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Home , Abdominal distension, Stool osmotic gap

Normal Bowel Frequency Acute

Akeek S . Bhatt , MD 3 times/day  3 times/week Assistant Professor of Clinical Medicine Division of , Hepatology, & Nutrition Director of Endoscopy University Hospital East The Ohio State University’s Wexner Medical Center

Diarrhea Definition Acute Diarrhea

• Formal definition: Stool weight >200g/day INFECTIOUS Non-Infectious (5%) • Practical definition: (GASTROENTERITIS) -Persistent/chronic – ≥ 3 loose/watery stools/day -Self-limited 1. Drugs – Decrease in consistency AND increase in 1. Viruses 2. Food allergy/intolerance frequency from the patient’s norm 2. 3. Other disease states 4. Primary GI disease • Acute: 2 weeks or less 3. Protozoa • Persistent: 2-4 weeks • Chronic: > 4 weeks

1 Initial Evaluation Social History

• Quit smoking (UC flare, OTC nicotine) • Duration of symptoms • Alcohol • Frequency • Illicit drugs • Stool characteristics • Sexual history: MSM, anal intercourse • Signs/symptoms of volume depletion • Occupation (exposures) • Fever • Travel • Peritoneal signs • Pets • Extraintestinal symptoms • Recreational activities

Food History

• Exposure to particular type of food associated with foodborne disease (in the Important Clues in week preceding illness) Acute Diarrhea • Time interval between exposure and onset of symptoms

2 Small bowel vs Large Acute Diarrhea with Fever Bowel Indicates intestinal inflammation • Small Bowel • Large Bowel 1. Invasive Bacteria – Large volume – Small volume -Salmonella, Campylobacter, Shigella – Watery – Frequent 2. Enteric viruses – Abdominal – PPainfulainful bobowelwel cramping, movements -Norovirus, Rotavirus, Adenovirus , gas – Bloody/mucoid 3. Cytotoxic organism – Weight loss – Fever -C. diff, E. histolytica *Enterohemorrhagic E. coli fever is absent or low grade (EHEC/STEC) – Rarely fever – Positive occult 4. Inflammatory bowel disease blood and stool – Negative occult 5. Severe ischemic colitis blood and stool WBC WBC

Differential Diagnosis of Bloody Indications for Medical Evaluation of Diarrhea Diarrhea: Severe Illness

1. Shiga toxin producing E.coli (O157:H7) • Profuse watery diarrhea with dehydration 2. Shigella • Passage of many small volume stools with 3. Salmonella visible blood and (dysentery) 4. Campylobacter 5. Clostridium difficile • Fever (≥38.5°C or 101.3°F) 6. Ischemic colitis • ≥6 unformed stools/24h or >48h duration 7. Inflammatory Bowel Disease 8. Entamoeba Histolytica • Severe

3 Indications for Medical Evaluation of Ordering Stool Cultures Diarrhea • Routine • Elderly (≥ 70yo) – Salmonella – Shigella • Immunocompromised – Campylobacter – Yersinia (most strains) * • Signs/symptoms of systemic illness along with - E.coli O157:H7** diarrhea (esp. pregnant women—suspect - Aeromonas and Plesiomonas * listeriosis) *Grow on routine culture but notify lab as frequently overlooked • Hospitalized patients or recent use of antibiotics **Specific order for other Shiga toxin producing E.coli

When to Obtain Stool Ordering Stool Cultures Cultures • Severe Illness • One time is sufficient • Patients with comorbidities that increase – Continuous excretion of pathogens the risk for complications • UdUnder lilying IBD • Require specific orders: • Occupation (daycare workers or food – Shiga toxin producing E.coli handlers) requires negative cultures to return to work – Vibrio • Untreated persistent diarrhea – Listeria • (+) stool WBC, lactoferrin, or occult blood

4 Salmonellosis

• Symptoms: watery diarrhea, fever, , Bacterial Gastroenteritis (colitis less common) (Foodborne Illness) • Duration: 4-10 days • Treatment in healthy persons with mild symptoms may prolong excretion

Salmonellosis Salmonellosis Complications • Non-typhoidal salmonella • Bacteremia (5%) • Leading foodborne disease in the U.S. – Endovascular (arteritis, • Transmission: poultry, eggs, milk aortitis, mycotic aneurysms, stent/graft products, produce, raw meats, infections) pets/animals – Orthopedic prostheses • Incubation: 8-72 hrs – Prosthetic heart valves – Osteomyelitis in sickle cell patients

5 Campylobacter Shigellosis

• S. sonnei or S. flexneri • C. jejuni or C. coli

• Transmission: person to person; nd • 2 leading cause foodborne disease U.S. contaminated water or food (raw vegetables, salads, sandwiches) • Transmission: poultry/cross- contamination, unpasteurized milk, • Increased risk: children (toddlers); animals daycares and institutional settings

Campylobacter Shigellosis

• Incubation: 2-5 days • Incubation: 3 days (1-7) • Symptoms: Watery or hemorrhagic, fever, cramps, vomiting • Syypmptoms: watery ypg progressing to dy sentery (bloody/mucoid), fever, tenesmus, N/V • Duration: 2-7 days • Duration: 2-7 days • Complications: reactive arthritis and Guillain- Barré syndrome • Complications: HUS and TTP (children)

6 Enterohemorrhagic E.coli (Shiga- HUS and TTP toxin producing E.coli) • Life threatening complication of STEC • (EHEC/STEC) – 5-10% – O157:H7 most common serotype – Children, elderly (40% mortality) • Clinical diagnosis • Transmission: undercooked ground beef, – Bloody diarrhea unpasteurized, cattle, petting zoos/exhibits – Microangiopathic Hemolytic Anemia – Purpura/thrombocytopenia – Anuria/Acute renal failure • Two-thirds cases June-September – Neurologic symptoms

• Incubation: 1-7 days Rx: supportive care, dialysis/plasmapheresis (<10% mortality)

EHEC Yersinia • Symptoms: • Y. enterocolitica (U.S), Y. pseudotuberculosis – Watery diarrheahemorrhagic (Europe) – Abdominal pain • Uncommon; undercooked pork, unpasteurized – Absent/low grade fever milk, contaminated water • Self-limiting enterocolitis • Few or no fecal leukocytes – Watery or bloody diarrhea – Fever • Self-limiting terminal ileitis (pseudoappendicitis) • Rx: NO ANTIBIOTCS OR • Increased risk of in hereditary ANTI-PERISTALTIC AGENTS hemochromatosis (siderophilic bacteria)

7 Empiric AntibioticTreatment for Acute Diarrhea

• Fever and bloody • >1 week duration stools Anti-Diarrheal • Fever and Aggents hlflhemoccult, fecal • Hospitalization leukocyte or being considered lactoferrin positive stools • Immuncompromised • >8 stools/d • Volume depletion

Empiric Antibiotic Treatment • *Fluoroquinolone x 3-5 days • Drug of Choice when stools are nonbloody and – Cipro 500mg BID fever is low grade or absent and low suspicion of C. diff – Norfloxacin 400mg BID – Significant reduction in stools when combined with – Levofloxacin 500mg qd cipro – Dose: 2 tabs initially (4mg), then 2mg after each * Avoid in EHEC unformed stool (max 16mg/d) for <= 2 days

• If suspect campylobacter: *Could facilitate HUS in EHEC **Aggresively hydrate as fluid loss may be masked by – Azithromycin 500mg qd x 3d pooling in the intestine – Erythromycin 500mg po qd x 5d

8 Lomotil (Diphenoxylate and Atropine) Clostridium difficile

• 2 tabs (4mg) qid <= 2 days • Antibiotic associated colitis • Central opiate effects • Most common nosocomial infection • Cholinergic side effects – > 3 million hospital infections U.S/yr – 10% patients hospital admission >48hrs • Rising incidence *Could facilitate HUS in EHEC **Aggresively hydrate as fluid loss may be • Occuring outside hospitals (20,000/yr) masked by pooling in the intestine • IBD patients without antibiotics

Bismuth Subsalicylate (Pepto-Bismol) Risk Factors for C.diff

• Antibiotics • Consider in patients with febrile bloody • Advanced age diarrhea • Hospitalization • Improves vomiting • Severe illness • 30mL or 2 tabs q 30 min x 8 doses • Cancer • suppression

9 Severe CDAD C.Diff Treatment

• Stop inciting abx ASAP • Systemic toxicity • Mild/Moderate: Flagyl 500mg PO TID x 10-14d – Fever – IV only when not able to tolerate po – Abdominal tenderness • If severe: Vancomycin 125mg po qid x 10-14d (enemas if ) +/- IV Flagyl – Acu te men tltal s tttatus c hanges – Consult ID • WBC >15k • If underlying infection requiring abx – Continue for additional week after completion • Albumin <2.5 • Repeat initial antibiotic for initial recurrence if of • Elevated Cr same severity • Tapered or pulse regimen vancomycin for 2nd or • Age >60 later recurrences

C.Diff Testing C. Diff and PPI Use

• One time testing is sufficient • FDA warning Feb. 2012 • C. diff toxin PCR: – Evaluate the clinical necessity – Highly sensitive and specific – Use lowest dose and shortest duration – Rapid – H2B being reviewed • EIA C.diff toxin A/B – Less sensitive – Variation: GDH +, cytotoxicity on + samples only – Only repeat if neg and clinical suspicion remains high

10 Traveler’s Diarrhea (TD) Traveler’s Diarrhea

• Low risk: US, Canada, Australia, Northern and • 80-90% bacterial Western Europe • Enterotoxigenic E. coli

• Intermediate risk: Eastern Europe, Carribean, S. • 80% watery diarrhea Afr ica, Chi na, R uss ia • 5-10% dysentery (Shigellosis, Campy)

• High risk: Africa, Asia, Middle East, Central and • Course: 1-2 -7 days South America • Important cause of post-infectious IBS

TD Preventive Measures TD Prophylaxis

• Eat freshly cooked foods that are steaming • High risk hosts hot (avoid buffets and street vendors) • Critical trips • Avoid salads (washed in water) • High risk areas • Avoid unpeeled fruits and veggies • Avoid tap water, ice/beverages diluted with 1) Bismuth 2 tabs qid (<3 weeks) water 2) Antibiotic prophylaxis • Safe beverages: bottled and sealed, • Ciprofloxacin 500mg once daily carbonated • Rifaximin ? • Carry alcohol-based (60%) hand cleaner 3) Insufficient evidence for

11 TD EmpiricTreatment Norovirus (Norwalk-like)

• Loperamide + • Most common cause of GE in U.S. ( flu) – Ciprofloxacin 500mg bid 3-5 days – Familial and community outbreaks – Norfloxacin 400mg bid 3 -5days5 days • Acute explosive vomiting (children) and – Azithromycin 1000mg x 1 or 500mg day watery diarrhea (adults) 1, 250mg day 2-4 • Transmssion: person to person, prepared foods, produce, shellfish – Rifaximin 200mg TID x 3d* • Incubation: 12-48hrs *Approved for noninvasive E.coli • Duration: 2-3 days

VIRAL GASTROENTERITIS Parasites

12 Giardiasis

• lamblia • Incubation: 7-14 days • Most common parasitic cause of diarrhea in the U.S. • Duration: One to several weeks • Risk factors: – campers/hikers/travelers • Long term complications: malabsorption – Institutional exposure (nursing homes, day cares) (steatorrhea) and weight loss – Food/waterborne – Unprotected anal sex, MSM • Dx: stool antigen (EIA), O&P (cysts) – HIV/AIDS • Rx: metronidazole 250mg TID x 5 days

Giardiasis Giardiasis: Persistent Diarrhea • Symptoms: – Abdominal pain • Consider empiric treatment for Giardiasis – Profuse watery diarrhea – Excess in immunocompetent hosts – Sulfur tasting burps – *Flagyl may also be affecive against – Distended /bloating small bowel bacterial overgrowth – Loss of appetite syndrome—seen after enteric infections – – Vomiting and also a cause of persistent diarrhea – Low grade fever – Headache

13 Cryptosporidiosis Cyclosporosis

• C. parvum • C. cayetanensis • Transmission • Transmission: contaminated food and – contaminated drinking or swimming water; outbreaks (raspberries and basil) water or food and sporadic – person to person (households, sexual • Nepal, Peru, Haiti, Guatemala partners, daycares, healthcare workers) • Incubation: 7 days (2-14) • Incubation: 1 week (up to 4 weeks)

Cryptosporidiosis Cyclosporosis • Sx: • Self-limited (1-2 weeks) – Watery diarrhea – Intense fatigue and malaise – severely dehydrating watery diarrhea – Loss of appetite • Dx: Stool Ag ( EIA), acid fast staining of – Wt loss stools – Abdomi nal crampi ng • Rx: usually symptomatic – Nausea – Nitazoxanide 500mg po BID x 3 days – Gas/flatulence • Duration: can last more than 3 weeks • Relapses • Dx: Acid fast O&P (specific request) • DOC: TMP/SMX 160/800 bid x 7-10 days

14 Amebiasis Amebiasis

• Entamoeba histolytica • Risk factors: • Dysentery with few leukocytes – Migrants and travelers • Crowded tropical areas (Africa, • Dx: stool antigen EIA, trophozoites stool Mexico, India, parts S. America) • Rx: Metronidazole – Institutionalized patients – MSM • Incubation: 7-10 days • Duration: 2 weeks, relapses if untreated

Amebiasis Indications for Stool O&P • Mild diarrhea – 3-8 semiformed stools Giardia Cryptosporidium Entamoeba Cyclospora – Occasional passage of blood and mucus lamblia – Fatigue Persistent – Gas diarrhea XX X – Tenesmus Travel to Russia, Nepal, or XX X • Severe dysentery (alcoholics, corticosteroids, , mountainous young/ldl/elderly, cancer, mal nouri ihd)shed) regions – 10-20 bloody liquid stools/day Exposure to infants in X X – Abdominal tenderness daycare

– Fever MSM – Vomiting X X Waterborne • Hematologic spread: outbreak XX – Bloody diarrhea, few or no fecal X – leukocytes – Brain

15 Ordering Ova & Parasite Other High Risk Occupations • Screen: EIA stool antigens – Giardia • Daycare (child/adult) – Cryptosporidium – E. histolytica • Health Care • Same rules as food handlers except no Rx • Comprehensive: Travel hx or Immunocompromised or stool testing required: – Smears – Salmonella – Wet preps – Stains – Campylobacter – Yersinia • Three specimens separated by 24 hrs (intermittent – Cryptosporidium excretion)

Food Handlers Ohio Reportable Diseases

• Notify your local health department All known causes of infectious diarrhea require rx – By the end of the next business day: or additional testing after cessation of diarrhea: • Salmonella 1) Salmonella, Shigella, STEC, Yersnia : 2 neg. stool • Shigella samples • Shiga toxin producing E.coli 2) Campylobacter: 2 neg. samples or 48h rx • Hemolytic uremic syndrome 3) Giardia: 72hrs of Rx or 3 neg. stool samples • Cyclosporiasis 4) Cryptosporidium: 3 neg. samples – By the end of the work week 5) Amebiasis: 3 negative stool samples • Campylobacter 6) Cyclospora: Rx begun • Cryptosporidiosis • Giardiasis • Non-cholera vibrio

16 Indications for Endoscopy in Acute Diarrhea

• Colonoscopy: CAREFUL HANDWASHING – Distinguish IBD from infectious diarrhea WITH SOAP AND WATER FOR – Unclear colitis, evaluate ischemia 20 SECONDS ESPECIALLY AFTER USING BATHROOM – Aid in diagnosis of C . diff (not as common) FACILITIES – Colitis in immunocompromised (CMV, HSV) – Suspicion of amebiasis with negative stool – GVHD in bone marrow transplant patients

Indications for Endoscopy in Acute Diarrhea References

1. DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters • EGD/flex sig: Committee of the American College of Gastroenterology. Am J Gastroenterol 1997; 92:1962. 2. Pawlowski SW, Warren CA, Guerrant R. Diagnosis and Treatment of Acute or Persistent -Immunocompromised to evaluate for Diarrhea. Gastroenterology. 2009 May;136(6):1874-86. 3. Thielman, N., Guerrant, R. Acute Infectious Diarrhea N Egl J Med 2004: 350:38-47 opportunistic infections (- stool cx, - o&p) 4. Linsky A, Gupta K, Lawler EV, Fonda JR, Hermos JA Proton pump inhibitors and risk for recurrent Clostridium difficile infection infection. Arch Intern Med. 2010; 170(9):772 5. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society -Persistent diarrhea not responsive to empiric rx of America (IDSA). Infection Control and Hospital Epidemiology May 2010, Vol. 31, No. 5 or negative stool pathogens 6. Allen SJ, Okoko B, Martinez E, et al. Probiotics for treating infectious diarrhoea. Cochrane Database Systematic Rev 2004

17 Chronic Diarrhea Chronic Diarrhea • Epidemiology: – There is a lack of robust data demonstrating the relative incidence and cost of chronic diarrhea in the Developed World. Sheetal Sharma, MD • EtiEstimat es suggest ttht3 that 3-5% of th e popul ati on have chronic diarrhea. Assistant Professor of Clinical Medicine • Estimates of work related loss of revenue are Division of Gastroenterology, Hepatology, & Nutrition $350,000,000 annually, not including the The Ohio State University’s Wexner Medical Center medical evaluation and work-up/treatment.

Fine KD, Gastroenterology 1999

Chronic Diarrhea Chronic Diarrhea • Chronic diarrhea is a clinical challenge, and can be frustrating to evaluate, and the differential diagnosis can be vast. • The effects of chronic diarrhea also • Definition: Presence of decreased stool consistency for significantly impacts on a patient’s quality more than 4 weeks duration. of life. – Greater than 200 grams of stool daily. – Greater than 3 stools/daily that are of a loose – Leading to: Depression, anxiety, and consistency. loss/quitting work. Fine KD, Gastroenterology 1999 Siddiqui et.al, J.Clin Gastro 2007 Sleisenger and Fortran 9th Edition 2010

18 Chronic Diarrhea Bloody Diarrhea

• Infection is an uncommon cause of • Approach to Chronic Diarrhea. chronic diarrhea: • Is it: – Stool culture: – Bloody ? • Salmonella, Campylobacter, Yersinia, Aeromonas, Plesiomonas, and C.Difficile – Fatty ? – Ova & Parasites – Watery/Liquid? –Osmotic vs Secretory vs Functional

Bloody Diarrhea Bloody Diarrhea • Differential Diagnosis: – Infection • Work-up of Bloody Diarrhea: – Inflammatory Bowel Disease (IBD) – Colonoscopy is the primary mode of – Ischemia diagnosis. – Medications • Referral to a Gastroenterologist – SCAD: Segmental Colitis should be made when bloody diarrhea Associated Diverticulosis occurs, to differentiate IBD from ischemic and infectious etiologies. – Radiation – Post-operative

19 Bloody Diarrhea Fatty Diarrhea

• Ulcerative • Steatorrhea: Colitis – Vitamin malabsorbtion • Vitamins A, D, E, and K • Vitami n A : Ni ght bli nd ness • Vitamin D: Osteomalacia • Vitamin K: Easy Bruising/Bleeding

• Crohn’s Colitis

Fatty Diarrhea Fatty Diarrhea • Fecal Fat Analysis • Fatty Diarrhea: Clues in the clinical setting • Qualitative: – Steatorrhea – Subjective: – Weight loss – Stools: • Quantitative: • Not always diarrhea – 24hour collection while on a 100gram • Hard to flush/float within toilet diet • Oily droplets – Stool Weight; <200-300grams – Fat; <7gram/24hour period

Sleisenger and Fortran 9th Edition 2010

20 Fatty Diarrhea Fatty Diarrhea • Pancreatic Insufficiency: • Caveats – Indirect testing: – High diet; increases stool • Serum Trypsin volume to 300-400grams • Fecal Chymotrypsin – Voluminous stools will raise fat • Fecal Elastase excretion; up to 14g/24hrs – Correct for fat intake; ie low fat diets • All have poor sensitivity and – False positives; Olestra and tree nuts specificity – Pancreatic/Biliary sources; >9.5grams/100gm stool Leeds et.al. Nature Rev Gastro Hep 2011

Fatty Diarrhea Fatty Diarrhea • Steatorrhea: – Luminal causes: • Pancreatic Insufficiency • Pancreatic insufficiency • Evaluate and rule out mucosal disease first • Salt deficiency – Then consider trial of pancreatic • Bacterial Overgrowth replacement therapy • Monitor weight gain and fecal fat – Mucosal: • Celiac sprue • Crohn’s Disease; especially small bowel disease

21 Celiac Disease Malabsorbtion • Diarrhea caused by gluten sensitivity. • Epidemiology: • Parasites: Uncommon – Prevalence is 1: 133 in the USA, increased to – Giardia 1:22 if first degree relative with celiac disease. • Gastric surgery/Reflux surgery (Fasano A et.al, Arch Intern Med 2003 • Chron ic mesent eri c i sch emi a – May also have associated features • Radiation • Weight Loss, Abdominal Distension, • Significant Ilietis/ileal resection Abnormal LFTs, Iron Deficiency, • Medications: Infertility/Recurrent fetal loss, Microscopic – HAART Colitis, DM I, and Thyroid diseases.

Celiac Disease Malabsorption • Celiac Disease: Test while on Gluten diet – Antibody Tests: IgA tTG or EMA and Serum IgA • Malabsorption: • 2-3% of Celiac patient are deficient in IgA – Small bowel diseases (uncommon) • Preferable to have tTG testing • Collagenous sprue • Use of Anti-gliaden Antibody is not recommenddded • Whippl e’ s di sease – Small bowel biopsies: • Eosinophillic enteritis • Consult GI for biopsies; still gold standard. – Genotype • Lymphoma • HLADQ2, DQ8 • Amyloid • If negative, rules our celiac disease • Not recommended for screening purposes

22 Chronic Diarrhea: Watery Diarrhea Medications • Diseases: • Osmotic: • Secretory: – – Surgical: – Citrates – Antibiotics • Cholecystectomy – NSAIDs – • Gastric containing – Allopurinol/Colchi cine • Small intestinal – Sugars; sorbitol , – Family History: – Antineoplastics xylitol, mannitol • Celiac • Motility – Metformin • IBD – Macrolides – Prostaglandins – Sexual history: – Reglan – : Senna • HIV and Docusate – Laxatives; • Infections Bisacodyl – Travel History: • High risk areas/activities

Watery Diarrhea Watery Diarrhea • Dietary: • Evaluation of Watery Diarrhea: – Alcohol – H&P – Dairy – Labs: – Supplements • CBC, CMP, Thyroid tests, Celiac serology, ESR/CRP, and Stool FOBT – OTC medications • Stool culture is low yield – Herbals • Only several months of symptoms; – Fructose/Sorbitol consider: –Ameba, Giardia, • Medications: Cryptosporidium/cyclospora, and Candida – 7% of all medication side effects (Elderly)

23 Watery Diarrhea Watery Diarrhea after Cholecystectomy • Evaluation: Send to Gastroenterology? • Cholecystectomy – Secretory Diarrhea – Post-Cholecystectomy related diarrhea – Colonoscopy with biopsy; Evaluation • Incidence 20% • Crohn’s Disease • Can be delayed • Microscopic colitis • Rarely severe • Colon cancer – Mechanism: Low bile acid absorption at terminal ileum; especially nocturnal. • Bile acids induce colonic salt and – EGD with Duodenal biopsy water secretion – Treatment: Bile acid binders

Watery Diarrhea and Microscopic Colitis Diabetes • Microscopic colitis: • Visceral autonomic neuropathy – Intermittent secretory type diarrhea. • Bacterial overgrowth – Types: • Celiac sprue • Lymphocytic Colitis • Pancreatic insufficiency • Collagenous Colitis • Unabsorbed : – Sugarfree products

24 Watery Diarrhea Secretory Diarrhea

• Continues despite fasting. • Hormonally Induced: • Watery Diarrhea: – Zollinger-Ellisison Syndome: Elevated – Fecal fat testing (off PPI therapy) – screen – VVIPoma:IPoma: ElevatedElevated VIP – Carcinoid: 5-HIAA (24hr urine collection) – Osmotic Gap – Medullary Thyroid Carcinoma:

– Idiopathic Secretory Diarrhea Sleisenger and Fortran 9th Edition 2010

Stool Osmotic Gap Osmotic Diarrhea • Osmotic Gap – Normal: 290 – 2(Na + K) • Related to ingested foods/medications: – Close examination of ingested materials – Secretory Diarrhea: <50 assists in diagnosis. – Osmotic Diarrhea: >100-125 – Resolves with fasting. – Contamination: >375 – Most common cause: Lactase Deficiency • Wanes over time, and increased symptoms with advancing age. – FYI: Labs do not test stool that is solid; used to indirectly confirm that patient is having diarrhea Fine KD, Gastroenterology 1999 Sleisenger and Fortran 9th Edition 2010 Sleisenger and Fortran 9th Edition 2010

25 Chronic Diarrhea • Functional: – (IBS) is the most common cause of functional diarrhea in adults in the developed world. • 3-20% of the USA population has IBS • Women affected more than Men • Ages 15-35 most commonly – Diagnosis of exclusion: • Do they respond to dietary changes, fiber, and exercise? – Watch for RED FLAGS: • Bleeding, substantial weight loss, abnormal imaging and/or nocturnal symptoms

Fine KD, Gastroenterology 1999 Sleisenger and Fortran 9th Edition 2010 Lembo AL Practical Gastroenterology 2007

When to send to GI? • In General, any diarrhea that is suspected to be Fatty, Inflammatory, or Secretory should be sent to Gastroenterology for endoscopic biopsy or specific radiographic testing sooner than later.

• Any diarrhea with “warning features”; ie progressive pain, significant weight loss, bleeding/iron deficiency anemia, and severe metabolic abnormalities.

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