveal Clues and Severity • Weight loss

  25. History • Hx Surgery, radiation therapy. • PMHx: Chronic pancreatitis, Peptic Ulcers, Thyroid disease, Diabetes, HIV. • Check Diet: caffeine, FODMAPs, lactose, alcohol, diet sweeteners. • Travel History. • Well water ( giardia). • Sick contacts.

  26. Medications • OTC and Prescription • Vitamin C (it is an acid) • Cholinergics • Laxatives: osmotic and non-osmotic

  27. Physical Exam • Important for severity of problem • Sometimes can give clue to etiology • flushing= carcinoid, VIPoma • cirrhosis, telangectasia= alcohol • thyroid nodules= medullary carcinoma • dermatitis= celiac disease • aphthous ulcers= inflammation • rectal exam : DRE

  28. LABS Stool tests: • C. Diff, O&P, Cx/S • Calprotectin, Lactoferrin, FOBT, fecal WBCs • FOG( Na&K), pH, Mg ( if suspecting laxative). • Elastase • Sudan III fat stain Serology: • CBC, BMP , TSH, albumin, vitamins(A,D,E,K), INR • TTG and IgA, HLA DQ2/ DQ8 (for Celiac) • CRP, ESR • B12 and Folate ( for SIBO)

  29. Imaging • CT with IV Contrast: colitis, enteritis, diverticulitis, pancreatic tumor. • MRE or CTE with and without contrast : small bowel inflammation, fistula. • MRCP: biliary dilatation. XR or non-contrast CT: fecal loading pancreatic calcification

  30. Indications for ENDOSCOPY • Colonoscopy • EGD • EUS • SI Capsule ASGE Guidelines: GIE Vol. 71, No. 6:2010

  31. Colonoscopy • If mucus, blood, copious watery • If suspect: IBD, microscopic, serrated villous adenoma, cancer, NSAID ileitis/colitis, eosinophilic colitis. • Flexible Sigmoidoscopy : suspect distal viral or ischemia when full colon is high-risk ASGE Guidelines: GIE Vol. 71, No. 6:2010

  32. EGD/EUS • Giardia • Gastric ulcers • ZES • Celiac • SI Crohns • Lymphangectasia • Lymphoma ASGE Guidelines: GIE Vol. 71, No. 6:2010

  33. Small Bowel Capsule • If colonoscopy and EGD normal and suspect small bowel source for inflammation • CT and MRI may not show mucosal lesion or bleeding ASGE Guidelines: GIE Vol. 71, No. 6:2010

  34. CASE #1: MICROSCOPIC COLITIS • 11/2015: 30 yo female presents with chronic alcohol abuse, severe neuropathy, large ascites. • She reports history of Crohns diagnosed at 26yo. Had diarrhea and colonoscopy in 2012. Tried Lialda but stopped medication. Now reports 2 BM per day. • Treated for cirrhosis and discharged to Acute Rehab for severeneuropathy.

  35. CASE #1. MICROSCOPIC • 5/2016: f/up to GI clinic after lifeflight for UGIB with HEMATEMESIS. EGD showed Grade 1 varices. Still reports BM 2 per day. NO Crohns medication. Focus on cirrhosis. • Strength and spirit improving • Request made for Colon OP Report and PATH from 2012. Although she has HX CROHN’s, she makes no relevant complaint yet.

  36. CASE #1. MICROSCOPIC • 9/2016: Cirrhosis now compensated, neuropathy improving. SOBER and outlook positive. NOW: She reports that for past 5 years she had 6-10 watery BM/day . No blood, no tenesmus. • Colon report 2012: lymphocytic colitis. • Look at Medication list.

  37. CASE #1. MED LIST • Lyrica • baclofen, • ativan • MVI • Sertraline • Mag Oxide • Sertraline • melatonin • thiamine • Lasix • Synthroid • Iron • Vitamin C

  38. Microscopic Colitis • 12/100,000 people prevalence similar to IBD • Associated: NSAIDs and PPI • Labs not necessary but fecal WBC and calprotectin are elevated ( 50-75%) • Collagenous • Lymphocytic • Secretory, Inflammatory Sleisenger & Fordtran

  39. Lymphocytic Sleisenger & Fordtran

  40. Collagenous Sleisenger & Fordtran

  41. Reproduced from Munch A, Aust D, Bohr J, Et al. Microscopic Colitis: current status, present and past. Jcrohns Colitis 2012;6:932

  42. Treatment of Microscopic Colitis • Modify Med List. {She changed to Lexapro} • Budesonide 9mgQD x 4wks, taper 3mg every weeks • Alternative: Bismuth subsalicylate 8 tabs/day x 8 weeks • Alternative: Prednisolone

  43. CASE #1. 3RD f/up Microscopic Colitis • 12/2017 • Repeat Colonoscopy in December 2017: NORMAL • NEW Med list: • Lyrica • MVI • Mag Ox • Nadolol • Synthroid • Vistaril Doing well January 2017.

  44. CASE #1. Microscopic Colitis Microscopic Colitis can recur. OK to retreat empirically without scope but 1st check Stool tests for infection, and blood for ESR/CRP.

  45. CASE# 2: SIBO • 19 yo female from NH going to college in ME, active as rock climber and backcountry pursuits presents with HX diarrhea past 2 years. 4-6 per day but some days>10 per day. • Brown, watery or mushy, not greasy, No blood. Weight stable. • Frequent bloating, nausea, and occasional bilious vomit. • MED: lexapro • FM HX: Mom has IBS-C.

More Related