Chronic diarrhea causes

Chronic diarrhea Microchapters
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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

Depending on the socio economic status of the population, chronic diarrhea can be caused by several factors. In a developing nation, the most likely causes of chronic bacteria include; mycobacterial and parasitic infections and less likely to include functional disorders such as malabsorption and inflammatory bowel diseases. In a developed nation however, the most likely cause of diarrhea include; irritable bowel syndrome (IBS), inflammatory bowel disease, malabsorption syndromes (such as lactose intolerance and celiac disease), and chronic infections (particularly in patients who are immunocompromised).

Causes

Some common causes of chronic diarrhea and their clinical findings include;

• Celiac disease: Patients present with hronic malabsorptive diarrhea, fatigue, iron deficiency anemia, weight loss, dermatitis herpetiformis, and a positive family history of celiac disease. Tests that can be done include immunoglobulin A, antiendomysium and antitissue transglutaminase antibodies, the most accurate being duodenal biopsy.

• Clostridium difficile infection: Patients often presents with an inflammatory diarrhea with weight loss, recent history of antibiotic use, evidence of colitis and fever which may not resolve with discontinuation of antibiotics. Some tests that can be useful in the diagnosis include fecal leukocyte level, enzyme immunoassay that detects toxins A and B, positive fecal toxin assay and sigmoidoscopy demonstrating pseudomembranes.

• Drug-induced diarrhea: If diarrhea is osmotic consider magnesium, phosphates, sulfates, and sorbitol. If hypermotility consider stimulant laxatives or malabsorption acarbose, orlistat. Elimination of offending agent is often curative.

• Endocrine diarrhea: Secretory diarrhea e,g Addison disease, carcinoid tumors, vipoma, gastrinoma (Zollinger-Ellison syndrome), and mastocytosis or increased motility (hyperthyroidism). Tests that can be ordered included thyroid-stimulating hormone level, serum peptide concentrations, urinary histamine level.

• Giardiasis: Patients presents with excess gas, steatorrhea (malabsorption). Giardia fecal antigen test is diagnostic.

• Infectious enteritis or colitis (diarrhea not associated with C. difficile): Examples include bacterial gastroenteritis, viral gastroenteritis, amebic dysentery. Patients present with inflammatory diarrhea, nausea, vomiting, fever, abdominal pain. History of travel, camping, infectious contacts, or day care attendance. Fecal leukocyte level, elevated erythrocyte sedimentation rate

Cultures or stained fecal smears for specific organisms are more definitive.

• Inflammatory bowel disease: Crohn disease, ulcerative colitis, patients present with bloody inflammatory diarrhea, abdominal pain, nausea, vomiting, loss of appetite, family history, eye findings (e.g., episcleritis), perianal fistulae, fever, tenesmus, rectal bleeding, weight loss. Tests include complete blood count, fecal leukocyte level, erythrocyte sedimentation rate, fecal calprotectin level. Characteristic intestinal ulcerations are seen on colonoscopy.

• Irritable bowel syndrome: Patients present with sool mucus, crampy abdominal pain, altered bowel habits, watery functional diarrhea after meals, exacerbated by emotional stress or eating. It is twice as common in women than men. All laboratory test results are normal. Increased fiber intake, exercise, dietary modification should be recommended.

• Ischemic colitis:History of vascular disease and pain associated with eating. Colonoscopy and abdominal arteriography is diagnostic.

• Microscopic colitis: Patients present with watery, secretory diarrhea affecting older persons. Nonsteroidal anti-inflammatory drug association is possible. There is usually no response to fasting; nocturnal symptoms present. Colon biopsy is recommended.

Drugs that commonly cause diarrhea

• Gastrointestinal drugs
  • Magnesium containing antacids
  • Laxatives
  • Cisapride
  • Olsalazine
• Cardiac drugs
  • Digitalis
  • Quinidine
  • Procainamide
  • Hydralazine
  • Beta-blockers
  • ACE inhibitors
  • Diuretics
• Antibiotics
  • Clindamycin
  • Ampicillin
  • Amoxycillin
  • Erythromycin
  • Cephalosporins
• Chemotherapeutic agents
• Hypolipidemic agents
  • Clofibrate
  • Gemfibrozil
  • Lovastatin
• Neuropsychiatric drugs
  • Lithium
  • Fluoxetine
  • Alprazolam
• Others
  • Aminophylline
  • Salbutamol
  • Non-steroidal anti-inflammatory drugs
  • Thyroid hormones
  • Colchicine