Chronic fatty diarrhea differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Differential Diagnosis of Chronic Fatty Diarrhea from other diseases

The following table outlines the major differential diagnoses of chronic fatty diarrhea.

Abbreviations: GI: Gastrointestinal, CBC: Complete blood count, WBC: White blood cell, RBC: Red blood cell, Plt: Platelet, Hgb: Hemoglobin, ESR: Erythrocyte sedimentation rate, CRP: C–reactive protein, IgE: Immunoglobulin E, IgA: Immunoglobulin A, ETEC: Escherichia coli enteritis, EPEC: Enteropathogenic Escherichia coli, EIEC: Enteroinvasive Escherichia coli, EHEC: Enterohemorrhagic Escherichia coli, EAEC: Enteroaggregative Escherichia coli, Nl: Normal, ASCA: Anti saccharomyces cerevisiae antibodies, ANCA: Anti–neutrophil cytoplasmic antibody, DNA: Deoxyribonucleic acid, CFTR: Cystic fibrosis transmembrane conductance regulator, SLC10A2: Solute carrier family 10 member 2, SeHCAT: Selenium homocholic acid taurine or tauroselcholic acid, IEL: Intraepithelial lymphocytes, MRCP: Magnetic resonance cholangiopancreatography, ANA: Antinuclear antibodies, AMA: Anti-mitochondrial antibody, LDH: Lactate dehydrogenase, CPK: Creatine phosphokinase, PCR: Polymerase chain reaction, ELISA: Enzyme–linked immunosorbent assay, LT: Heat–labile enterotoxin, ST: Heat–stable enterotoxin, RT-PCR: Reverse–transcriptase polymerase chain reaction, CD4: Cluster of differentiation 4, HIV: Human immunodeficiency virus, RUQ: Right-upper quadrant, VIP: Vasoactive intestinal peptide, GI: Gastrointestinal, FAP: Familial adenomatous polyposis, HNPCC: Hereditary nonpolyposis colorectal cancer, MTP: Microsomal triglyceride transfer protein, Scl‑70: Anti–topoisomerase I, TSH: Thyroid-stimulating hormone, T4: Thyroxine, T3: Triiodothyronine, DTR: Deep tendon reflex, RNA: Ribonucleic acid

Cause		Clinical manifestation									Lab findings									Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Symptoms								GI signs
		Duration		Diarrhea			Fever	Abdominal pain	Weight loss
											Stool exam					CBC			Other lab findings
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Crohn's disease		–	+	+	+	+	±	+	+	Abdominal tenderness Oral mucosal lesions	+	+	–	Nl	–	↑	↓	↑	Anti saccharomyces cerevisiae antibodies (ASCA) Vitamin B12 deficiency Elevated ESR Elevated CRP	Uveitis Arthritis Erythema nodosum Pyoderma gangrenosum Amyloidosis Venous and arterial thromboembolism Renal stones Bronchiectasis	Abnormal immune response to self antigens	Colonoscopy with biopsy
Ulcerative colitis		–	+	+	+	+	±	+	+	Abdominal tenderness Blood on rectal examination	+	+	–	Nl	–	↑	↓	↑	Anti–neutrophil cytoplasmic antibody (P–ANCA) Hypoalbuminemia Hypokalemia Hypomagnesemia Elevated ESR Elevated CRP	Skin rash Iritis Uveitis Seronegative arthritis Clubbing Erythema nodosum	Abnormal immune response to self antigens	Colonoscopy with biopsy
Celiac disease		–	+	±	–	±	–	+	+	Abdominal distention Increased bowel sounds Oral mucosal lesions Hepatosplenomegaly Ascites	–	–	–	Nl	Fat droplets on sudan stain	Nl	↓	Nl	IgA endomysial antibody Anti–tissue transglutaminase antibody Anti–gliadin antibody Fat soluble vitamins deficiency	Malabsorption Dementia Dermatitis herpetiformis	HLA–DQ2 HLA–DQ8 Innate responses to wheat proteins	IgA endomysial antibody Anti–tissue transglutaminase antibody
Cause		Duration		Diarrhea			Fever	Abdominal pain	Weight loss	GI signs	Stool exam					CBC			Other lab findings	Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Cystic fibrosis		–	+	–	–	+	±	+	+	Abdominal distention Hepatosplenomegaly Rectal prolapse	–	–	–	Nl	Fat droplets on sudan stain	Nl	↓	Nl	Positive DNA analysis for cystic fibrosis transmembrane conductance regulator (CFTR) Nasal transepithelial potential difference Fat soluble vitamins deficiency	Malabsorption Recurrent respiratory tract infection Bronchiectasis Diabetes mellitus Scoliosis Infertility	Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein	Positive genetic testing Elevated sweat chloride ≥60 mmol/L
Chronic pancreatitis		–	+	+	–	+	–	+	+	Abdominal tenderness	–	–	–	Nl	Fat droplets on sudan stain Positive fecal elastase measurement	Nl	Nl	Nl	Slightly elevated amylase and lipase Abnormal pancreatic function test Secretin stimulation test	Malabsorption Diabetes mellitus Pancreatic pseudocyst	Toxins Recurrent acute pancreatitis Genetic predesposition Autoimmune	Magnetic resonance cholangiopancreatography (MRCP)
Bile acid malabsorption		–	+	+	–	+	–	–	+		–	–	–	Nl	Fat droplets on sudan stain	Nl	Nl	Nl	Reduced cholesterol level	Malabsorption Hypotension Tachycardia	Genetic defects in SLC10A2	SeHCAT test
Irritable bowel syndrome		–	+	±	–	±	–	±	–	Abdominal tenderness Abdominal distention Normal bowel sounds	–	–	–	Nl	–	Nl	Nl	Nl	Nl	Anxiety Palpitation	Unknown	Diagnosis of exclusion
Cause		Duration		Diarrhea			Fever	Abdominal pain	Weight loss	GI signs	Stool exam					CBC			Other lab findings	Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Whipple's disease		–	+	+	–	+	±	+	+	Hepatosplenomegaly Ascites	–	–	–	Nl	Positive fecal fat	↓	↓	↓/↑	Hypoalbuminemia Fat soluble vitamins deficiency	Malabsorption Abnormal extraocular movement Lymphadenopathy Hyperpigmentation Uveitis Endocarditis Encephalitis Dementia Pleural effusion	Tropheryma whipplei	Small intestine biopsy for Tropheryma whipplei testing PCR testing
Tropical sprue		+	+	+	–	+	+	+	+	Angular stomatitis Oral mucosal lesion	+	–	–	Nl	Positive stool culture	Nl	↓	Nl	Fat soluble vitamins deficiency Vitamin B12 deficiency Folate deficiency Hypokalemia	Myalgia Neuropathy Edema	Escherichia coli Klebsiella pneumoniae Enterobacter cloacae	Diagnosis of exclusion
Small bowel bacterial overgrowth		–	+	+	–	+	–	+	+	Abdominal distention	+	–	–	Nl	Positive stool culture Positive fecal fat	Nl	↓	Nl	Hypoalbuminemia Abnormal hydrogen breath test Lactic acidosis	Malabsorption Rosacea	Excess bacteria in the small intestine Alterations in intestinal anatomy or GI motility	Diagnosis of exclusion
Cause		Duration		Diarrhea			Fever	Abdominal pain	Weight loss	GI signs	Stool exam					CBC			Other lab findings	Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Giardia		–	+	+	–	+	–	+	+	Abdominal distention Diffuse abdominal tenderness	–	–	+	Nl	–	Nl	Nl	Nl	–	Malabsorption Urticaria Depression	Giardia lamblia	Antigen detection assays
Isospora		+	+	+	–	+	+	+	+	Abdominal distention Diffuse abdominal tenderness	+	+	+	Nl	Positive stool microscopy Positive fecal fat	↑	Nl	Nl	Elevated eosinophils  Hypokalemia Increased creatinine	Chronic illness in immunocompromised patients	Isospora	Detecting oocysts in the feces
VIPoma		+	+	+	–	+	–	+	+	Abdominal distention Abdominal RUQ tenderness Nausea Vomiting	–	–	–	↓	–	Nl	Nl	Nl	Elevated VIP level Hypokalemia Hypochlorhydria or achlorhydria Low osmotic gap (<50 mOsm/kg)	Rash Facial flushing Dehydration Lethargy Muscle weakness	Primary secretory tumor	Blood VIP levels Followed by imaging
Zollinger–Ellison syndrome		–	+	+	+	+	–	+	+	Epigastric tenderness	–	–	–	↓	–	Nl	↓	Nl	Positive secretin stimulation test Elevated serum chromogranin A	Jaundice	Gastrin producing tumor mainly in duodenum	Secretin stimulation test
Cause		Duration		Diarrhea			Fever	Abdominal pain	Weight loss	GI signs	Stool exam					CBC			Other lab findings	Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Colorectal cancer		–	+	+	+	+	–	+	+	Diffuse abdominal tenderness	–	+	–	Nl	–	Nl	↓	Nl	Positive carcinoembryonic antigen	Metastasis	FAP gene HNPCC gene	Colonoscopy and biopsy
Medications ACE inhibitors Digoxin Cephalosporins Statins Thiazide diuretics Triptans Lactulose Anti retroviral agents Chemotherapeutic agents Antifungals Magnesium		+	+	+	–	±	±	+	+	Abdominal distention Dehydration	–	–	–	↑/↓	–	↑	Nl	Nl	Elevated plasma level of drug	–	Inflammation Pseudomembranous colitis	Clinical evaluation after discontinuation of the drugs
Cause		Duration		Diarrhea			Fever	Abdominal pain	Weight loss	GI signs	Stool exam					CBC			Other lab findings	Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Short bowel syndrome		+	+	+	–	+	–	–	+	Abdominal distention Abdominal tenderness	–	–	–	Nl	Positive fecal fat	Nl	↓	↑	Hypoalbuminemia High level of acute phase reactant Abnormal liver function tests	Prior intestinal surgery Malabsorption Crohn's disease Malignancy Peripheral edema Muscle atrophy	Surgical bowel resection	Clinical diagnosis following bowel resection
Radiation enteritis		+	+	+	+	+	–	+	+	Abdominal tenderness	+	+	–	Nl	Positive fecal fat	Nl	↓	Nl	Vitamin B12 deficiency Hypoalbuminemia	Prior history of malignancy and radiation therapy Malabsorption Telangiectasias	Radiation	Segmental bowel inflammation on endoscopy or colonoscopy
Dumping syndrome		–	+	+	–	+	–	–	+	Hyperactive bowel sound	–	–	–	Nl	–	Nl	Nl	Nl	Hypoglycemia Hydrogen breath test	Malnutrition Fat soluble vitamin deficiency	Postgastrectomy	Clinical diagnosis following gastrectomy
Cause		Duration		Diarrhea			Fever	Abdominal pain	Weight loss	GI signs	Stool exam					CBC			Other lab findings	Extra intestinal findings	Cause/Pathogenesis	Gold standard diagnosis
		Acute	Chronic	Watery	Bloody	Fatty					WBC	RBC	Ova/Parasite	Osmotic gap	Other	WBC	Hgb	Plt
Abetalipoproteinemia		–	+	+	–	+	–	+	+	Abdominal distension	–	–	–	Nl	–	Nl	Nl	Nl	Low triglyceride Low total cholesterol levels  Acanthocytes Low vitamin E levels	Ataxia Visual field defect Dysarthria	Autosomal recessive disorder caused by mutations encoding the microsomal triglyceride transfer protein (MTP)	Clinical findings and low triglyceride and cholesterol level
Diabetic neuropathy		–	+	+	–	+	–	+	+	Fecal incontinence	–	–	–	Nl	Positive fecal fat	Nl	↓	Nl	Hyperglycemia Azotemia Hypokalemia	Malabsorption	Unclear Disordered motility Increased intestinal secretion Small intestinal bacterial overgrowth	Clinical diagnosis in a patient with long lasting diabetes mellitus
Systemic sclerosis		–	+	+	±	+	–	+	+	Epigastric tenderness Fecal incontinence	–	+	–	Nl	Positive fecal fat	Nl	↓	Nl	Anti–topoisomerase I (Scl‑70) antibodies Antinuclear antibodies (ANA) Anti–centromere antibodies Anti–RNA polymerase III antibody	Malabsorption Skin changes Raynaud phenomenon Pulmonary hypertension Arthritis Telangiectasia Chronic renal failure	Autoimmune reaction	Clinical diagnosis Followed by serologic tests