1.Identify the problems from the history.

• Young college student

• Increased frequency of bowel movements

• Stools fill up the toilet bowl

• Stools float in the bowl

• Foul odor and offensive flatus

• Long standing problem with bowels movements

• Cystic fibrosis

• Frequent pulmonary infections

2. Identify the salient findings from physical examination.

• Diminished breath sounds with few expiratory wheezes

• Loud P2

• Clubbing

• Decreased subcutaneous fat and muscle mass

• Abdomen "doughy" consistency

• Stool pasty and malodorous

3. Based on history and physical examination cite the major clinical problem (not the diagnosis):             

• Diarrhea 

• Steatorrhea/malabsorption 

• Cystic fibrosis

4. Before we define what is diarrhea, tell me what is normal bowel movements.

Normal stool 

• Normal bowel frequency ranges from three times a week three times a day

• Weight 200 g/d

5. What is the definition for diarrhea?

The definition of diarrhea is somewhat controversial.  It depends on the patient’s as well as the physician’s perspective.  

• Patients usually consider diarrhea as being an increase in the daily frequency, liquidity, or volume of the stool. Also an urgency to defecate. 

• Scientifically, diarrhea exists if more that 300 gms stool is passed daily on the Western diet. 

• Clinically, it may be defined as more than 3 bowel movements day. 

• Relative to what the patient’s “usual” habit has been. 

It is important to take a good history and ask appropriate questions regarding stooling.  Don’t just accept the patient’s statement of diarrhea. 

6. What is Pseudodiarrhea or hyper defecation: 

Increase in frequency without an increase in weight of the stool.

• Irritable bowel syndrome

• Proctitis

• Hyperthyroidism

7. Define Fecal incontinence

• Involuntary release of rectal contents

8. How do we clinically classify Diarrhea?

• Diarrhea lasting two weeks or less is considered to be Acute Diarrhea

• Diarrhea lasting longer than two weeks or is intermittent over months or years  is considered Chronic Diarrhea.

9. Which of these diarrhea does our patient have?

Chronic Diarrhea 

 

 

 

 

 

 

 

 

10. What is the difference between acute and chronic diarrhea?

• Acute Diarrhea

  • lasts two weeks or less

  • self-limited

  • requiring no diagnostic work-up 

  • symptomatic treatment only (fluids) 

  • Acute diarrhea should be investigated only if there is

    • evidence of tissue invasion such as blood or pus in the stool 

    • fever 

    • leukocytosis 

    • severity that produces significant fluid and electrolyte loss  

• Chronic diarrhea 

  • lasts longer than two weeks 

  • or is intermittent over months or years 

  • This form requires a diagnostic work-up and a treatment strategy

11. What questions would you ask a patient with diarrhea?          

• Compare the patient’s usual or normal frequency and pattern with that of the current pattern or frequency.  

• Ask about the characteristics

  • Watery, bulky, color, presence of blood or pus

  • Bulky greasy foul smelling stools : Intestinal malabsorption

• Change in odor 

• Change in timing   

  • Frequency, duration

  • Continuous, intermittent

  • Time of day or night

  • Diarrhea alternating with constipation : Irritable bowel syndrome, Cancer colon

• Precipitating events such as food or drug

• Causes of relief

  • Improves with fasting : Osmotic diarrhea

• Ask about associated symptoms 

  • Fever, nausea, vomiting, abdominal pain, anorexia: Inflammatory diarrhea

  • Symptoms of autonomic dysfunction: Diabetic diarrhea

  • Flatulence and bloating : Intestinal mucosal disease

  • Arthritis, skin lesions, ocular symptoms: Idiopathic inflammatory bowel disease

  • Edema, Ascites: Protein loosing enteropathy

• Ask about predisposing  factors such as travel, diet, drug history, family history, other medical surgical problems.

 12. Summarize pertinent historical information on our patient with regards to diarrhea.

• 3-4 bowel movements/ day which he has accepted as normal

• Bulky greasy foul smelling stools that float in toilet bowl

• Continuous

• No identified precipitating or relieving factor

• No associated symptoms

• History of Cystic fibrosis

13. What physical findings would you look for in the evaluation of a patient with Chronic diarrhea?   

Consequences to diarrhea             

• Edema, Ascites /  Protein loosing enteropathy

• Signs of Vitamin deficiency of fat-soluble vitamins (A, D, E, K)./ Steatorrhea

• Signs of hypovolemia and dehydration

Etiology of diarrhea

• CNS disturbances / Altered motility

• Signs of autonomic dysfunction / Diabetes

• Arthritis, skin lesions, ocular signs: Idiopathic inflammatory bowel disease

14. What are the pertinent physical findings in this patient?

• Decreased subcutaneous fat and muscle mass

• Tympanitic abdomen

• "doughy" consistency

• Loud P2 / Pulmonary hypertension

• Expiratory wheeze / Consistent with CF

• Clubbing / Consistent with CF

15. Classify the chronic diarrhea  into subgroups: 

Chronic diarrhea can be classified as follows: 

Steatorrhea : Passage of stools containing an excessive amount of fat (>7 gm fecal fat/24 hrs or more than 10% of ingested fat)

• Intraluminal stage

  • Deficiency of pancreatic enzymes/Chronic pancreatitis

  • Bacterial overgrowth in the small bowel/decreased motility in a diabetic

  • Deficient bile salts/biliary tract disease

• Intestinal stage

  • Damage to the absorptive surface (mucosa)/Celiac disease

• Removal stage

  • Damaged lymphatic channels/Whipple disease

Watery diarrhea

• Osmotic diarrhea. A consequence of increased amounts of poorly absorbable, osmotically active solutes in the lumen of the intestine

  • Disaccharide deficiency/lactase deficiency

  • Ingestion of drugs such as laxatives and antacids containing magnesium or phosphate

  • Chewing gum (sorbitol)

• Secretary diarrhea: Secretion of electrolytes and water exceed absorption or absorption of electrolytes and water are impaired

  • Certain laxatives/castor oil

  • Bacterial toxin/infection

• Exudative Inflammation of the bowel mucosa may result in loss of pus, mucus, blood, protein

  • E. histolytica

  • Giardia

• Intestinal dysmotility

  • Increased motility/hyperthyroidism

  • Delayed transit time with bacterial growth/ blind loop syndrome or diabetic neuropathy

16. What investigational options do we have in the workup of patients with Chronic diarrhea, based on the knowledge of subgroups of chronic diarrhea ?

Stool

• Blood and leukocytes in stool : Inflammatory diarrhea. Inflammatory colonic disease. 

• Fecal fat. Steatorrhea (>7 gm fecal fat/24 hrs)

• Stool for ova and parasites

• Stool for C/S

• C. dificile toxin. 

Malabsorption

• Iron, folate, B12  : Malabsorption

• Vitamin deficiency of fat-soluble vitamins (A, D, E, K).

• Fecal fat. Steatorrhea (>7 gm fecal fat/24 hrs)

• D-xylose absorption test

Bowel changes

• EGD: Small intestine biopsy

• Colonoscopy indicated if stool is negative for pathogens. Colonic mucosa may have to be looked at endoscopically and biopsied if inflammatory bowel disease is suspected. 

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17. What are the appropriate investigations in this patient? 

• Stool 

• Malabsorption studies

18. You have the results of stool for pathogens and fecal fat. 

• No blood or leukocytes in stools

• >11 gm fecal fat/24 hrs,

• No pathogens detected in stools.

19. What is D-xylose test? 

• D-xylose test should be done when there is steatorrhea .

• Helps distinguish steatorrhea due to Pancreatic disease from small bowel disease

  • Normal D-xylose indicates pancreatic disease.  

  • Abnormal D-xylose indicates small bowel disease and small bowel biopsy is indicated. 

• >25% of ingested dose (25gm) in the 5 hr urine collection.

• Understand the mechanism of the D-xylose test.  

  

 

 

 

 

 

 

20.   Let us summarize the results of diagnostic tests in this patient?

• Stool is negative for blood, pus, pathogens. 

• Stool fecal fat is >11 gm/24hr.

• D-xylose is normal 

These findings localize the problem to Pancreas. 

  

 

 

 

 

 

 

 

21.  What is this patient’s diagnosis?

• Malabsorption 

• Secondary to chronic pancreatic insufficiency 

• Secondary to with cystic fibrosis.

 

 

 

 

 

 

 

 

22. What is/are the primary manifestations of pancreatic involvement in cystic fibrosis

 

 

 

 

 

 

 

 

 

29. What would your diagnosis be if the patient were a 42 y/o /f with a similar problem associated with ingestion of  certain  graincontaining food?  What pathology would be found in this instance?  What dietary recommendations would you make for  

• Celiac disease

• Abnormal small bowel biopsy (flat mucosa  with varying degrees of villous atrophy and infiltration of the lamina propria with lymphocytes and plasma cells.  

• Avoid gluten (wheat,oats,barley,rye) in diet.

 

 

 

 

 

 

 

 

30. What are the common etiologies for acute diarrhea?

Infectious

• Viruses

• Bacteria

• Toxins S aureus, C difficile, toxigenic E.coli

• Invasion Shiegella, Salmonella

• Parasites Giardia, Cryptosporidium

Non-infectious.

• Drugs 

  • laxatives

  • antacids

  • alcohol

  • antibiotics 

  • chemotherapy

  • a host of other pharmaceuticals used in everyday practice

• Food toxins / Preformed toxins / Starts within several hours following ingestion / Rarely fever

  • Mushrooms

  • Seafood

• Metabolic causes (hyperthyroidism)

• Motor disorders such as irritable bowel syndrome

• Redemption of enteral feeding following prolonged fast

• Fecal impaction

Onset of chronic diarrhea

31. Who are the People at risk for acute diarrhea?

• Developing nations

• Who ingest shell fish

• Male homosexuals

• AIDS

• IV drug users

• Residential homes/ nursing homes

• Day care centers