Chronic diarrhea differential diagnosis: Difference between revisions
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==Differential diagnosis== | ==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 diarrhea|watery]], [[Steatorrhea|fatty]], [[inflammatory]]. Watery chronic diarrhea can then further be sub-divided into [[osmotic]] or [[Secretory component|secretory]] diarrhea. Below is a list of differential diagnosis of chronic diarrhea by [[Stool examination|stool]] characteristics.<ref name="pmid10348832">{{cite journal| author=Fine KD, Schiller LR| title=AGA technical review on the evaluation and management of chronic diarrhea. | journal=Gastroenterology | year= 1999 | volume= 116 | issue= 6 | pages= 1464-86 | pmid=10348832 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10348832 }} </ref><ref name="LacyMearin2016">{{cite journal|last1=Lacy|first1=Brian E.|last2=Mearin|first2=Fermín|last3=Chang|first3=Lin|last4=Chey|first4=William D.|last5=Lembo|first5=Anthony J.|last6=Simren|first6=Magnus|last7=Spiller|first7=Robin|title=Bowel Disorders|journal=Gastroenterology|volume=150|issue=6|year=2016|pages=1393–1407.e5|issn=00165085|doi=10.1053/j.gastro.2016.02.031}}</ref> | 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 diarrhea|watery]], [[Steatorrhea|fatty]], [[inflammatory]]. Watery chronic diarrhea can then further be sub-divided into [[osmotic]] or [[Secretory component|secretory]] diarrhea. Below is a list of differential diagnosis of chronic diarrhea by [[Stool examination|stool]] characteristics.<ref name="pmid10348832">{{cite journal| author=Fine KD, Schiller LR| title=AGA technical review on the evaluation and management of chronic diarrhea. | journal=Gastroenterology | year= 1999 | volume= 116 | issue= 6 | pages= 1464-86 | pmid=10348832 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10348832 }} </ref><ref name="LacyMearin2016">{{cite journal|last1=Lacy|first1=Brian E.|last2=Mearin|first2=Fermín|last3=Chang|first3=Lin|last4=Chey|first4=William D.|last5=Lembo|first5=Anthony J.|last6=Simren|first6=Magnus|last7=Spiller|first7=Robin|title=Bowel Disorders|journal=Gastroenterology|volume=150|issue=6|year=2016|pages=1393–1407.e5|issn=00165085|doi=10.1053/j.gastro.2016.02.031}}</ref> | ||
*The stool osmotic gap is a calculation performed to distinguish among different causes of diarrhea. | |||
*290 − 2 * (stool Na + stool K)<ref name="pmid8159195">{{cite journal| author=Topazian M, Binder HJ| title=Brief report: factitious diarrhea detected by measurement of stool osmolality. | journal=N Engl J Med | year= 1994 | volume= 330 | issue= 20 | pages= 1418-9 | pmid=8159195 | doi=10.1056/NEJM199405193302004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8159195 }} </ref> | |||
*A low stool osmolic gap can imply secretory diarrhea, while a high gap can imply osmotic diarrhea.<ref name="pmid3994188">{{cite journal| author=Shiau YF, Feldman GM, Resnick MA, Coff PM| title=Stool electrolyte and osmolality measurements in the evaluation of diarrheal disorders. | journal=Ann Intern Med | year= 1985 | volume= 102 | issue= 6 | pages= 773-5 | pmid=3994188 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3994188 }} </ref> | |||
'''Watery''' | '''Watery''' | ||
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* [[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. | ||
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==References== | ==References== |
Revision as of 12:27, 3 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
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]
- The stool osmotic gap is a calculation performed to distinguish among different causes of diarrhea.
- 290 − 2 * (stool Na + stool K)[3]
- A low stool osmolic gap can imply secretory diarrhea, while a high gap can imply osmotic diarrhea.[4]
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)
Table showing watery causes of chronic diarrhea (Table 1)
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
Table showing fatty causes of chronic diarrhea ( Table 2)
Cause | Osmotic gap | History | Physical exam | Gold standard | Treatment | |
---|---|---|---|---|---|---|
< 50
mOsm per kg |
> 125
mOsm per kg* | |||||
lactose intolerance | - | + |
|
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Lactose breath hydrogen test | Restriction of lactose and maintain calcium and vitamin D intake. |
Celiac sprue | - | + |
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Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper ebdoscopy with biopsy. | Dietary counseling, elimination of gluten in the diet. |
Whipple disease | - | + |
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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
Table showing inflammatory causes of chronic diarrhea ( Table 3)
Cause | History | Laboratory findings | Diagnosis | Treatment |
---|---|---|---|---|
Diverticulitis |
|
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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 |
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Endoscopy | Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease. See ... |
Entamoeba histolytica |
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cysts shed with the stool | detects ameba DNA in feces | Amebic dysentery ;
Luminal amebicides for E. histolytica in the colon:
For amebic liver abscess:
|
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.
- ↑ Topazian M, Binder HJ (1994). "Brief report: factitious diarrhea detected by measurement of stool osmolality". N Engl J Med. 330 (20): 1418–9. doi:10.1056/NEJM199405193302004. PMID 8159195.
- ↑ Shiau YF, Feldman GM, Resnick MA, Coff PM (1985). "Stool electrolyte and osmolality measurements in the evaluation of diarrheal disorders". Ann Intern Med. 102 (6): 773–5. PMID 3994188.