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35-year old female shop assistant presents with "diarrhea for five…
35-year old female shop assistant presents with "diarrhea for five months"
Steatorrhoea
(greasy, foul-smelling, bulky stools that float in water): fat malabsorption; defect in emulsification by bile salts, hydrolysis by lipase or absorption by mucosa
Lipase insufficiency
: (1) pancreas [chronic pancreatitis, duct obstruction e.g. stones/cystic fibrosis; insufficient functional reserve e.g. carcinoma, resection]; (2) gastrinoma (gut too alkaline for lipase to act; (3) drugs e.g. lipase inhibitors e.g. orlistat
Bile salt insufficiency
: (1) liver insufficiency or cirrhosis; (2) bile duct (obstructive jaundice preventing bile salt outflow)
Mucosal malabsorption
: lipid is harder to digest than protein or carbohydrate, malabsorption may first present as steatorrhea; causes: (1) short gut syndrome after resection, (2) inflammation e.g. Crohn's, (3) celiac disease
Inflammatory diarrhea
: painful, bloody stool +/- systemic symptoms e.g. fever
IBD
: Crohn's, ulcerative colitis; typically gradual onset of bloody diarrhea, abdominal pain, weight loss and fever; symptoms are intermittent but with flares
Infective colitis
: chronic infection with particular mucosal-invading organisms
Others
: ischemic, radiation injury, etc; elicit risk factors for atherosclerotic disease, PMHx of abdominal radiation
Watery or partially formed stools
Secretory diarrhea (large volume, watery stool, usually painless and unrelated to food intake) vs. osmotic diarrhea (watery stools occuring on intake of non-absorbable, osmotically active solutes, ceasing when intake of culprit is stopped) vs. abnormal motility
Secretory and osmotic
Gut irritation
(chronic infection: in patients with risk factors e.g. travel, immunosuppression incl. HIV, antibiotics use, contaminated drinking water. assess C. diff risk e.g. recent hospital stay or institutionalization; drugs as a side effect)
Malabsorption
(osmotically active agent e.g. laxative ingestion, lactose intolerance due to lactase deficiency, increased bile acids in colon due to cholecystectomy; short gut syndrome post resection or fistula, mucosal disease e.g. celiac disease)
Endocrine tumors
(secretion of vasoactive substances from carcinoid e.g. diarrhea, flushing and VIPoma)
Abnormal motility
Colorectal cancer
: change in bowel habits, blood in stools, change in stool calibre, weight loss, etc - absence do not rule of CA colon!
Endocrine
: hyperthyroidism
Neurologic
: autonomic neuropathy e.g. diabetes
Pseudo-diarrhea
: mimics diarrhea
Fecal incontinence
: neuromuscular disorders or anorectal anatomical problems
Overflow (spurious) diarrhea
: fecal impaction with only fluid matter able to pass the impacted feces; often due to constipating drugs in elderly but may be secondary to obstructing tumor
Functional disorders
: diagnosis of exclusion
Irritable bowel syndrome
: chronic lower abdominal colic with both diarrhea and constipation episodes, assoc. with psychologic stress; pseudodiarrhea, frequent passage of small volumes of stool with rectal urgency, is usually IBS
Functional diarrhea
: chronic diarrhea without abdominal pain, lack of significant weight loss
Step 1: diarrhea vs. fecal incontinence (involuntary release of rectal contents; problem is with anal sphincter dysfunction and not dysregulated intestinal fluid or electrolyte absorption) vs. impaction
Step 2: rule out medications-induced diarrhea (antacids, nutritional supplements containing magnesium, antibiotics, PPI, SSRIs, NSAIDs, chemotherapy agents)
Step 3: distinguish acute (<2 weeks) from chronic (>4 weeks) diarrhea
Step 4: categorize diarrhea as inflammatory, fatty or watery
Step 5: Consider factitious diarrhea (intentionally self-inflicted disorder)