GREGORY JUCKETT, MD, MPH, and RUPAL TRIVEDI, MD, West Virginia University, Morgantown, West Virginia
Am Fam Physician. 2011 Nov 15;84(10):1119-1126.
http://www.aafp.org/afp/2011/1115/p1119.html?printable=afpAccording to the most trusted medical reference online, Wikipedia, diarrhea is defined as "3 or more loose or liquid bowel movements per day". This article defines it as a change in consistency for more than 4 weeks. There are three basic categories of diarrhea: watery, fatty, and inflammatory.
Let's start with watery diarrhea. There are three subcategories: osmotic, secretory, and functional. Watery diarrhea can be classified by doing a fecal osmotic gap. A high osmotic gap (>125 mOsm per kg) would point to osmotic diarrhea. If fasting improved the diarrhea and there is a positive hydrogen breath test, then the most likely cause is lactose intolerance. A fecal pH test below 5.5 would point towards that as well.
If the osmotic gap is low (<50 mOsm per kg), then it is most likely secretory. You (or an intern) may need to collect a 24 hour stool sample to "quantify stool production". Once anatomic defects are ruled out (through sigmoidoscopy, colonoscopy and radiography), stool culture, ova and parasite can be done to look for infections. A stool acid fast staining test can pick out Cryptosporidium, which can be missed. Hormone secreting endocrine tumors can be ruled out as well with metanephrine (for pheochromocytoma), TSH, serum peptides, urinary histamine and ACTH levels. If the patient is older with nocturnal diarrhea, and does not improve with fasting, the cause may be microscopic colitis. This can be confirmed with biopsy of the transverse colon. Or the problem could just be excessive use of stimulant laxatives (which may also cause osmotic diarrhea).
If the osmotic gap is normal, then the diarrhea is functional. If the symptoms fit into the Rome III or Manning criteria, the cause may be irritable bowel syndrome. If so, a colonoscopy is not necessary. The patient should respond to fiber, exercise and dietary changes. The patient should also be screened for celiac if these changes do not improve the symptoms. Patients with type 1 diabetes, thyroid disease, chronic fatigue, iron deficiency anemia, weight loss, infertility, or elevated liver enzymes should be screened as well.
The second class of diarrhea is fatty diarrhea. The two main causes here are malabsorption issues and pancreatic insufficiency. Some malabsorptive causes can be celiac (hello again!), intestinal bypass, mesenteric ischemia, Whipple disease, giardiasis and bacterial overgrowth. A celiac panel of IgA antiendomysium and anti-tissue transglutaminase antibodies are accurate predictors. A stool chymotrypsin and confirmatory secretin test can determine if it is pancreatic insufficiency. Otherwise the other causes may be investigated.
The last class is inflammatory diarrhea. This is usually due to IBD or and infection such as C. diff. A positive stool for blood, WBC's and calprotectin would lead towards IBD, and a biopsy would be needed to confirm. If the patient has a history of travel, camping, recent antibiotic use, drinking unpasteurized milk, excessive PPI's or a recent hospital stay, you may want to rule out infection as described above. Stool cytotoxin assay may help if you think the patient has that new hyper-virulent strain of C.diff.
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