Sandbox/v04

Adults with Chronic Diarrhea (>4 weeks)

History ❑ Onset (Congenital, abrupt, or gradual) ❑ Pattern : Continuous / intermittent ❑ Duration ❑ Epidemiology : Travel / food / water ❑ Stool characteristics : Watery / bloody / fatty ❑ Fever ❑ Abdominal pain ❑ Weight loss ❑ Fecal incontinence ❑ Aggravating factors : Diet / stress ❑ Mitigating factors : Diet / over-the-counter drugs / use of prescription ❑ Previous evaluations ❑ Iatrogenic : Medication / radiation therapy / surgery ❑ Factitious diarrhea : Eating disorders / laxative ingestion / malingering ❑ Systemic disease : Cancer, diabetes, HIV, hyperthyroidism, other conditions

Physical Examination ❑ General : Nutrition / vitals / volume status ❑ Skin : Flushing / rashes / dermatographism ❑ CVS : Murmur ❑ RS : Wheeze ❑ Thyroid : Mass ❑ Abdomen : Ascitis / hepatomegaly / mass / tenderness ❑ Anorectal : Abscess / blood / fistula / sphincter competence ❑ Extremities : Edema

Routine laboratory tests ❑ CBC and differential : Anemia / eosinophilia / leucocytosis ❑ ESR ❑ Serum electrolytes ❑ Total serum protein and albumin ❑ Thyroid function tests ❑ Urine analysis

Stool analysis ❑ Weight ❑ Stool electrolytes / fecal osmotic gap ❑ Stool pH ❑ Fecal occult blood testing ❑ Stool WBC's ❑ Fat output : Quantitative /Sudan stain ❑ Laxative screen

Categorize diarrhea

Chronic osmotic diarrhea

Chronic secretory diarrhea

Chronic inflammatory diarrhea

Chronic fatty diarrhea

Low pH : Carbohydrate malabsorption

High Mg : Inadvertent ingestion or laxative abuse.

Exclude infection ❑ Stool culture ❑ Stool for ova and parasites ❑ Giardia antigen ❑ Bacterial overgrowth : Small bowel aspirate or breath H2 test

Exclude structural disease ❑ Small bowel radiographs ❑ Sigmoidoscopy or colonoscopy with biopsy ❑ CT abdomen ❑ Small bowel biopsy

Exclude structural disease ❑ Small bowel radiographs ❑ CT abdomen ❑ Small bowel biopsy and aspirate for quantitative culture

Dietary review / breath H2 test (lactose) or lactase assay in biopsy

Exclude structural disease ❑ Small bowel radiographs ❑ Sigmoidoscopy or colonoscopy with biopsy ❑ CT abdomen ❑ Biopsy of the proximal small bowel mucosa

Exclude infection ❑ Stool culture : Standard Aeromonas, Plesiomonas, tuberculosis ❑ Clostridium toxin assay ❑ Other specific test : Virus and parasites

Exclude exocrine pancreatic insufficieny ❑ Secretin test ❑ Stool chymotrypsin activity ❑ Bentiromide test ❑ Others : D-xylose absorption tests / Schilling test

Selective testing ❑ Cholestyramine test for bile acid diarrhea ❑ Plasma peptides : Gastrin / calcitonin / vasoactive intestinal polypeptide / somatostatin ❑ urine : 5-hydroxyindole acetic acid / metanephrine / histamine ❑ Others : TSH / ACTH stimulation test / serum protein electrophoresis / serum immunoglobulins

Specific Rx per results / Symptomatic Rx

No confirmatory diagnosis / no specific treatment

Emperical therapy ❑ Adequate hydration : ORS / IVF / parental nutrition ❑ Antimicrobial therapy : Depending upon the prevalence of bacterial or protozoal infection in a specific community or situation ❑ Bile acid binding resins : cholestyramine ❑ Opiates / octreotide

This management is as per the American Gastroenterological Association guidelines for the evaluation and management of chronic diarrhea.