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. | *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> | *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> | *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> | ||
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*'''Secretory''' (often nocturnal; unrelated to food intake; fecal osmotic gap < 50 mOsm per kg*) | *'''Secretory''' (often nocturnal; unrelated to food intake; fecal osmotic gap < 50 mOsm per kg*) | ||
**[[Alcoholism]] | **[[Alcoholism]] | ||
**Bacterial enterotoxins (e.g., [[cholera]]) | **Bacterial [[enterotoxins]] (e.g., [[cholera]]) | ||
**Bile acid [[malabsorption]] | **[[Bile acid]] [[malabsorption]] | ||
**[[Brainerd diarrhea]] (epidemic secretory diarrhea) | **[[Brainerd diarrhea]] (epidemic secretory diarrhea) | ||
**[[Congenital syndromes]] | **[[Congenital syndromes]] | ||
**[[Crohn's disease|Crohn disease]] (early [[ileocolitis]]) | **[[Crohn's disease|Crohn disease]] (early [[ileocolitis]]) | ||
**Endocrine disorders e.g., [[hyperthyroidism]] | **[[Endocrine]] disorders e.g., [[hyperthyroidism]] | ||
**[[Medications]] (see causes section) | **[[Medications]] (see causes section) | ||
**[[Microscopic colitis]] ([[Lymphocytic colitis|lymphocytic]] and [[Collagenous colitis|collagenous]] subtypes) | **[[Microscopic colitis]] ([[Lymphocytic colitis|lymphocytic]] and [[Collagenous colitis|collagenous]] subtypes) | ||
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**[[Vasculitis]] | **[[Vasculitis]] | ||
*'''Osmotic''' (fecal osmotic gap > 125 mOsm per kg*) | *'''Osmotic''' (fecal osmotic gap > 125 mOsm per kg*) | ||
**Carbohydrate [[malabsorption]] syndromes (e.g., [[lactose]], [[fructose]]) | **[[Carbohydrate]] [[malabsorption]] syndromes (e.g., [[lactose]], [[fructose]]) | ||
**[[Celiac disease]] | **[[Celiac disease]] | ||
**Osmotic [[laxatives]] and antacids (e.g., [[magnesium]], [[phosphate]], [[sulfate]]) | **Osmotic [[laxatives]] and [[antacids]] (e.g., [[magnesium]], [[phosphate]], [[sulfate]]) | ||
**Sugar alcohols (e.g., [[mannitol]], [[sorbitol]], [[xylitol]]) | **Sugar alcohols (e.g., [[mannitol]], [[sorbitol]], [[xylitol]]) | ||
*'''Functional''' (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting) | *'''Functional''' (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting) | ||
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Table showing watery causes of chronic diarrhea (Table 1) | Table showing watery causes of chronic diarrhea (Table 1) | ||
{| class="wikitable" | {| class="wikitable" | ||
! | ! colspan="3" rowspan="2" |Cause | ||
! colspan="2" |Osmotic gap | ! colspan="2" |Osmotic gap | ||
! rowspan="2" |History | ! rowspan="2" |History | ||
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| rowspan="5" |Watery | | rowspan="5" |Watery | ||
| rowspan="3" |Secretory | | rowspan="3" |Secretory | ||
|Crohns | |[[Crohns disease|Crohns]] | ||
|<nowiki>+</nowiki> | |<nowiki>+</nowiki> | ||
|<nowiki>-</nowiki> | |<nowiki>-</nowiki> | ||
| | | | ||
* Abdominal pain followed by diarrhea | * [[Abdominal pain]] followed by diarrhea | ||
| | | | ||
* [[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]] | ||
*[[Tachycardia]] | *[[Tachycardia]] | ||
*[[Hypotension]] | *[[Hypotension]] | ||
| | | | ||
* Colonoscopy with biopsy | * [[Colonoscopy]] with [[biopsy]] | ||
| | | | ||
* 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 | ||
|- | |- | ||
|Hyperthyroidism | |[[Hyperthyroidism]] | ||
|<nowiki>+</nowiki> | |<nowiki>+</nowiki> | ||
|<nowiki>-</nowiki> | |<nowiki>-</nowiki> | ||
| | | | ||
* Excessive sweating | * Excessive [[sweating]] | ||
* Heat intolerance | * Heat intolerance | ||
* Increased bowel movements | * [[Hypermotility|Increased bowel movements]] | ||
| | | | ||
* Lump in the neck | * Lump in the neck | ||
* Proptosis | * [[Proptosis]] | ||
* Tremors | * [[Tremors]] | ||
* Increased DTR | * Increased DTR | ||
| | | | ||
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| | | | ||
* [[Carbimazole]] and [[methimazole]] | * [[Carbimazole]] and [[methimazole]] | ||
* Beta blockers like [[propylthiouracil]] | * [[Beta blockers]] like [[propylthiouracil]] | ||
* [[Iodine-131]] | * [[Iodine-131]] | ||
|- | |- | ||
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| | | | ||
* [[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 | ||
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:* [[Flatulence]] | :* [[Flatulence]] | ||
| | | | ||
* Abdominal tenderness | * [[Abdominal tenderness]] | ||
| | | | ||
* Intestinal biopsy | * Intestinal [[biopsy]] | ||
| | | | ||
* Avoidance of dietary lactose | * Avoidance of dietary [[lactose]] | ||
* 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 | |[[Celiac disease (patient information)|Celiac disease]] | ||
| - | | - | ||
| + | | + | ||
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* Bloatedness | * Bloatedness | ||
| | | | ||
* [[Abdominal pain]] and cramping | * [[Abdominal pain]] and [[cramping]] | ||
* Abdominal distention | * [[Abdominal distention]] | ||
* Tetany | * [[Tetany]] | ||
* 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 vitamins A, D, E, and K deficiency | ||
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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: | [[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 | * Improves with [[defecation]] | ||
* Onset associated with change in frequency of stool | * Onset associated with change in frequency of [[stool]] | ||
* Onset associated with change in appearance of stool | * Onset associated with change in appearance of stool | ||
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History of straining is also common | History of straining is also common | ||
| | | | ||
* Abdominal tenderness | * [[Abdominal tenderness]] | ||
* Hard stool in the rectal vault | * Hard stool in the rectal vault | ||
| | | | ||
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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]]) | ||
|}{{WikiDoc Help Menu}} {{WikiDoc Sources}} | |}{{WikiDoc Help Menu}} {{WikiDoc Sources}} | ||
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**[[Celiac sprue]] (gluten [[enteropathy]])–various clinical presentations | **[[Celiac sprue]] (gluten [[enteropathy]])–various clinical presentations | ||
**[[Gastric bypass]] | **[[Gastric bypass]] | ||
**Lymphatic damage (e.g., [[congestive heart failure]], some [[lymphomas]]) | **[[Lymphatic]] damage (e.g., [[congestive heart failure]], some [[lymphomas]]) | ||
**Medications (e.g., [[orlistat]] [[Xenical]]; inhibits fat absorption, [[acarbose]] [[Precose]]; inhibits carbohydrate absorption]) | **Medications (e.g., [[orlistat]] [[Xenical]]; inhibits fat absorption, [[acarbose]] [[Precose]]; inhibits [[carbohydrate]] absorption]) | ||
**[[Mesenteric ischemia]] | **[[Mesenteric ischemia]] | ||
**Noninvasive small bowel parasite (e.g., [[Giardia]]) | **Noninvasive [[small bowel]] parasite (e.g., [[Giardia]]) | ||
** | **Post-resection diarrhea | ||
**[[Short bowel syndrome]] | **[[Short bowel syndrome]] | ||
**Small bowel bacterial overgrowth (> 105 bacteria per mL) | **Small bowel [[bacterial]] overgrowth (> 105 bacteria per mL) | ||
**[[Tropical sprue]] | **[[Tropical sprue]] | ||
**[[Whipple's disease|Whipple disease]] (Tropheryma whippelii infection) | **[[Whipple's disease|Whipple disease]] (Tropheryma whippelii infection) | ||
*Maldigestion (loss of digestive function) | *[[Maldigestion]] (loss of digestive function) | ||
** | **[[Hepato-biliary diseases|Hepato-biliary disorders]] | ||
**Inadequate luminal bile acid | **Inadequate [[luminal]] [[bile acid]] | ||
**Loss of regulated gastric emptying | **Loss of regulated [[gastric]] emptying | ||
**Pancreatic exocrine insufficiency | **[[Pancreatic]] exocrine insufficiency | ||
Table showing fatty causes of chronic diarrhea ( Table 2) | Table showing fatty causes of chronic diarrhea ( Table 2) | ||
{| class="wikitable" | {| class="wikitable" | ||
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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. | ||
|} | |} | ||
==References== | ==References== |
Revision as of 19:42, 5 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*)
- Carbohydrate malabsorption syndromes (e.g., lactose, fructose)
- Celiac disease
- Osmotic laxatives and antacids (e.g., magnesium, phosphate, sulfate)
- Sugar alcohols (e.g., mannitol, sorbitol, xylitol)
- 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 | |||
---|---|---|---|---|---|---|---|---|
< 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)
- Post-resection diarrhea
- Short bowel syndrome
- Small bowel bacterial overgrowth (> 105 bacteria per mL)
- Tropical sprue
- Whipple disease (Tropheryma whippelii infection)
- Maldigestion (loss of digestive function)
- Hepato-biliary 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 | - | + |
|
|
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
Table showing inflammatory causes of chronic diarrhea ( Table 3)
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. See ... |
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:
|
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.