Chronic diarrhea differential diagnosis: Difference between revisions

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* May be asymptomatic
* May be [[asymptomatic]]
* Vague [[abdominal pain]]
* Vague [[abdominal pain]]
* [[Diarrhea]]
* [[Diarrhea]]
* [[Weight loss]]
* [[Weight loss]]
* [[Malabsorption]] / [[steatorrhea]]
* [[Malabsorption]]/[[steatorrhea]]
* Bloatedness
* Bloatedness
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* Onset associated with change in frequency of [[stool]]
* Onset associated with change in frequency of [[stool]]


* Onset associated with change in appearance of stool
* Onset associated with change in appearance of [[stool]]


* 25% of [[Bowel movement|bowel movements]] are loose stools
* 25% of [[Bowel movement|bowel movements]] are loose [[stools]]
History of straining is also common
History of straining is also common.
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* [[Abdominal tenderness]]
* [[Abdominal tenderness]]
* Hard stool in the rectal vault
* Hard [[stool]] in the rectal vault
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* [[Diagnosis|Clinical diagnosis]]
* [[Diagnosis|Clinical diagnosis]]
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* [[Bloating|Bloating,]]
* [[Bloating]]
* [[Flatulence]]
* [[Flatulence]]
* [[Abdominal pain]], and/or [[chronic diarrhea]]  
* [[Abdominal pain]] and/or [[chronic diarrhea]]  
* After ingestion of [[lactose]]
* After ingestion of [[lactose]]
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* [[Nausea and vomiting]]
* [[Nausea and vomiting]]
|[[Hydrogen Breath Test|Lactose breath hydrogen test]]
|[[Hydrogen Breath Test|Lactose breath hydrogen test]]
|Restriction of  [[lactose]] and  maintain [[calcium]] and [[vitamin D]] intake.
|Restriction of  [[lactose]] and  maintaining [[calcium]] and [[vitamin D]] intake.
|-
|-
|[[Celiac sprue]]
|[[Celiac sprue]]
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* [[Diarrhea]] with bulky, [[Steatorrhea|foul-smelling stools]]
* [[Diarrhea]] with bulky, [[Steatorrhea|foul-smelling stools]]
* [[Growth failure]] in children,  
* [[Growth failure]] in children,
* [[Weight loss|Weight loss,]]  
* [[Weight loss]]  
* [[Anemia]],
* [[Anemia]]
* [[Neurologic diseases|Neurologic disorders]]
* [[Neurologic diseases|Neurologic disorders]]
* [[Osteopenia]]
* [[Osteopenia]]
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* [[Thrombocytopenia]]
* [[Thrombocytopenia]]
* [[Skin hyperpigmentation]]
* [[Skin hyperpigmentation]]
|Upper [[endoscopy]] with [[biopsies]] of the [[small intestine]] for ''[[Tropheryma whipplei|T. whipplei]]'' testing ([[histology]] with [[Periodic acid-Schiff stain|PAS staining]], [[polymerase chain reaction]] [[[PCR]]] testing, and [[immunohistochemistry]])
|Upper [[endoscopy]] with [[biopsies]] of the [[small intestine]] for ''[[Tropheryma whipplei|T. whipplei]]'' testing ([[histology]] with [[Periodic acid-Schiff stain|PAS staining]], [[polymerase chain reaction]] [[PCR]] testing, and [[immunohistochemistry]])
|[[Doxycycline]] and [[hydroxychloroquine]] are [[bactericidal]]
|[[Doxycycline]] and [[hydroxychloroquine]] are [[bactericidal]].
|}
|}
'''The table below summarizes the findings that differentiate inflammatory causes of chronic diarrhea'''<ref name="pmid8209928">{{cite journal| author=Konvolinka CW| title=Acute diverticulitis under age forty. | journal=Am J Surg | year= 1994 | volume= 167 | issue= 6 | pages= 562-5 | pmid=8209928 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8209928  }} </ref><ref name="pmid16151544">{{cite journal| author=Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR et al.| title=Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. | journal=Can J Gastroenterol | year= 2005 | volume= 19 Suppl A | issue=  | pages= 5A-36A | pmid=16151544 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16151544  }} </ref><ref name="pmid16698746">{{cite journal| author=Satsangi J, Silverberg MS, Vermeire S, Colombel JF| title=The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. | journal=Gut | year= 2006 | volume= 55 | issue= 6 | pages= 749-53 | pmid=16698746 | doi=10.1136/gut.2005.082909 | pmc=1856208 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16698746  }} </ref><ref name="pmid12700377">{{cite journal| author=Haque R, Huston CD, Hughes M, Houpt E, Petri WA| title=Amebiasis. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 16 | pages= 1565-73 | pmid=12700377 | doi=10.1056/NEJMra022710 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12700377  }} </ref><ref name="pmid12700377">{{cite journal| author=Haque R, Huston CD, Hughes M, Houpt E, Petri WA| title=Amebiasis. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 16 | pages= 1565-73 | pmid=12700377 | doi=10.1056/NEJMra022710 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12700377  }} </ref>
'''The table below summarizes the findings that differentiate inflammatory causes of chronic diarrhea'''<ref name="pmid8209928">{{cite journal| author=Konvolinka CW| title=Acute diverticulitis under age forty. | journal=Am J Surg | year= 1994 | volume= 167 | issue= 6 | pages= 562-5 | pmid=8209928 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8209928  }} </ref><ref name="pmid16151544">{{cite journal| author=Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR et al.| title=Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. | journal=Can J Gastroenterol | year= 2005 | volume= 19 Suppl A | issue=  | pages= 5A-36A | pmid=16151544 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16151544  }} </ref><ref name="pmid16698746">{{cite journal| author=Satsangi J, Silverberg MS, Vermeire S, Colombel JF| title=The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. | journal=Gut | year= 2006 | volume= 55 | issue= 6 | pages= 749-53 | pmid=16698746 | doi=10.1136/gut.2005.082909 | pmc=1856208 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16698746  }} </ref><ref name="pmid12700377">{{cite journal| author=Haque R, Huston CD, Hughes M, Houpt E, Petri WA| title=Amebiasis. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 16 | pages= 1565-73 | pmid=12700377 | doi=10.1056/NEJMra022710 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12700377  }} </ref><ref name="pmid12700377">{{cite journal| author=Haque R, Huston CD, Hughes M, Houpt E, Petri WA| title=Amebiasis. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 16 | pages= 1565-73 | pmid=12700377 | doi=10.1056/NEJMra022710 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12700377  }} </ref>
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* [[Sterile]] [[pyuria]] on [[urinalysis]]
* [[Sterile]] [[pyuria]] on [[urinalysis]]
|Abdominal [[CT scan]] with oral and intravenous [[Contrast medium|(IV) contrast]]
|Abdominal [[CT scan]] with oral and intravenous [[Contrast medium|(IV) contrast]]
|bowel rest, [[Intravenous fluids|IV fluid]] resuscitation, and [[Broad-spectrum antibiotic|broad-spectrum antimicrobial therapy]] which covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]]
|Bowel rest, [[Intravenous fluids|IV fluid]] resuscitation, and [[Broad-spectrum antibiotic|broad-spectrum antimicrobial therapy]] that covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]]
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|-
|[[Ulcerative colitis]]
|[[Ulcerative colitis]]
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* [[Diarrhea]] mixed with blood and [[mucus]], of gradual onset.
* [[Diarrhea]] mixed with blood and [[mucus]], of gradual onset
* Signs of [[weight loss]]
* Signs of [[weight loss]]
* [[Rectal pain|Rectal urgency]]
* [[Rectal pain|Rectal urgency]]
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|Induction of  [[Remission (medicine)|remission]] with [[mesalamine]] and [[corticosteroids]] followed by the administration of [[sulfasalazine]] and [[Mercaptopurine|6-Mercaptopurine]] depending on the severity of the [[disease]].  
|Induction of  [[Remission (medicine)|remission]] with [[mesalamine]] and [[corticosteroids]] followed by the administration of [[sulfasalazine]] and [[Mercaptopurine|6-Mercaptopurine]] depending on the severity of the [[disease]].  
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|[[Entamoeba histolytica]]
|''[[Entamoeba histolytica]]''
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* [[Abdominal cramps]]
* [[Abdominal cramps]]
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* Unintentional [[weight loss]]
* Unintentional [[weight loss]]
|Cysts shed with the stool
|Cysts shed with the stool
|Detects ameba [[DNA]] in feces
|Detects amoeba [[DNA]] in feces
|[[Amebic dysentery]]
|[[Amebic dysentery]]
* [[Metronidazole]] 500-750mg three times a day for 5-10 days
* [[Metronidazole]] 500-750mg three times a day for 5-10 days

Revision as of 21:01, 8 August 2017

Chronic diarrhea Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Chronic diarrhea from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]

Overview

The differential diagnosis for chronic diarrhea is enormous, with a large number of diagnostic tests available that can be used to evaluate these patients. Classifying a patient's chronic diarrhea into a subcategory helps to direct the diagnostic work-up.

Differential diagnosis

The table below summarizes the findings that differentiate watery causes of chronic diarrhea[1][2][3][4]

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50 mOsm per kg > 50 mOsm per kg*
Watery Secretory Crohn's disease + -
Hyperthyroidism + -
VIPoma + -
  • Elevated VIP levels
  • Followed by imaging
Osmotic Lactose intolerance - +
Celiac disease - +
Functional Irritable bowel syndrome - -

Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:

  • Onset associated with change in frequency of stool
  • Onset associated with change in appearance of stool

History of straining is also common.

Template:WikiDoc Sources

The table below summarizes the findings that differentiate fatty causes of chronic diarrhea[5][6][7]

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50

mOsm

per kg

> 50

mOsm

per kg*

Lactose intolerance - + Lactose breath hydrogen test Restriction of lactose and maintaining calcium and vitamin D intake.
Celiac sprue - + Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper endoscopy with biopsy. Dietary counseling, elimination of gluten in the diet.
Whipple disease - + Upper endoscopy with biopsies of the small intestine for T. whipplei testing (histology with PAS staining, polymerase chain reaction PCR testing, and immunohistochemistry) Doxycycline and hydroxychloroquine are bactericidal.

The table below summarizes the findings that differentiate inflammatory causes of chronic diarrhea[8][1][9][10][10]

Cause History Laboratory findings Diagnosis Treatment
Diverticulitis Abdominal CT scan with oral and intravenous (IV) contrast Bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy that covers anaerobic bacteria and gram-negative rods
Ulcerative colitis Endoscopy Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease.
Entamoeba histolytica Cysts shed with the stool Detects amoeba DNA in feces Amebic dysentery

Luminal amebicides for E. histolytica in the colon:

For amebic liver abscess:

References

  1. ↑ 1.0 1.1 Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR; et al. (2005). "Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology". Can J Gastroenterol. 19 Suppl A: 5A–36A. PMID 16151544.
  2. ↑ Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D (2002). "Bowel habits and bile acid malabsorption in the months after cholecystectomy". Am J Gastroenterol. 97 (7): 1732–5. doi:10.1111/j.1572-0241.2002.05779.x. PMID 12135027.
  3. ↑ Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R; et al. (1991). "Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia". Gastroenterology. 100 (2): 359–69. PMID 1702075.
  4. ↑ RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC (1960). "Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue". Gastroenterology. 38: 28–49. PMID 14439871.
  5. ↑ Hertzler SR, Savaiano DA (1996). "Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance". Am J Clin Nutr. 64 (2): 232–6. PMID 8694025.
  6. ↑ Briet F, Pochart P, Marteau P, Flourie B, Arrigoni E, Rambaud JC (1997). "Improved clinical tolerance to chronic lactose ingestion in subjects with lactose intolerance: a placebo effect?". Gut. 41 (5): 632–5. PMC 1891556. PMID 9414969.
  7. ↑ BLACK-SCHAFFER B (1949). "The tinctoral demonstration of a glycoprotein in Whipple's disease". Proc Soc Exp Biol Med. 72 (1): 225–7. PMID 15391722.
  8. ↑ Konvolinka CW (1994). "Acute diverticulitis under age forty". Am J Surg. 167 (6): 562–5. PMID 8209928.
  9. ↑ Satsangi J, Silverberg MS, Vermeire S, Colombel JF (2006). "The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications". Gut. 55 (6): 749–53. doi:10.1136/gut.2005.082909. PMC 1856208. PMID 16698746.
  10. ↑ 10.0 10.1 Haque R, Huston CD, Hughes M, Houpt E, Petri WA (2003). "Amebiasis". N Engl J Med. 348 (16): 1565–73. doi:10.1056/NEJMra022710. PMID 12700377.


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