DIARRH
EA
PGI Dheeraj Jayakumar
• Diarrhea definition: Abnormally liquid or unformed stools, >200
g/day; categorized as:
• Acute (<2 weeks)
• Persistent (2-4 weeks)
• Chronic (>4 weeks)
• Similar conditions:
• Pseudodiarrhea: Frequent passage of small stool volumes, often
linked to IBS or proctitis.
• Fecal incontinence: Involuntary discharge of stool, typically from
neuromuscular disorders.
• Overflow diarrhea: Occurs with fecal impaction, common in nursing
home patients.
Acute diarrhea causes:90% from infectious agents (often accompanied by vomiting, fever,
abdominal pain).
• 10% from medications, toxic ingestions, ischemia, and food-related issues.
1.High-risk groups for infectious diarrhea: Travelers (e.g., E. coli, Campylobacter).
2.Food consumers (e.g., Salmonella, Listeria).
3.Immunodeficient individuals (e.g., AIDS patients).
4.Daycare attendees/families (e.g., Shigella).
5.Institutionalized individuals (e.g., C. difficile).
• Noninfectious causes: Medications (antibiotics, NSAIDs), ischemic colitis, diverticulitis, toxic
ingestions, and acute anaphylaxis.Chronic diarrhea confusion: Early onset inflammatory
conditions (e.g., IBD) may mimic acute diarrhea
Treatment
Fluid and electrolyte replacement: Crucial for all forms of acute diarrhea.
• Oral rehydration solutions (e.g., sport drinks) are important for severe diarrhea to prevent dehydration
• IV rehydration is needed for profound dehydration (especially in infants/elderly).
Symptom control:
• Antimotility and antisecretory agents (e.g., loperamide) can help with nonfebrile, nonbloody diarrhea.
• Avoid these agents in febrile dysentery; caution with drugs that increase loperamide levels due to cardiotoxicity.
• Bismuth subsalicylate can reduce symptoms but should be avoided in immunocompromised or renal-impaired patients.
Antibiotic use:Empirical antibiotics (e.g., ciprofloxacin) may be used for febrile dysentery without diagnostic evaluation.
• Metronidazole may be considered for suspected giardiasis.
• Newer agents like nitazoxanide are needed for resistant infections (e.g., Giardia, Cryptosporidium).
• Antibiotics are recommended for immunocompromised patients, those with heart valves or vascular grafts, and the
elderly.
Traveler’s diarrhea:Bismuth subsalicylate can reduce frequency.
• Antibiotic prophylaxis (ciprofloxacin, azithromycin, rifaximin) is indicated for high-risk travelers.
• Rifaximin is unsuitable for invasive disease, but effective for uncomplicated traveler’s diarrhea.
Endoscopic evaluation: Rarely needed except for immunocompromised patients.
Outbreak vigilance: Early identification and reporting to public health authorities can limit spread.
Chronic diarrhea (>4 weeks) warrants evaluation for non-infectious
causes
• Secretory diarrhea: Caused by fluid/electrolyte imbalance; persists
with fasting; can result from medications (e.g., laxatives, olmesartan),
bowel resection, and certain bacterial infections.
• Hormonal causes: Includes carcinoid tumors, VIPomas, and medullary
thyroid carcinoma, leading to massive watery diarrhea and electrolyte
imbalances.
• Congenital ion absorption defects: Rare, resulting in watery diarrhea
from birth.
• Osmotic diarrhea: Due to poorly absorbable solutes like magnesium,
lactose intolerance, or FODMAP intolerance; ceases with fasting.
• Steatorrhea: Fat malabsorption causing greasy, foul-smelling diarrhea
often linked to pancreatic insufficiency, celiac disease, or bacterial
overgrowth.
• Inflammatory causes: Conditions like IBD (Crohn's, ulcerative colitis)
or infections cause pain, fever, and bleeding; microscopic colitis seen
in middle-aged women.
• Dysmotility-related diarrhea: Hyperthyroidism, carcinoid syndrome,
or diabetic dysmotility may result in rapid transit diarrhea.
• IBS: Common, with alternating stool frequency, pain, and no weight
loss.
• Factitious diarrhea: Self-induced via laxatives or water/urine
contamination, often linked to psychiatric illness.
Treatment
Treatment of chronic diarrhea depends on the specific cause: curative, suppressive, or
empirical.
Curative treatment:
• Resection of colorectal cancer, antibiotics for Whipple’s disease or tropical sprue, or
discontinuing offending drugs.
Suppressive treatment:
• Eliminate lactose (lactase deficiency) or gluten (celiac disease).
• Glucocorticoids or anti-inflammatory agents for idiopathic IBD.
• Bile acid sequestrants for bile acid malabsorption.
• PPIs for gastrinomas.
• Octreotide (somatostatin analogue) for malignant carcinoid syndrome.
• Indomethacin (prostaglandin inhibitor) for medullary thyroid carcinoma.
• Pancreatic enzyme replacement for pancreatic insufficiency.
Empirical therapy:
• Mild opiates (diphenoxylate, loperamide) for mild/moderate watery diarrhea.
• Codeine or tincture of opium for severe diarrhea (avoid in severe IBD due to
risk of toxic megacolon).
• Clonidine for diabetic diarrhea (may cause postural hypotension).
• 5-HT3 receptor antagonists (alosetron, ondansetron) for IBS-related diarrhea.
• Rifaximin and eluxadoline for IBS diarrhea (eluxadoline may cause
pancreatitis, especially after cholecystectomy).
Fluid and electrolyte repletion is essential for all patients.Fat-soluble vitamin
replacement may be necessary.
Thank you
