Chronic diarrhea differential diagnosis: Difference between revisions
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**Loss of regulated gastric emptying | **Loss of regulated gastric emptying | ||
**Pancreatic exocrine insufficiency | **Pancreatic exocrine insufficiency | ||
{| class="wikitable" | |||
! rowspan="2" |Cause | |||
! colspan="2" |Osmotic gap | |||
! rowspan="2" |History | |||
! rowspan="2" |Physical exam | |||
! rowspan="2" |Gold standard | |||
! rowspan="2" |Treatment | |||
|- | |||
!< 50 | |||
mOsm | |||
per kg | |||
!> 125 | |||
mOsm | |||
per kg* | |||
|- | |||
|[[lactose intolerance]] | |||
| - | |||
| + | |||
| | |||
* Bloating, | |||
* Flatulence | |||
* Abdominal pain, and/or chronic diarrhea | |||
* after ingestion of lactose | |||
| | |||
* [[Abdominal]] [[tenderness ]]when palpated in severe disease | |||
* Fever | |||
* Hypotension | |||
* Tachycardia | |||
* Nausea and vomitting | |||
|Lactose breath hydrogen test | |||
|Restriction of lactose and maintain calcium and vitamin D intake. | |||
|- | |||
|[[Celiac sprue]] | |||
| - | |||
| + | |||
| | |||
* Diarrhea with bulky, foul-smelling stools | |||
* Growth failure in children, | |||
* Weight loss, | |||
* Anemia, | |||
* Neurologic disorders | |||
* Osteopenia | |||
| | |||
* Neuropsychiatric disease | |||
* Dermatitis herpetiformis | |||
* Arthritis | |||
* Iron deficiency | |||
* Metabolic bone disease | |||
* Hyposplenism | |||
* Kidney disease | |||
* Idiopathic pulmonary hemosiderosis | |||
|Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper ebdoscopy with biopsy. | |||
|Dietary counseling, elimination of gluten in the diet. | |||
|- | |||
|[[Whipple's disease|Whipple disease]] | |||
| - | |||
| + | |||
| | |||
* Arthralgias | |||
* Weight loss | |||
* Diarrhea | |||
* Abdominal pain | |||
| | |||
* Leukocytopenia | |||
* Thrombocytopenia | |||
* Skin hyperpigmentation | |||
* | |||
|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 was bactericidal | |||
|} | |||
'''Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)''' | '''Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)''' |
Revision as of 14:23, 23 June 2017
Chronic diarrhea Microchapters |
Diagnosis |
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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 | |||
---|---|---|---|---|---|---|---|---|
< 50 mOsm per kg | > 125 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 |
|
|
|
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
Cause | Osmotic gap | History | Physical exam | Gold standard | Treatment | |
---|---|---|---|---|---|---|
< 50
mOsm per kg |
> 125
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 ebdoscopy 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 was bactericidal |
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.