Chronic diarrhea

Definition: - a decrease in fecal consistency lasting for three or more weeks

- frequency 3 /day
- increase stool weight > 200g/day
Main pathogenic types:
- Osmotic diarrhea: osmotic laxative (Fortrans, Lactulosis), antiacids (MgO, Mg(OH)2, drugs
(Colchicine, cholestyramine), lactase deficiency (pancreatic insufiency, Celiac disease);
- Secretory diarrhea: Bacterial or viral enterotoxins (Cholera, E. Coli enterotoxigenic, Rotavirus),
Neuroendocrine tumors (gastrinoma, VIPoma, Carcinoid syndrome, Medullary carcinoma of
thyroid);
- Disordered motility: Postvagotomy diarrhea, Diabetic autonomic neuropathy, Hyperthyroidism
Irritable bowel syndrome;
- Inflammatory diarrhea: Inflammatory bowel disease (Ulcerative colitis, Crohn's disease),
Colagenous colitis (autoimmune), Diverticulitis, Infectious diseases (Pseudomembranous colitis-
Clostridium difficile), Tuberculosis, Yersinosis, Ulcerating viral infections (Cytomegalovirus,
Herpes simplex, Amebiasis), Ischemic colitis, Radiation colitis; Neoplasia (Colon cancer,
Lymphoma)

Common causes:
1. Gastroenteritis: viral or bacterial(salmonella), parasitic ( lamblia), toxin ( E. Coli, Shigella sp)
2. Irritable bowel syndrome
3. Colorectal carcinoma
4. Ulcerative colitis, Crohn disease
5. Coeliac disease
6. Microscopic colitis (colagenous and lymphocytic colitis)
7. Hyperthyroidism (thyreotoxicosis)

Diagnosis tests:
1. Stool analysis:
- Macroscopic appearance:
- The volume of the diarrhea (eg, voluminous watery diarrhea is more likely to be
due to a disorder in the small bowel while small-volume frequent diarrhea is more likely
to be due to disorders of the colon)
- Microscopic: parasites, Fecal leukocytes (IBD, infectious),
- Fecal calprotectin levels are increased in intestinal inflammation, and may be useful for
distinguishing inflammatory from noninflammatory causes of chronic diarrhea.
- Fecal occult blood test (gFOBT) Guaiac testing of stool samples identifies hemoglobin by
the presence of a peroxidase reaction, which turns the guaiac-impregnated paper blue. Several
guaiac reagents are marketed; Hemoccult-SENSA is more sensitive than Hemoccult. (colorectal
cancer, ischemic colitis)
- Stool cultures
- Measured stool electrolytes (calculate osmolarity)
- Stool fat. Steatorrhea is quantitative estimation of stool fat, usually performed over 72 hours,
while the patient eats a diet containing at least 100 g of fat per day. More than 6 g/day of fat in
stool is pathologic, although patients with steatorrhea usually have more than 20 g/day.
2. Blood culture (patients with fever)
3. Blood chemistry: Na, K, BUN, creatinina (dehydration), inflammatory syndrome ( ESR,
CRP, fibrinogen)
4. Macroscopic and microscopic evaluation of the small and large intestine:
- upper endoscopy (with DII biopsy- caeliac disease)
- sigmoidoscopy or
- colonoscopy with biopsy ( colorectal cancer, IBD, microscopic colitis)
5. Ultrasound and CT scan: asses pancreas, small and large bowel, tumours
6. Serum TSH and free T4 and T3 concentrations, ultrasound of the thyroida
7. Celiac serology. Currently, the most valuable test is for antibodies against tissue
transglutaminase (anti-tTG), which is highly sensitive, specific, and more cost-effective than
other antibody tests
Treatment:
- opiates: Codeine 15-60 mg/zi (4X/day)
Loperamide cps 2 mg: 2-4 mg (4X/day)
- adrenergic 2 agonist : Clonidina (dose: 0,1-0.3 TID) - diabetes mellitus
- somatostatin analogues: octreotide (Sandostatin 50-250 g?TID SQ)
- NSAID: 5-ASA compounds: sulfasalazina (5_ASA + sulfapyridina), mesalazina (Salofalk) (IBD)
- corticosteroids: IBD
- probiotics