Diarrhoea in adults
Generally defined as passing loose watery stools at least 3 times a day
Best defined in terms of
○ frequency
○ consistency
○ volume or weight
Consistency is determined by water holding capacity of the stool ( amount of non-bound free water ) and this possibly best defines the concept of diarrhoea
Stool weight > 200 g/D- often regarded as Upper Limit of normal Other terms often associated / used
○ Frequency – relates to number of stools passed
○ Urgency – sensation of need to defecate without delay
○ Incontinence ( faecal ) uncontrolled passage of solid or liquid faeces at socially inappropriate time and places
○ Faecal impaction or loading- when rectum & often lower colon is full with hard or soft stool –> can lead to overflow diarrhea
How commmon–Noravirus is associated with approximately 1/5th of all infectious
diarrhoea cases ( adults & children ) Incidence of rotavirus has reduced due to vaccination Chronic diarrhoea is often caused by inflammatory
bowel disease ( Crohn’s and Ulcerative colitis ) Acute diarrhoeal infection is a leading cause of hospitalization, out-patient visits and lost quality of life ( both in domestic setting & those who are travelling) Most commonly isolated pathogen ( acute diarrhoea ) include noravirus , sapovirus , Campylobacter spp and rotavirus ) In the USA management of acute diarrhoea costs $ 150 million upwards to the healthcare economy
Pathophysiology
Osmotic diarrhoea
○ soluble compound cannot be absorbed by the small intestine –> draws fluid into intestinal lumen
○ eg ingestion of non-absorbable substance as a laxative like Mg sulphate or Mg containing antacid
○ generalized malabsorption eg coeliac disease and pancreatic insufficiency
○ consuming large quantities of artificial sweeteners as sorbitol
Secretory diarrhoea
○ both active intestinal secretions of fluid and electrolytes as well as decreased absorption
○ net fluid loss
○ Enterotoxins –> cholera , E.coli , C.difficile
○ Neurohormonal agents eg VIP , bile salts
○ laxatives as docusate
Secretory diarrhoea continues on fasting
Inflammatory diarrhoea- damage to intestinal mucosal cells–> loss of fluid
and blood + defective absorption of fluid and electrolytes- eg include
○ infective causes as shigella
○ inflammatory conditions as ulcerative collitis , Crohn’s , coeliac
Abnormal gut motility – eg diabetic and hyperthyroid diarrhoea
Acute diarrhoea –Most acute episodes are infectious- look for supporting information as
○ fever
○ recent contact with a person with diarrhoea
○ exposure to possible source
♦ meals outside , takeaways
♦ farm visit , camping
○ travel history
Drug related- new drugs particularly antibiotics Stress and anxiety Abdominal symptoms – eg marked tenderness
? appendicitis Radiation treatment CV dis or hypercoagulable
state –> risk intestinal ischaemia
Red flags –Blood in stool Recent hospital admission or antibiotic Rx- consider antibiotic associated diarrhoea Persistent vomiting Weight loss Painless , watery , high volume diarrhoea ↑↑ risk dehydration Nocturnal symptoms disturbing sleep ↑↑ risk organic cause
Consider admission –Risk dehydration or shock- vomiting and unable to retain fluids Age ( people < 60 ↑ risk of complications ) Fever Bloody diarrhoea Abdominal symptoms as pain and tenderness Co-morbidities as
○ immunodeficiency
○ lack of stomach acid
○ inflammatory bowel disease
○ valvular heart disease
○ diabetes mellitus
○ renal impairment
○ rheumatoid disease , SLE
○ drugs as immunosuppresants or systemic steroids , PPIs ,ACE , diuretics
Check stool sample-Systemically unwell- needs hospital admission and or antibiotics Blood or pus in stool Immunocompromised state Recent antibiotics use or hospital admission
○ request specifically for Clostridium difficile History of foreign travel- ask for ova , cysts and parasites Diarrhoe > 2 weeks and Giardia is suspected Reassurance
Consider public health advice –Suspected public health hazard
○ diarrhoea in food handlers , health-care workers , elderly residents in care homes Outbreak in community or family Contacts of people infected with organisms as E.coli 0157:H7 ( may have serious clinical sequeale )
Chronic diarrhea causesColonic
○ colonic neoplasia
○ UC and Crohn’s
○ microscopic colitis (watery nocturnal diarrhoea in older ♀ often associated with coeliac disease )
Small bowel
○ Coeliac disease
○ Crohn’s
○ other small bowel enteropathies as
♦ Whipple’s ♦ Tropical sprue ♦ Amyloid
♦ Intestinal lymphangiectasia
○ Bile acid malabsorption
○ Disaccharide deiciency
○ Small bowel bacterial overgrowth
○ Mesenteric ischaemia
○ Radiation enteritis
○ Lymphoma
○ Giardiasis ( & other chronic infections )
Pancreatic
○ Chronic pancreatitis
○ Pancreatic carcinoma
○ Cystic fibrosis
Endocrine
○ Hyperthyroidism
○ Diabetes
○ Hypoparathyroidism
○ Addison’s disease
○ Hormone secreting tumours
♦ VIPoma ♦ gastrinoma ♦ carcinoid
Other
○ Factitious diarrhoea ( laxative use )
○ surgical causes- eg small bowel resection , internal fistulae
○ Drugs
○ Alcohol
○ Autonomic neuropathy
investigations –FBC- anaemia or ↑ platelet count ( inflammation ) LFT Tests for malabsorption
○ Calcium
○ Vit B12 and red cell folate
○ Ferritin TFT ESR and CRP Coeliac screen Stool sample
○ culture and sensitivity
○ ova cysts and parasites
Three specimens 2-3 days apart
○ consider checking for C.difficile
Medications –Allopurinol ARB’s Antibiotics Digoxin Colchicine Cytotoxic drugs ( eg chemotherapy , methotrexate ) H-2 receptor antagonists Laxatives Magnesium- containing antacids Metformin NSAIDs NSAID’s PPI’s SSRI’s Statins Theophylline Thyroxine High dose vitamin C
Symptoms suggestive of Colorectal cancer Age 40 + or older
○ rectal bleeding with a CIBH towards loose stools and/ or
○ ↑ stool frequency persisting 6 weeks or more Right lower abdominal mass – consistent with involvement of large bowel Palpable rectal mass Aged 60 or over with
○ CIBH to looser stools and/ or ↑ frequent stools persisting for 6 weeks or more with ot without rectal bleeding Men of any age with unexplained iron deficiency anemia and a Hb of 11 or less Non menstruating ♀ with unexplained iron deficiency anemia and a Hb of 10 or less
LINKS AND RESOURCES
PATIENT INFORMATION
Diarrhoea information from NHS Inform Scot https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/diarrhoea
Travellers diarrhoea from Fit for Travel a very useful resource https://www.fitfortravel.nhs.uk/advice/disease-prevention-advice/travellers-diarrhoea.aspx
Norovirus patient information leaflet from Buckinghamshire Healthcare NHS Trust https://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-Infection-Control/Diarrhoea%20and%20vomiting%20caused%20by%20Norovirus%20-%20information%20for%20patients.pdf
Sothercross Medical Library on diarrhoea https://www.southerncross.co.nz/group/medical-library/diarrhoea-causes-treatment-prevention
Clostridium difficile –PIL https://www.cuh.nhs.uk/infection-control/well-known-infections-faqs/clostridium-difficile-diarrhoea
INFORMATION FOR CLINICIANS
Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition Ramesh P Arasaradnam1,2,3, Steven Brown4, Alastair Forbes5, Mark R Fox6,7, Pali Hungin8, Lawrence Kelman9, Giles Major10, Michelle O’Connor9, Dave S Sanders4, Rakesh Sinha11, Stephen Charles Smith12, Paul Thomas13, Julian R F Walters14 https://gut.bmj.com/content/67/8/1380