Chronic diarrhea medical therapy

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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]

Medical Therapy

Adults with chronic diarrhea (> 4 weeks)

Characterize the symptoms: ❑ Onset (congenital, abrupt or gradual) ❑ Pattern (continuous or intermittent) ❑ Duration ❑ Stool characteristics (watery, bloody or fatty) ❑ Fever ❑ Abdominal pain ❑ Weight loss ❑ Fecal incontinence Obtain a detailed history: ❑ Aggravating factors (diet or stress) ❑ Over-the-counter drugs or use of prescription ❑ Previous evaluations (objective records, radiograms or biopsy specimens) ❑ Radiation therapy or surgery ❑ Factitious diarrhea (eating disorders, laxative ingestion, secondary gain or malingering) ❑ Systemic disease (cancer, diabetes, HIV, hyperthyroidism) Elicit the epidemiological factors: ❑ Travel before the onset of illness ❑ Exposure to contaminated food or water ❑ Illness in other family members

Examine the patient: Assess the volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑ Eyes ❑ Mucosa Perform a general physical exam: ❑ Skin (flushing, rashes or dermatographism) ❑ Oral cavity (ulcers) ❑ Cardiovascular system (murmur) ❑ Respiratory system (wheezing) ❑ Thyroid (mass) ❑ Abdomen (ascites, hepatomegaly, mass or tenderness) ❑ Anorectal (Abscess, blood, fistula or sphincter competence) ❑ Extremities (edema)

Order routine laboratory tests: ❑ CBC and differential ❑ ESR ❑ Serum electrolytes ❑ Total serum protein and albumin ❑ Thyroid function tests ❑ Urinalysis

Start altered diet: ❑ Stop lactose products ❑ Avoid alcohol and high osmolar supplements ❑ Drink 8-10 large glasses of clear fluids (fruit juices, soft drinks etc) ❑ Eat frequent small meals (rice, potato, banana, pastas etc) ❑ Start oral rehydration therapy or intravenous fluids depending on the hydration status

Any specific obvious diagnosis through history and examination?

Yes

No

Chronic infection (outbreaks or endemic areas) ❑ Trial of oral metronidazole 500 mg TID for 5 days for protozoal diarrhea ❑ Oral ciprofloxacin 500 mg BD X 3 days for enteric bacterial diarrhea Medication induced: ❑ Discontinuation of the drug Irritable bowel syndrome (chronic abdominal pain and altered bowel habits in the absence of any organic disorder) ❑ Trial of antispasmodic agents (oral dicyclomine 20 mg QID),OR ❑ TCA's(amitriptyline 10-25 mg OD), OR ❑ SSRI (fluoxetine 20-40 mg OD), OR ❑ Rifaximin

No resolution of the diarrhea

Order stool analysis: ❑ Stool weight ❑ Stool electrolytes and fecal osmotic gap ❑ Stool pH ❑ Fecal occult blood testing ❑ Stool WBC's ❑ Stool fat: Quantitative / Sudan stain ❑ Laxative screen

This management is as per the American Gastroenterological Association guidelines for the evaluation and management of chronic diarrhea.

References

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