Chronic diarrhea differential diagnosis: Difference between revisions
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|<nowiki>-</nowiki> | |<nowiki>-</nowiki> | ||
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* [[Abdominal pain]] followed by diarrhea | * [[Abdominal pain]] followed by [[diarrhea]] | ||
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* [[Abdominal]] [[tenderness ]]when palpated in severe disease | * [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]] | ||
* Blood seen on [[rectal exam]] | * Blood seen on [[rectal exam]] | ||
*[[Fever]] | *[[Fever]] | ||
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* [[Colonoscopy]] with [[biopsy]] | * [[Colonoscopy]] with [[biopsy]] | ||
| | | | ||
* Topical mucosamine and [[corticosteroids]] are | * Topical mucosamine and [[corticosteroids]] are preferred | ||
* [[Mesalamine]] and [[sulfasalazine]] are used for remission | * [[Mesalamine]] and [[sulfasalazine]] are used for remission | ||
|- | |- | ||
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* Increased DTR | * Increased DTR | ||
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* TSH with T3 and T4 | * [[TSH]] with [[T3]] and [[T4]] | ||
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* [[Carbimazole]] and [[methimazole]] | * [[Carbimazole]] and [[methimazole]] | ||
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* [[Iodine-131]] | * [[Iodine-131]] | ||
|- | |- | ||
|VIPoma | |[[VIPoma]] | ||
|<nowiki>+</nowiki> | |<nowiki>+</nowiki> | ||
| - | | - | ||
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* [[Abdominal tenderness]] in the right upper abdominal quadrant | * [[Abdominal tenderness]] in the right upper abdominal quadrant | ||
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* Elevated VIP levels | * Elevated [[VIP]] levels | ||
* Followed by imaging | * Followed by imaging | ||
| | | | ||
* [[Sandostatin]] or [[chemotherapy]] for malignant tumors | * [[Sandostatin]] or [[chemotherapy]] for [[malignant tumors]] | ||
* Surgical removal of the [[tumor]] | * Surgical removal of the [[tumor]] | ||
|- | |- | ||
| rowspan="2" |Osmotic | | rowspan="2" |[[Osmotic]] | ||
|Lactose intolerance | |[[Lactose intolerance]] | ||
| - | | - | ||
|<nowiki>+</nowiki> | |<nowiki>+</nowiki> | ||
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* Substitution to maintain nutrient intake | * Substitution to maintain nutrient intake | ||
* Regulation of [[calcium]] intake | * Regulation of [[calcium]] intake | ||
* Use of enzyme [[lactase]] | * Use of [[enzyme]] [[lactase]] | ||
|- | |- | ||
|[[Celiac disease (patient information)|Celiac disease]] | |[[Celiac disease (patient information)|Celiac disease]] | ||
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* [[Mouth ulcers]] | * [[Mouth ulcers]] | ||
* [[Dermatitis herpetiformis]] | * [[Dermatitis herpetiformis]] | ||
* Signs of the fat-soluble vitamins A, D, E, and K deficiency | * Signs of the fat-soluble [[Vitamin A|vitamins A]], D, E, and K deficiency | ||
| | | | ||
* IgA tissue transglutaminase Ab | * [[IgA]] tissue [[transglutaminase]] Ab | ||
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* [[Gluten-free diet]] | * [[Gluten-free diet]] | ||
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|Functional | |Functional | ||
|Irritable bowel syndrome | |[[Irritable bowel syndrome]] | ||
| - | | - | ||
| - | | - | ||
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* Onset associated with change in appearance of stool | * Onset associated with change in appearance of stool | ||
* 25% of bowel movements are loose stools | * 25% of [[Bowel movement|bowel movements]] are loose stools | ||
History of straining is also common | History of straining is also common | ||
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* Hard stool in the rectal vault | * Hard stool in the rectal vault | ||
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* Clinical diagnosis | * [[Diagnosis|Clinical diagnosis]] | ||
** ROME III criteria | ** ROME III criteria | ||
** Pharmacologic studies based criteria | ** [[Pharmacological|Pharmacologic]] studies based criteria | ||
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* High [[dietary fiber]] | * High [[dietary fiber]] | ||
* Osmotic [[laxatives]] such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]] | * [[Osmotic]] [[laxatives]] such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]] | ||
* [[Antispasmodic]] drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]]) | * [[Antispasmodic]] drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]]) | ||
|}{{WikiDoc Help Menu}} {{WikiDoc Sources}} | |}{{WikiDoc Help Menu}} {{WikiDoc Sources}} | ||
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| + | | + | ||
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* Bloating, | * [[Bloating|Bloating,]] | ||
* Flatulence | * [[Flatulence]] | ||
* Abdominal pain, and/or chronic diarrhea | * [[Abdominal pain]], and/or [[chronic diarrhea]] | ||
* after ingestion of lactose | * after ingestion of [[lactose]] | ||
| | | | ||
* [[Abdominal]] [[tenderness ]]when palpated in severe disease | * [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]] | ||
* Fever | * [[Fever]] | ||
* Hypotension | * [[Hypotension]] | ||
* Tachycardia | * [[Tachycardia]] | ||
* Nausea and | * [[Nausea and vomiting]] | ||
|Lactose breath hydrogen test | |[[Hydrogen Breath Test|Lactose breath hydrogen test]] | ||
|Restriction of lactose and maintain calcium and vitamin D intake. | |Restriction of [[lactose]] and maintain [[calcium]] and [[vitamin D]] intake. | ||
|- | |- | ||
|[[Celiac sprue]] | |[[Celiac sprue]] | ||
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| + | | + | ||
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* Diarrhea with bulky, foul-smelling stools | * [[Diarrhea]] with bulky, [[Steatorrhea|foul-smelling stools]] | ||
* Growth failure in children, | * [[Growth failure]] in children, | ||
* Weight loss, | * [[Weight loss|Weight loss,]] | ||
* Anemia, | * [[Anemia]], | ||
* Neurologic disorders | * [[Neurologic diseases|Neurologic disorders]] | ||
* Osteopenia | * [[Osteopenia]] | ||
| | | | ||
* Neuropsychiatric disease | * [[Neuropsychiatric|Neuropsychiatric disease]] | ||
* Dermatitis herpetiformis | * [[Dermatitis herpetiformis]] | ||
* Arthritis | * [[Arthritis]] | ||
* Iron deficiency | * [[Iron deficiency]] | ||
* Metabolic bone disease | * [[Metabolic]] bone disease | ||
* Hyposplenism | * [[Hyposplenism]] | ||
* Kidney disease | * [[Kidney disease]] | ||
* Idiopathic pulmonary hemosiderosis | * [[Idiopathic pulmonary hemosiderosis]] | ||
|Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper | |[[Immunoglobulin A]] ([[IgA]]) [[Tissue transglutaminase|anti-tissue transglutaminase]] (TTG) antibody followed by upper [[endoscopy]] with [[biopsy]]. | ||
|Dietary counseling, elimination of gluten in the diet. | |Dietary counseling, elimination of [[gluten]] in the diet. | ||
|- | |- | ||
|[[Whipple's disease|Whipple disease]] | |[[Whipple's disease|Whipple disease]] | ||
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| + | | + | ||
| | | | ||
* Arthralgias | * [[Arthralgias]] | ||
* Weight loss | * [[Weight loss]] | ||
* Diarrhea | * [[Diarrhea]] | ||
* Abdominal pain | * [[Abdominal pain]] | ||
| | | | ||
* Leukocytopenia | * [[Leukocytopenia]] | ||
* Thrombocytopenia | * [[Thrombocytopenia]] | ||
* Skin hyperpigmentation | * [[Skin hyperpigmentation]] | ||
|Upper [[endoscopy]] with [[biopsies]] of the [[small intestine]] for ''[[Tropheryma whipplei|T. whipplei]]'' testing ([[histology]] with [[Periodic acid-Schiff stain|PAS staining]], [[polymerase chain reaction]] [[[PCR]]] testing, and [[immunohistochemistry]]) | |||
|Upper endoscopy with biopsies of the small intestine for ''T. whipplei'' testing (histology with PAS staining, polymerase chain reaction [PCR] testing, and immunohistochemistry) | |[[Doxycycline]] and [[hydroxychloroquine]] are [[bactericidal]] | ||
|Doxycycline and hydroxychloroquine | |||
|} | |} | ||
'''The table below summarizes the findings that differentiate inflammatory causes of chronic diarrhea''' | '''The table below summarizes the findings that differentiate inflammatory causes of chronic diarrhea''' | ||
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!Treatment | !Treatment | ||
|- | |- | ||
|Diverticulitis | |[[Diverticulitis]] | ||
| | | | ||
* Bloody diarrhea | * [[Bloody diarrhea]] | ||
* Left lower quadrant abdominal pain | * Left lower quadrant [[abdominal pain]] | ||
* Abdominal tenderness on physical examination | * [[Abdominal tenderness]] on [[physical examination]] | ||
* Low grade fever | * Low grade [[fever]] | ||
| | | | ||
* Leukocytosis | * [[Leukocytosis]] | ||
* Elevated serum amylase and lipase | * Elevated serum [[amylase]] and [[lipase]] | ||
* Sterile pyuria on urinalysis | * [[Sterile]] [[pyuria]] on [[urinalysis]] | ||
|Abdominal CT scan with oral and intravenous (IV) contrast | |Abdominal [[CT scan]] with oral and intravenous [[Contrast medium|(IV) contrast]] | ||
|bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]] | |bowel rest, [[Intravenous fluids|IV fluid]] resuscitation, and [[Broad-spectrum antibiotic|broad-spectrum antimicrobial therapy]] which covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]] | ||
|- | |- | ||
|Ulcerative colitis | |[[Ulcerative colitis]] | ||
| | | | ||
* [[Diarrhea]] mixed with blood and [[mucus]], of gradual onset. | * [[Diarrhea]] mixed with blood and [[mucus]], of gradual onset. | ||
* Signs of [[weight loss]] | * Signs of [[weight loss]] | ||
* Rectal urgency | * [[Rectal pain|Rectal urgency]] | ||
* [[Tenesmus]] | * [[Tenesmus]] | ||
* Blood is often noticed on underwear | * [[Blood]] is often noticed on underwear | ||
* Different degrees of [[abdominal pain]] | * Different degrees of [[abdominal pain]] | ||
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* A high [[platelet]] count | * A high [[platelet]] count | ||
* | * Elevated [[ESR]] (>30mm/hr) | ||
* Low albumin | * Low [[albumin]] | ||
|[[Endoscopy]] | |[[Endoscopy]] | ||
|Induction of [[Remission (medicine)|remission]] with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease | |Induction of [[Remission (medicine)|remission]] with [[mesalamine]] and [[corticosteroids]] followed by the administration of [[sulfasalazine]] and [[Mercaptopurine|6-Mercaptopurine]] depending on the severity of the [[disease]]. | ||
|- | |- | ||
|Entamoeba histolytica | |[[Entamoeba histolytica]] | ||
| | | | ||
* [[Abdominal cramps]] | * [[Abdominal cramps]] | ||
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* Unintentional [[weight loss]] | * Unintentional [[weight loss]] | ||
|cysts shed with the stool | |cysts shed with the stool | ||
|detects ameba DNA in feces | |detects ameba [[DNA]] in feces | ||
|Amebic dysentery | |[[Amebic dysentery]] | ||
* [[Metronidazole]] 500-750mg three times a day for 5-10 days | * [[Metronidazole]] 500-750mg three times a day for 5-10 days | ||
* [[Tinidazole]] 2g once a day for 3 days is an alternative to metronidazole | * [[Tinidazole]] 2g once a day for 3 days is an alternative to [[metronidazole]] | ||
Luminal amebicides for ''[[E. histolytica]]'' in the colon: | Luminal amebicides for ''[[E. histolytica]]'' in the [[colon]]: | ||
* [[Paromomycin]] 500mg three times a day for 10 days | * [[Paromomycin]] 500mg three times a day for 10 days | ||
* [[Diloxanide furoate]] 500mg three times a day for 10 days | * [[Diloxanide furoate]] 500mg three times a day for 10 days | ||
* [[Iodoquinol]] 650mg three times a day for 20 days | * [[Iodoquinol]] 650mg three times a day for 20 days | ||
For amebic liver abscess: | For [[Amoebiasis|amebic liver abscess]]: | ||
* [[Metronidazole]] 400mg three times a day for 10 days | * [[Metronidazole]] 400mg three times a day for 10 days | ||
* [[Tinidazole]] 2g once a day for 6 days is an alternative to metronidazole | * [[Tinidazole]] 2g once a day for 6 days is an alternative to [[metronidazole]] | ||
* [[Diloxanide furoate]] 500mg three times a day for 10 days must always be given afterwards. | * [[Diloxanide furoate]] 500mg three times a day for 10 days must always be given afterwards. | ||
|} | |} |
Revision as of 12:52, 26 July 2017
Chronic diarrhea Microchapters |
Diagnosis |
---|
Treatment |
Case Studies |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]
Overview
The differential diagnosis for chronic diarrhea is enormous, with a large number of diagnostic tests available that can be used to evaluate these patients. Classifying the patient with chronic diarrhea into a subcategory helps to direct the diagnostic work-up.
Differential diagnosis
The table below summarizes the findings that differentiate watery causes of chronic diarrhea
Cause | Osmotic gap | History | Physical exam | Gold standard | Treatment | |||
---|---|---|---|---|---|---|---|---|
< 50 mOsm per kg | > 50 mOsm per kg* | |||||||
Watery | Secretory | Crohns | + | - |
|
|
|
|
Hyperthyroidism | + | - |
|
|||||
VIPoma | + | - |
|
|
|
| ||
Osmotic | Lactose intolerance | - | + |
|
||||
Celiac disease | - | + |
|
|
|
|||
Functional | Irritable bowel syndrome | - | - |
Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:
History of straining is also common |
|
|
|
The table below summarizes the findings that differentiate fatty causes of chronic diarrhea
Cause | Osmotic gap | History | Physical exam | Gold standard | Treatment | |
---|---|---|---|---|---|---|
< 50
mOsm per kg |
> 50
mOsm per kg* | |||||
lactose intolerance | - | + |
|
|
Lactose breath hydrogen test | Restriction of lactose and maintain calcium and vitamin D intake. |
Celiac sprue | - | + |
|
Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper endoscopy with biopsy. | Dietary counseling, elimination of gluten in the diet. | |
Whipple disease | - | + | Upper endoscopy with biopsies of the small intestine for T. whipplei testing (histology with PAS staining, polymerase chain reaction [[[PCR]]] testing, and immunohistochemistry) | Doxycycline and hydroxychloroquine are bactericidal |
The table below summarizes the findings that differentiate inflammatory causes of chronic diarrhea
Cause | History | Laboratory findings | Diagnosis | Treatment |
---|---|---|---|---|
Diverticulitis |
|
|
Abdominal CT scan with oral and intravenous (IV) contrast | bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobic bacteria and gram-negative rods |
Ulcerative colitis |
|
|
Endoscopy | Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease. |
Entamoeba histolytica |
|
cysts shed with the stool | detects ameba DNA in feces | Amebic dysentery
Luminal amebicides for E. histolytica in the colon:
For amebic liver abscess:
|