Chronic diarrhea causes

Chronic diarrhea Microchapters
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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]

Overview

Depending on the socio economic status of the population, chronic diarrhea can be caused by several factors. In a developing nation, the most likely causes of chronic bacteria include; mycobacterial and parasitic infections and less likely to include functional disorders such as malabsorption and inflammatory bowel diseases. In a developed nation however, the most likely cause of diarrhea include; irritable bowel syndrome (IBS), inflammatory bowel disease, malabsorption syndromes (such as lactose intolerance and celiac disease), and chronic infections (particularly in patients who are immunocompromised).

Causes

Major causes

• Malabsorption: Malabsorptive and maldigestive diarrhea result from impaired nutrient absorption and impaired digestive function respectively. Cystic fibrosis, celiac disease, disaccharidase deficiency (eg, lactase deficiency due to infectious diarrhea), can all cause loss of absorptive capacity. Absent pancreatic enzymes or bile acids can cause maldigestion. Classic symptoms include abdominal distention with foul-smelling, large, floating, pale, fatty stools (steatorrhea) and weight loss.
• Irritable bowel syndrome: Patients present with stool mucus, crampy abdominal pain, altered bowel habits, watery functional diarrhea after meals, exacerbated by emotional stress or eating. It is twice as common in women than men. All laboratory test results are normal. Increased fiber intake, exercise, dietary modification should be recommended.
• Inflammatory bowel disease:May manifest as either crohn disease or ulcerative colitis, patients present with bloody inflammatory diarrhea, abdominal pain, nausea, vomiting, loss of appetite, family history, eye findings (e.g., episcleritis), perianal fistulae, fever, tenesmus, rectal bleeding, weight loss. Tests include complete blood count, fecal leukocyte level, erythrocyte sedimentation rate, fecal calprotectin level. Characteristic intestinal ulcerations are seen on colonoscopy.
• Microscopic colitis: Patients present with watery, secretory diarrhea affecting older persons. Nonsteroidal anti-inflammatory drug association is possible. There is usually no response to fasting; nocturnal symptoms present. Colon biopsy is recommended.

Minor causes

• Gastrointestinal infections; such as viruses, bacteria and parasites.
• Non-gastrointestional infections (parenteral diarrhea); systemic infections, staphylococcal toxic shock syndrome, urinary tract infections and other systemic infections.
• Anatomic abnormalities; Intussusception, hirschsprung disease (± toxic megacolon) partial bowel obstruction, blind loop syndrome (also in patients with dysmotility), Intestinal lymphangiectasis, short gut syndrome.

• Immunodeficiency; Severe combined immunodeficiencies and other genetic disorders, HIV

• Drug-induced diarrhea: If diarrhea is osmotic consider magnesium, phosphates, sulfates, and sorbitol. If hypermotility consider stimulant laxatives or malabsorption acarbose, orlistat. Elimination of offending agent is often curative.

• Endocrine diarrhea: Secretory diarrhea e,g Addison disease, carcinoid tumors, vipoma, gastrinoma (Zollinger-Ellison syndrome), and mastocytosis or increased motility (hyperthyroidism). Tests that can be ordered included thyroid-stimulating hormone level, serum peptide concentrations, urinary histamine level.

• Giardiasis: Patients presents with excess gas, steatorrhea (malabsorption). Giardia fecal antigen test is diagnostic.

• Infectious enteritis or colitis (diarrhea not associated with C. difficile): Examples include bacterial gastroenteritis, viral gastroenteritis, amebic dysentery. Patients present with inflammatory diarrhea, nausea, vomiting, fever, abdominal pain, a positive history of travel, camping, infectious contacts, day care attendance, increased fecal leukocyte level, elevated erythrocyte sedimentation rate. Cultures or stained fecal smears for specific organisms are more definitive.

• Ischemic colitis:History of vascular disease and pain associated with eating. Colonoscopy and abdominal arteriography is diagnostic.

• Miscellaneous; Antibiotic-associated diarrhea, pseudomembranous colitis, toxins, hemolytic uremic syndrome, neonatal drug withdrawal

Drugs that commonly cause diarrhea

• Gastrointestinal drugs
  • Magnesium containing antacids
  • Laxatives
  • Cisapride
  • Olsalazine
• Cardiac drugs
  • Digitalis
  • Quinidine
  • Procainamide
  • Hydralazine
  • Beta-blockers
  • ACE inhibitors
  • Diuretics
• Antibiotics
  • Clindamycin
  • Ampicillin
  • Amoxycillin
  • Erythromycin
  • Cephalosporins
• Chemotherapeutic agents
• Hypolipidemic agents
  • Clofibrate
  • Gemfibrozil
  • Lovastatin
• Neuropsychiatric drugs
  • Lithium
  • Fluoxetine
  • Alprazolam
• Others
  • Aminophylline
  • Salbutamol
  • Non-steroidal anti-inflammatory drugs
  • Thyroid hormones
  • Colchicine