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Chronic Diarrhea

See Also
Definition
1. Persistent Diarrhea >4 weeks
Causes
1. Chronic Fatty Diarrhea (Diarrhea due to Malabsorption)
2. Chronic Inflammatory Diarrhea
3. Chronic Watery Diarrhea
4. Infectious Diarrhea
5. Functional Diarrhea (diagnosis of exclusion)
  1. Irritable Bowel Syndrome
History
1. Age
  1. Young patients
    1. Inflammatory Bowel Disease
    2. Tuberculosis
    3. Functional bowel disorder (Irritable bowel)
  2. Older patients
    1. Colon Cancer
    2. Diverticulitis
2. Diarrhea pattern
  1. Diarrhea alternates with Constipation
    1. Colon Cancer
    2. Laxative abuse
    3. Diverticulitis
    4. Functional bowel disorder (Irritable bowel)
  2. Intermittent Diarrhea
    1. Diverticulitis
    2. Functional bowel disorder (Irritable bowel)
    3. Malabsorption
  3. Persistent Diarrhea
    1. Inflammatory Bowel Disease
    2. Laxative abuse
3. Differentiating small bowel from large bowel
  1. Small intestine or proximal colon involved
    1. Large stool Diarrhea
    2. Abdominal cramping persists after Defecation
  2. Distal colon involved
    1. Small stool Diarrhea
    2. Abdominal cramping relieved by Defecation
4. Diurnal variation
  1. No relationship to time of day: Infectious Diarrhea
  2. Morning Diarrhea and after meals
    1. Gastric cause
    2. Functional bowel disorder (e.g. irritable bowel)
    3. Inflammatory Bowel Disease
  3. Nocturnal Diarrhea (always organic)
    1. Diabetic Neuropathy
    2. Inflammatory Bowel Disease
5. Weight Loss
  1. Despite normal appetite
    1. Hyperthyroidism
    2. Malabsorption
  2. Associated with fever
    1. Inflammatory Bowel Disease
  3. Weight loss prior to Diarrhea onset
    1. Pancreatic Cancer
    2. Tuberculosis
    3. Diabetes Mellitus
    4. Hyperthyroidism
    5. Malabsorption
6. Stool characteristics
  1. Water: Chronic Watery Diarrhea
  2. Blood, pus or mucus: Chronic Inflammatory Diarrhea
  3. Foul, bulky, greasy stools: Chronic Fatty Diarrhea
7. Medication and dietary intakes
  1. See Drug-Induced Diarrhea
  2. See Foodborne Illness
  3. See Waterborne Illness
  4. High fructose corn syrup
  5. Excessive Sorbitol or mannitol
  6. Excessive coffee or other caffeine
8. Recent travel to undeveloped areas
  1. See Traveler's Diarrhea
  2. See Infectious Diarrhea
Red Flags: Suggestive of organic cause
1. Painless Diarrhea
2. Recent onset in an older patient
3. Nocturnal Diarrhea (especially if wakes patient)
4. Weight loss
5. Blood in stool
6. Large stool volumes: >400 grams stool per day
7. Anemia
8. Hypoalbuminemia
9. Erythrocyte Sedimentation Rate increased
Labs
1. Blood tests
  1. Complete Blood Count
  2. Thyroid Stimulating Hormone (TSH)
  3. Serum electrolytes
  4. Serum Albumin
2. Stool evaluation
  1. Stool pH (<6 in carbohydrate malabsorption
  2. Fecal electrolytes (Fecal sodium and Osmolar Gap)
    1. Differentiates Chronic Watery Diarrhea category
  3. Fecal Occult Blood test
  4. Fecal Leukocytes
  5. Fecal fat (abnormal if >14 grams/24 hours)
  6. Stool Ova and Parasite (2-3 samples)
  7. Giardia lamblia antigen
    1. Indicated for Diarrhea >7 days and >10 stools/day
  8. Clostridium difficile Toxin
    1. Indicated if recent antibiotics or hospitalization
  9. Consider testing stools for Laxative abuse
Management
1. Direct to specific causes based on stool
2. Chronic Fatty Diarrhea (Diarrhea due to Malabsorption)
3. Chronic Inflammatory Diarrhea
4. Chronic Watery Diarrhea
References
1. Frank in Friedman (1991) Medical Diagnosis, p. 186-9
2. Schiller in Feldman (2002) Sleisenger GI, p. 136

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This page was written by Scott Moses, MD. This page was last revised on 4/26/2008 9:13:09 PM. This page was last published on 4/29/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.