Chronic diarrhea differential diagnosis: Difference between revisions
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!> 125 mOsm per kg* | !> 125 mOsm per kg* | ||
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| rowspan=" | | rowspan="5" |Watery | ||
| rowspan=" | | rowspan="3" |Secretory | ||
|Crohns | |Crohns | ||
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|<nowiki>-</nowiki> | |||
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* Abdominal pain followed by diarrhea | |||
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* [[Abdominal]] [[tenderness ]]when palpated in severe disease | * [[Abdominal]] [[tenderness ]]when palpated in severe disease | ||
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* Topical mucosamine and corticosteroids are prefferd | * Topical mucosamine and corticosteroids are prefferd | ||
* Mesalamine and sulfasalazine are used for remission | * Mesalamine and sulfasalazine are used for remission | ||
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|Hyperthyroidism | |Hyperthyroidism | ||
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|<nowiki>-</nowiki> | |||
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* Excessive sweating | |||
* Heat intolerance | |||
* Increased bowel movements | |||
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* Lump in the neck | |||
* Proptosis | |||
* Tremors | |||
* Increased DTR | |||
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* TSH with T3 and T4 | |||
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* [[Carbimazole]] and [[methimazole]] | * [[Carbimazole]] and [[methimazole]] | ||
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* [[Iodine-131]] | * [[Iodine-131]] | ||
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| | |VIPoma | ||
|<nowiki>+</nowiki> | |||
| - | |||
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* Watery [[diarrhea]] | |||
* [[Dehydration]] ([[thirst]], [[dry skin]], [[dry mouth]], [[tiredness]], [[headaches]], and [[dizziness]]) | |||
* [[Lethargy]], [[muscle weakness]] | |||
* [[Nausea]], [[vomiting]] | |||
* Crampy [[abdominal pain]] | |||
* [[Weight loss]] | |||
* [[Flushing]] | |||
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* [[Tachycardia]] | |||
* [[Rash]] | |||
* [[Facial flushing]] | |||
* [[Abdominal distention]] | |||
* [[Abdominal tenderness]] in the right upper abdominal quadrant | |||
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* Elevated VIP levels | |||
* Followed by imaging | |||
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* [[Sandostatin]] or [[chemotherapy]] for malignant tumors | |||
* Surgical removal of the tumor | |||
|- | |- | ||
| rowspan="2" |Osmotic | | rowspan="2" |Osmotic | ||
| | |Lactose intolerance | ||
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| | |<nowiki>+</nowiki> | ||
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:* [[Abdominal pain]] | |||
:* [[Bloating]] | |||
:* [[Diarrhea]] | |||
:* [[Flatulence]] | |||
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* Abdominal tenderness | |||
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* Intestinal biopsy | |||
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* Avoidance of dietary lactose | |||
* Substitution to maintain nutrient intake | |||
* Regulation of calcium intake | |||
* Use of enzyme lactase | |||
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|Celiac disease | |Celiac disease | ||
| - | |||
| + | |||
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* May be asymptomatic | |||
* Vague [[abdominal pain]] | |||
* [[Diarrhea]] | |||
* [[Weight loss]] | |||
* [[Malabsorption]] / [[steatorrhea]] | |||
* Bloatedness | |||
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* [[Abdominal pain]] and cramping | |||
* Abdominal distention | |||
* Tetany | |||
* Mouth ulcers | |||
* [[Dermatitis herpetiformis]] | |||
* Signs of the fat-soluble vitamins A, D, E, and K deficiency | |||
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* IgA tissue transglutaminase Ab | |||
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* [[Gluten-free diet]] | |||
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|Functional | |Functional | ||
|Irritable bowel syndrome | |Irritable bowel syndrome | ||
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| - | |||
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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: | |||
* Improves with defecation | |||
* Onset associated with change in frequency of stool | |||
* Onset associated with change in appearance of stool | |||
* 25% of bowel movements are loose stools | |||
History of straining is also common | |||
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* Abdominal tenderness | |||
* Hard stool in the rectal vault | |||
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* Clinical diagnosis | |||
** ROME III criteria | |||
** Pharmacologic studies based criteria | |||
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* High [[dietary fiber]] | |||
| | * Osmotic laxatives such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]] | ||
* antispasmodic drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]]) | |||
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Revision as of 20:01, 22 June 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
It is important to differentiate chronic diarrhea based on the kind of diarrhea that is produced. Chronic diarrhea can be subdivided into three major types; watery, fatty, inflammatory. Watery chronic diarrhea can then further be sub-divided into osmotic or secretory diarrhea. Below is a list of differential diagnosis of chronic diarrhea by stool characteristics.[1][2]
Watery
- Secretory (often nocturnal; unrelated to food intake; fecal osmotic gap < 50 mOsm per kg*)
- Alcoholism
- Bacterial enterotoxins (e.g., cholera)
- Bile acid malabsorption
- Brainerd diarrhea (epidemic secretory diarrhea)
- Congenital syndromes
- Crohn disease (early ileocolitis)
- Endocrine disorders e.g., hyperthyroidism
- Medications (see causes section)
- Microscopic colitis (lymphocytic and collagenous subtypes)
- Neuroendocrine tumors (e.g., gastrinoma, vipoma, carcinoid tumors, mastocytosis)
- Nonosmotic laxatives (e.g., senna, docusate sodium)
- Postsurgical (e.g., cholecystectomy, gastrectomy, vagotomy, intestinal resection)
- Vasculitis
- Osmotic (fecal osmotic gap > 125 mOsm per kg*)
- Functional (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting)
Cause | Osmotic gap | History | Physical exam | Gold standard | Treatment | |||
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< 50 mOsm per kg | > 125 mOsm per kg* | |||||||
Watery | Secretory | Crohns | + | - |
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Hyperthyroidism | + | - |
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VIPoma | + | - |
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Osmotic | Lactose intolerance | - | + |
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Celiac disease | - | + |
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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 |
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Fatty (bloating and steatorrhea in many, but not all cases)
- Malabsorption syndrome (damage to or loss of absorptive ability)
- Amyloidosis
- Carbohydrate malabsorption (e.g., lactose intolerance)
- Celiac sprue (gluten enteropathy)–various clinical presentations
- Gastric bypass
- Lymphatic damage (e.g., congestive heart failure, some lymphomas)
- Medications (e.g., orlistat Xenical; inhibits fat absorption, acarbose Precose; inhibits carbohydrate absorption])
- Mesenteric ischemia
- Noninvasive small bowel parasite (e.g., Giardia)
- Postresection diarrhea
- Short bowel syndrome
- Small bowel bacterial overgrowth (> 105 bacteria per mL)
- Tropical sprue
- Whipple disease (Tropheryma whippelii infection)
- Maldigestion (loss of digestive function)
- Hepatobiliary disorders
- Inadequate luminal bile acid
- Loss of regulated gastric emptying
- Pancreatic exocrine insufficiency
Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)
- Inflammatory bowel disease Crohn disease (ileal or early Crohn disease may be secretory)
- Diverticulitis
- Ulcerative colitis
- Ulcerative jejunoileitis
- Invasive infectious diseases
- Clostridium difficile (pseudomembranous) colitis–antibiotic history
- Invasive bacterial infections (e.g., tuberculosis, yersiniosis)
- Invasive parasitic infections (e.g., Entamoeba)–travel history
- Ulcerating viral infections (e.g., cytomegalovirus, herpes simplex virus)
- Neoplasia
- Colon carcinoma
- Lymphoma
- Villous adenocarcinoma
- Radiation colitis
References
- ↑ Fine KD, Schiller LR (1999). "AGA technical review on the evaluation and management of chronic diarrhea". Gastroenterology. 116 (6): 1464–86. PMID 10348832.
- ↑ Lacy, Brian E.; Mearin, Fermín; Chang, Lin; Chey, William D.; Lembo, Anthony J.; Simren, Magnus; Spiller, Robin (2016). "Bowel Disorders". Gastroenterology. 150 (6): 1393–1407.e5. doi:10.1053/j.gastro.2016.02.031. ISSN 0016-5085.