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35yo female, shop assistant, “diarrhoea for five months” (STEATORRHOEA…
35yo female, shop assistant, “diarrhoea for five months”
STEATORRHOEA
PRESENTATION: greasy, foul-smelling, bulky stools that float in water (due to fat malabsorption)
PP: Fat absorption requires emulsification by bile salts, hydrolysis by lipase, and absorption by mucosa. Defect in any component leads to steatorrhoea.
Bile salt insufficiency
- Liver: insufficiency / cirrhosis
- Bile duct: obstructive jaundice preventing bile salt outflow
Lipase insufficiency
- Pancreas: chronic pancreatitis, duct obstruction (stones, cystic fibrosis), insufficient functional reserve (carcinoma, resection).
- Gastrinoma: gut too alkaline for lipase to act.
- Drug: lipase inhibitors e.g. Orlistat
Mucosal malabsorption
- Short gut syndrome after resection,
- Inflammation (e.g. Crohn’s Disease)
- Celiac dx
INFLAMMATORY DIARRHOEA
PRESENTATION: painful, bloody stools ± systemic symptoms (e.g. fever due to colitis)
PP: Diarrhoea and systemic symptoms result of colitis which may be infective, ischemic, or inflammatory
Inflammatory bowel disease
- Crohn’s, ulcerative colitis. Gradual onset of bloody diarrhoea, abdominal pain, weight loss, and fever. Symptoms are intermittant with flares.
Infective colitis
- chronic infection with particular mucosal-invading organisms.
Others
- ischemic, radiation injury, etc. Elicit risk fx for atherosclerotic dx, and PMHx of abdominal radiation.
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FUNCTIONAL DISORDERS
Irritable bowel syn (IBS): chronic lower abdo colic w both diarrhoea and constipation episodes, associated w psychologic stress. Pseudodiarrhoea, the frequent passage of small volumes of stool, with rectal urgency, is usually IBS. Rome diagnostic criteria: recurrent abdo discomfort ≥3 days/mth in last 3 mths with at least 2 of:
- Improvement with defecation
- Onset assoc with change in frequency of stool
- Onset assoc with change in form of stool
Functional diarrhoea: chronic diarrhoea without abdominal pain, lack of significant weight loss.
PSEUDO-DIARRHOEA
Fecal incontinence: neuromuscular disorders or anorectal anatomical problems.
Overflow (spurious) diarrhoea: fecal impaction with only fluid matter able to pass the impacted feces. Often due to constipating drugs in the elderly, but may also be secondary to a obstructing tumor. Do per rectal for impacted feces.