CHRONIC DIARRHEA DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) DEFINITION: *LOOSE, WATERY STOOLS *MORE THAN 3 TIMES A DAY *FOR MORE THAN 4 WEEKS

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1 DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) TH ST. NW. CALGARY AB T2N2A1 PHONE (403) FAX (403) CHRONIC DIARRHEA DEFINITION: *LOOSE, WATERY STOOLS *MORE THAN 3 TIMES A DAY *FOR MORE THAN 4 WEEKS HISTORY OF SYMPTOMS: *ABRUPT OR GRADUAL IN ONSET *FREQUENCY AND CONSISTENCY OF DIARRHEA *NOCTURNAL DIARRHEA *CRAMPS, BLOATING AND ABDOMINAL PAIN *ANOREXIA, WEIGHT LOSS *RECTAL BLEEDING *WHAT HAPPENS TO THE DIARRHEA WHEN ONE IS FASTING HISTORY OF POSSIBLE CAUSATIVE FACTOR: *INITIAL INFECTION (THAT CAN CAUSE A POST- DYSENTERIC IBS) *TRAVEL *EXPOSURE TO CONTAMINATED FOOD *ILLNESS IN OTHER FAMILY MEMBER *NEW MEDICATIONS *SURGERY *CHANGE IN DIET *STRESS *FAMILY HISTORY OF CELIAC, INFLAMMATORY BOWEL DISEASE, COLON CANCER *RECENTLY QUIT SMOKING THAT CAN PRECIPITATE ULCERATIVE COLITIS *HISTORY OF EXCESSIVE ALCOHOL INTAKE AND SMOKING THAT CAN CAUSE EXOCRINE PANCREATIC INSUFFICIENCY DIFFERENTIAL DIAGNOSIS: 1) IRRITABLE BOWEL SYNDROME *CAN PRESENT AS CONSTIPATION DOMINANT, DIARRHEA DOMINANT OR ALTERNATING DIARRHEA AND CONSTIPATION *ASSOCIATED GAS, BLOATING, CRAMPING AND PAIN *NORMALLY THERE IS NO ASSOCIATED ANOREXIA AND WEIGHT LOSS UNLESS THERE IS CONCOMITANT DEPRESSION *STRESS IS A LARGE COMPONENT IN CAUSING AND AGGRAVATING THE SYMPTOMS *CHRONIC HISTORY *CAN BE ASSOCIATED WITH ANY OTHER DISEASE PROCESS THAT CAUSES DIARRHEA

2 *THERE IS USUALLY A PRECIPITATING FACTOR SUCH AN ANTECEDENT INFECTION, CHANGE IN DIET, NEW MEDICATION, TRAVEL, SURGERY OR STRESS *IT IS RARE TO DEVELOP SPONTANEOUSLY *PATIENT MAY BE PREDOMINANTLY TENDER IN THE LLQ 2) FOOD INTOLERANCES *ALLERGIES ARE RARE, FOOD INTOLERANCES ARE COMMON *PATIENT MAY HAVE DOMINANT GAS AND BLOATING *CAN BE PRECIPITATED BY AN INFECTION *CAN BE ASSOCIATED WITH ANY OTHER DISEASE PROCESS THAT CAUSES DIARRHEA *FOOD ELIMINATION TRIALS ARE VERY HELPFUL 3) CELIAC DISEASE *1% OF THE POPULATION MAY HAVE CELIAC *ALWAYS CONSIDER CELIAC IN ANY PATIENT WHO PRESENTS WITH GI SYMPTOMS *ENQUIRE IF THERE IS A FAMILY HISTORY *IRON DEFICIENCY ANEMIA CAN BE A PRESENTING SYMPTOM 4) INFLAMMATORY BOWEL DISEASE ULCERATIVE COLITIS: *PRESENTS CLASSICALLY WITH DIARRHEA AND RECTAL BLEEDING *MAY HAVE TENESMUS AND PASS BLOOD ALONE WITHOUT STOOL *MAY BE PRECIPITATED BY AN INITIAL INFECTION, STRESS OR QUITTING SMOKING *BE SUSPICIOUS IF THERE IS WEIGHT LOSS, ANEMIA OR INCREASED CRP CROHN S DISEASE: *PRESENTS CLASSICALLY WITH DIARRHEA AND ABDOMINAL PAIN *BE SUSPICIOUS IF THERE IS WEIGHT LOSS, ANEMIA, PERIANAL DISEASE OR INCREASED CRP *PATIENT IS PREDOMINANTLY TENDER IN THE RLQ 5) COLON CANCER *UNEXPLAINED CHANGE IN BOWEL PATTERN *MAY HAVE ASSOCIATED ANOREXIA, WEIGHT LOSS, GAS, BLOATING, ABDOMINAL PAIN, RECTAL BLEEDING *MAY HAVE ASSOCIATED IRON DEFICIENCY ANEMIA *FAMILY HISTORY OF COLON CANCER 6) MICROSCOPIC COLITIS *PRESENTS AS WATERY DIARRHEA IN OLDER WOMAN *MAY BE SECONDARY TO SUCH MEDICATION AS NSAID, SSRI, STATINS, PPI *DIAGNOSIS IS MADE BY COLONIC BIOPSIES AT A COLONOSCOPY. THE ENDOSCOPIC APPEARANCE IS NORMAL 7) MEDICATION RELATED *ANTIBIOTICS CAN CAUSE CLOSTRIDIUM DIFFICILE *NSAID, SSRI, STATINS AND PPI CAN CAUSE MICROSCOPIC COLITIS *ALWAYS ENQUIRE WHAT NEW MEDICATIONS THE PATIENT HAS STARTED

3 8) BILE ACID MALABSORPTION (CHOLERRHEIC DIARRHEA) POST- OPERATIVE: *POST- CHOLECYSTECTOMY *POST- ILEAL RESECTION IDIOPATHIC: *CAN OCCUR SPONTANEOUSLY *ALWAYS BE SUSPICIOUS IN THE SETTING OF IDIOPATHIC DIARRHEA *DIAGNOSIS IS MADE BY NEGATIVE INVESTIGATIONS AND RESPONSE TO CHOLESTYRAMINE (OLESTYR 2-4 GRAMS PO OD) 9) DUMPING SYNDROME POST- VAGOTOMY AND PYLOROPLASTY / POST- BILROTH 1 AND 2 GASTRECTOMY / POST NISSEN FUNDOPLICATION: *TREAT WITH DRY MEALS (NO FLUID AT MEALTIME), AVOID SUGARS AT MEALTIME 9) DIABETES CAN CAUSE DIARRHEA THRU SEVERAL MECHANISMS *CELIAC DISEASE *BACTERIAL OVERGROWTH *FUNCTIONAL EXOCRINE PANCREATIC INSUFFICIENCY *AUTONOMIC NEUROPATHY 10) EXOCRINE PANCREATIC INSUFFICIENCY *BE SUSPICIOUS IF CHRONIC ALCOHOL INTAKE AND SMOKING *CAN BE IDIOPATHIC IN ELDERLY INDIVIDUALS LABORATORY INVESTIGATION: *CBC *ALBUMIN *TSH *ESR, C- REACTIVE PROTEIN *CELIAC SEROLOGY STOOL TESTING: *STOOL FOR CULTURE AND SENSITIVITY, OVA AND PARASITES AND CLOSTRIDIUM DIFFICILE *BE SUSPICIOUS FOR C. DIFFICILE EVEN WITHOUT AN ANTECEDENT HISTORY OF ANTIBIOTIC USE *PATIENTS WITH ULCERATIVE COLITIS AND CROHN S ARE MORE LIKELY TO HAVE C. DIFFICILE EVEN IN THE ABSENCE OF ANTIBIOITICS *FECAL ELASTASE IF EXOCRINE PANCREATIC INSUFFICIENCY IS SUSPECTED *QUALITATIVE STOOL FOR FAT IF STEATORRHEA IS SUSPECTED *IF THERE IS SIGNIFICANT UNEXPLAINED DIARRHEA DO NOT DO A FIT TEST AS THE PATIENT REQUIRES A COLONOSCOPY

4 RADIOLOGICAL AND ENDOSCOPIC INVESTIGATION: *INITIALLY ONE EVALUATES THE COLON AND THEN THE SMALL BOWEL *ROUTINE ABDOMINAL AND PELVIC ULTRASOUND ARE NOT INDICATED COLON EVALUATION: *WHEN INDICATED COLONOSCOPY IS PREFERRED TO AN ACBE *IF COLONOSCOPY CANNOT BE PERFORMED OR IS INCOMPLETE A CT COLONOGRAPHY IS INDICATED *IF THE COLONOSCOPY IS INCOMPLETE AND A CT COLONOGRAPHY CANNOT BE PERFORMED DUE TO RENAL DYSFUNCTION THEN AN ACBE IS INDICATED SMALL BOWEL EVALUATION: *IF COLONIC INVESTIGATIONS ARE NORMAL THE SMALL BOWEL NEEDS TO BE EVALUATED WITH ONE OF THE FOLLOWING DEPENDING ON THE AVAILABILITY: CT ENTEROGRAPHY MR ENTEROGRAPHY CONTRAST ENHANCED ULTRASOUND SMALL BOWEL SERIES IS THE LAST CHOICE FOR EVALUATING THE SMALL BOWEL ENDOSCOPIC PROCEDURES: SIGMOIDOSCOPY: *IN THE SETTING OF DIARRHEA AND RECTAL BLEEDING WHERE ULCERATIVE COLITIS IS SUSPECTED SIGMOIDOSCOPY MAY BE AN INITIAL VALUABLE TEST COLONOSCOPY: *PREFERRED TEST TO EVALUATE THE COLON *ALSO ALLOWS FOR COLONIC BIOPSIES TO BE TAKEN TO RULE OUT MICROSCOPIC COLITIS GASTROSCOPY: *IF THERE IS A POSITIVE CELIAC TEST A GASTROSCOPY IS INDICATED TO OBTAIN SMALL BOWEL BIOPSIES TO CONFIRM THE DIAGNOSIS OF CELIAC *IF THE COLONIC AND SMALL BOWEL INVESTIGATIONS ARE NEGATIVE AND THE PATIENT CONTINUES TO HAVE SIGNIFICANT DIARRHEA A GASTROSCOPY WITH SMALL BOWEL BIOPSIES IS HELPFUL TO RULE OUT SEROLOGY NEGATIVE CELIAC DISEASE TREATMENT: SEQUENTIAL TRIALS OF: 1) DISCONTINUE ANY POTENTIAL OFFENDING MEDICATION 2) METAMUCIL 1 DOSE A DAY AS A 2 WEEK TRIAL (METAMUCIL IS A STOOL REGULATOR AND IS OF VALUE BOTH IN DIARRHEA AND CONSTIPATION OF THE IRRITABLE BOWEL SYNDROME) 3) DIETARY MANIPULATION: *SEQUENTIAL DIETARY ELIMINATION TRIALS *FODMAP DIET (AS OUTLINED IN THE GAS AND BLOATING SECTION)

5 4) CHOLESTYRAMINE (OLESTYR) 2-4 GRAMS PO DAILY AS A 4 WEEK TRIAL *EFFECTIVE BILE SALT BINDER THAT CAN BE OF VALUE IN IDIOPATHIC CHOLERRHEIC DIET, POST- CHOLECYSTECTOMY OR POST- ILEAL RESECTION INDUCED DIARRHEA *CAN BE TRIED IN IDIOPATHIC DIARRHEA WHEN METAMUCIL AND DIETARY ELIMINATION TRIALS FAIL AND INVESTIGATIONS ARE NORMAL 5) IMODIUM, LOMOTIL, CODEINE ON A PRN BASIS *IF ALL THE INVESTIGATIONS ARE NEGATIVE THEN ANTIDIARRHEAL DRUGS ARE HELPFUL FOR SYMPTOMATIC CONTROL 6) PROBIOTIC (ALIGN) 1 CAPSULE PO OD FOR A 2 WEEK TRIAL 7) IF STRESS IS A CONTRIBUTING FACTOR ARRANGE FOR TREATMENT *THIS IS OFTEN A COMMON PRECIPITATING AND AGGRAVATING FACTOR!!!! FOR EFFECTIVE STRESS MANAGEMENT STRATEGIES THE PATIENT CAN VIEW THE WEBSITE: WHO TO REFER: *NEW ONSET DIARRHEA LASTING FOR ONE MONTH WITH NO OBVIOUS EXPLANATION *ASSOCIATED ANOREXIA, WEIGHT LOSS, NAUSEA, VOMITING, FATIGUE *NOCTURNAL DIARRHEA *NEW ONSET RECTAL BLEEDING *PERSISTENT DIARRHEA FAILING TO RESPOND TO THE ABOVE THERAPEUTIC TRIALS *ASSOCIATED ANEMIA, THROMBOCYTOSIS, HYPOALBUMINEMIA *ELEVATED ESR / C- REACTIVE PROTEIN WITH NO OTHER ASSOCIATED INFLAMMATORY CONDITION