Evaluation of Diarrhea by Erika Hagee. Erika received her master's in nursing and completed the family nurse practitioner program at the University of San Francisco, where she also completed her public health and certified nurse specialist medical surgical degrees. Erika is a nurse practitioner with the Oregon Clinic, serving as a member of the Inflammatory Bowel Disease Division, and she is a preferred provider with Crohn's Colitis Foundation. Erika, the audience is all yours. So we're going to talk about the evaluation of the patient with diarrhea. And as Sarah said, my name is Erika Hagee. I work at the Oregon Clinic in Portland, Oregon. All right, so here's my disclosures. So objectives today, we'll review the definition of diarrhea and discuss acute diarrhea with the evaluation and appropriate testing, as well as chronic diarrhea. So I kind of brought up the idea that I kind of pulled together a slew of different definitions of diarrhea. Truly, it's the increased liquid frequency and consistency of the stools, passage of kind of loose, watery stools three times in a 24-hour period. Some people and your patients will consider diarrhea as the increased number of stools, but truly the hallmark is the stool consistency, having that kind of liquid stool. This reflects increased water content coming into the stool, whether due to impaired water absorption or active water secretion by the bowel. So the duration of diarrhea. Acute diarrhea is 14 days or fewer. Persistent diarrhea is more than 14 days, but less than 30. So it's kind of in that sweet spot there. And chronic diarrhea is more than 30 days. Acute diarrhea is, like I said, less than two weeks. Most of these cases will self-resolve. They'll be infectious, may be viral, but symptomatic treatment alone tends to be what fixes this situation. Most common infections are viruses such as norovirus, rotavirus, et cetera. Bacterial infections, you're thinking about salmonella, shigella, it could be even C. diff, and protozoa, such as cryptosporidium and giardia. The evaluation for acute diarrhea. We're not going to spend a lot of time on acute diarrhea because like I said, majority of the time this is self-limited, and many times this might actually stay with the PCP and not make it to you. But you want to ask about the duration of symptoms. You want to ask about the frequency and characteristics of the stool. Is it significant, severe, large amounts of watery stool? Then you're thinking more bacterial. Associated symptoms of abdominal pain, hematochezia, weight loss, fever. And we'll talk about those red flag symptoms that you really need to be worried about and act on. Potential exposures. What's their food history? Have they recently been at the coast eating raw sushi? Residences, other people sick in their home. Do they live in a care home that also may be having an outbreak? Occupational exposure. Are they a daycare worker? Thinking about kind of rotavirus. Travel, did they recently go to Mexico? Possibly picked up a parasite. And pets, pets. We don't always think about pets, but of course, if you're going to the petting zoo, or a lot of turtles, pigs, you can pick up some salmonella. You want to ask about their medical history. Were they recently exposed to antibiotics? We're always thinking about C. diff. Are they immunocompromised? Do you need to be thinking outside the box? And one thing that's frequently forgotten is sexual history. So receptive anal or oral anal intercourse increases the risk for bacterial and parasitic infections and pathogens. Also acute diarrhea can be a manifestation of a proctitis caused by an STI, such as chlamydia gonorrhea syphilis. So that's a part of the history that tends to be forgotten. So acute diarrhea, the evaluation. Of course, you're doing your physical exam. You're assessing for volume depletion. You're looking at their vital signs. Are they tachycardic and hypertensive? Do they have dry mucous membranes? Are they having dark urine, et cetera? Signs that would show for possible volume depletion. Doing an abdominal exam, making sure there's no distension, pain, concern for an ileus. Labs, truly, infectious stool studies should be for acute diarrhea. That's what you want to be doing first. Generally, you can wait a week before you do stool studies. And this is why I said it may get more, acute diarrhea may more stay within the primary care provider realm. But if it's been a week and they're still having diarrhea, then you want to be going forward and doing stool tests, especially if there's concern for inflammatory etiology, such as mucus in the stool, blood, or if they're a high-risk host or a public health concern. Electrolytes and renal function if concerned about hypovolemia and dehydration. Antibiotic exposure, as you well know, C. diff is your primary concern. So if someone's recently been treated for UTI or been to the dentist, C. diff should be the first thing that comes to mind. When you have those immunocompromised patients, you do need to think out of the box. Could this be CMV? Could this be non-infectious, such from medications or graft versus host? Do they have HIV? Are you thinking about an AIDS-defining condition? Or is it a neutropenic effect? The management of acute diarrhea, like I said, is more supportive measures generally. Oral hydration, bland diet, avoiding bowel stimulants, probiotics, fluid replacement if indicated. You really would only use empiric antibiotic treatment in select patients if you're concerned about severe disease, such as fever, more than six stools a day, volume depleted, requiring hospitalization. Or if you're concerned about invasive bacterial infections, having bloody mucousy stool with a fever, or looking at your host. If this is a patient that's over the age of 70, pregnant with potential exposure to listeria, those are things that would indicate that this could get a little bit more complicated, especially with volume and dehydration. The choice of your agents for the management of acute diarrhea is really more the azithromycin and fluoroquinolones, unless you have specific circumstances, like a pregnant patient where you're concerned about listeria or recent antibiotic use, where you are concerned about C. diff or travel history. There are HDG guidelines here to follow on acute diarrhea. I'm not going to describe each one of these because I just kind of went over the management. Down at the bottom of the teardrop, which didn't make it in there, is persistent diarrhea. This is kind of this gray zone, 14 to 30 days. Is it becoming chronic? Is it still acute? You wanna do the acute workup first. So making sure that you've ruled out any infections, treating if indicated. So now we'll move on to the bread and butter of the talk, which is chronic diarrhea. 30% of our patients in our GI practices come in with chronic diarrhea. So this is something you will or have been seeing often. Definition of chronic diarrhea is persistent alteration of stool consistency from the norm, consistent between types five and seven on the Bristol stool chart. Increased stool frequency of greater than three stools a day, at least for four weeks duration or longer. Organic causes such as malabsorptive, secretory, exubative, which could be inflammatory and functional are the main classifications of chronic diarrhea. And we'll talk about those today. I added here infectious at the bottom. That's technically not one of the main manifestations or classifications of chronic diarrhea, but I put it here to consider. I live in Oregon. There's lots of rivers, hunting and camping. Diarrhea can linger, so can cryptosporidium. So that's something you wanna think about. If somebody comes into your office and really never had the acute diarrhea workup, making sure that stool studies were done at some point to rule out these infections that can linger. When we're talking about malabsorptive diarrhea, you're talking about the non-absorbable solutes. So you have increased fluid into the lumen, and then this causes diarrhea. Examples of this include basically our colonoscopy PrEPs. We're bringing fluid to the colon, having a bunch of diarrhea. Or lactose intolerance, which is carbohydrate malabsorption, bile acid diarrhea, and pancreatic insufficiency is something else we think of because of the impaired digestion of fats due to low pancreatic enzyme levels, usually associated with chronic pancreatitis. Secretory diarrhea, this is an abnormal movement of electrolytes, especially sodium that follow, excuse me, water follows the sodium, and then causing the diarrhea. It persists during fasting. So this can be helpful in a situation where you're in the hospital and you make a patient NPO, and they continue to have diffuse diarrhea. You have an osmotic gap that's less than 50. Generally, these patients are having greater than one liter of diarrhea a day. Examples are cholera, VIPOMA, carcinoid, drugs can sometimes do this, and you can also have some bile acid diarrhea, such as the bile acids irritate the colon, causing this secretion. Inflammatory diarrhea. So this is inflammation of the small bowel or the colonic mucosa. You have damage to these absorptive surfaces, lose the ability for electrolyte transport and regulation, and then this causes diarrhea. Examples are, of course, inflammatory bowel disease. We think of chemotherapy-induced diarrhea, such as checkpoint inhibitor colitis or other invasive infections. Motility-related diarrhea. One of the more common diarrhea causes that we see in general GI practice, you have deranged motility, which affects the fluid absorption. So you have this faster motility, less time to contact a fluid with mucosa, and then can cause some diarrhea. Examples are irritable bowel syndrome and possibly some post-vagotomy diarrhea. Osmotic diarrhea. This is a result from poorly absorbed osmotically active solids in the gut lumen. Stops when the patient is fasting. So this is separate from the secretory diarrhea. On stool analysis, you may see an osmotic gap greater than 100, but the stool volume is less than a liter a day. Examples of this, you think about carbohydrate malabsorption, magnesium-induced diarrhea, GI lavage solutions, and laxatives. This can also be helpful, getting an osmotic gap in a patient where you're concerned about fictitious diarrhea. So someone that's claiming that they're having a lot of diarrhea, but they're actually taking laxatives to produce this, that can be helpful. So the evaluation of chronic diarrhea. We'll talk about the meticulous history that's necessary, physical exam, and diagnostic testing. So I have a couple of slides here that are very busy, and I agree that this is not PowerPoint 101 here. This should not be causing a slide to have this much content on it, but it's here for a reason. There are many differential diagnoses possible for the cause of chronic diarrhea. So I put this slide on here just as a reminder of all of the possibilities that could be and how you have a big checklist to get through. One of the most common that we think of in general GI is IBS with diarrhea. However, as you all know, we don't come to that diagnosis until we have ruled everything else out. We think about bile acid diarrhea, diet that could be impacting the diarrhea, colon cancer, of course, colonic neoplasm, inflammatory bowel disease. And within that, I put also microscopic colitis. So thinking about those more commonly in women kind of in their 60s, I think 50 to 70s, just average range. There are medications that can predispose to microscopic colitis as well as smoking. Those are things to think about. Drugs. So that is something that gets missed, I think, quite often when we see our patients with chronic diarrhea. We get a little bit kind of stuck in wanting to find the organic cause and rule things out. And really going over a medication list can be very helpful trying to pick out, are there any obvious offenders? You know, was the patient recently on antibiotics or are they on antibiotics? Do they take NSAIDs? Are they taking magnesium? Are they on diabetic meds? Those kinds of medications can cause diarrhea. So that can be helpful when you're doing the workup to have on your HPI kind of potential medication offenders and writing that down, or it could be in your plan or assessment. Is this recurrent C. diff? Overflow diarrhea is also something else we sometimes overlook thinking about the elderly population complaining of diarrhea, but really could it be a stool ball? And then there's watery diarrhea going around that stool ball. So you feel like you're having diarrhea, but really it's more constipation and they need to get cleaned out. And celiac screw, which is becoming more common, and we'll talk more today about celiac screw. I won't go through each of the less common causes of diarrhea but something to think about, of course, is SIBO. That's a popular diagnosis here on the West Coast. We have a lot of naturopaths that treat for SIBO. I'll talk about that a little bit later. And then also thinking about our pancreatic patients, could this be pancreatic insufficiency? Do they have chronic pancreatitis? Is there a pancreatic cancer that's blocking those pancreatic enzymes getting to the duodenum to aid with digestion? So these rare causes, I won't spend too much time on this because they are quite rare. Things to think about too, though, like I had mentioned is that fictitious diarrhea. So is someone actually taking a stimulant and maybe not really recognizing it, but having diarrhea, sorting that out can be a challenge. Once again, my apologies for a very cluttered slide, but this is where a meticulous history is key. Majority of the time, including in the West Coast, majority of the time in chronic diarrhea, and acute, actually, that is, you can figure out what's going on with a very meticulous history and asking all the right questions. So the questions you want to think about is duration. Was this sudden or gradual frequency and severity? Are you having large volume diarrhea that's very watery? Then you might be thinking more small bowel. Character of the stool, is it greasy? Do they see like an oily sheen in the toilet bowl? Then you might be thinking more fat malabsorption. Is this a pancreatic insufficiency situation? Blood in the stool, that is a red flag symptoms, and the next slide will review that, but of course you always want to act on blood in the stool. Travel history, nocturnal diarrhea is helpful. This is something I always ask when I'm meeting someone with chronic diarrhea for the first time. Does the diarrhea wake them up in the middle of the night? Generally, an IBS patient is able to sleep through the night without having diarrhea. If it's an inflammatory cause of diarrhea, such as inflammatory bowel disease, majority of those patients, if they're having a flare, are waking up in the middle of the night. Are there medications? Making sure you're, like I said, doing a good medication review. Dietary correlations. Do they say, you know, whenever I drink two glasses of milk, I have diarrhea. You know, then it's kind of like ding, ding, ding. Could this be lactose intolerance? Weight loss, also a red flag, and we'll talk about this. And then alcohol, especially with the COVID-19 pandemic, we've had quite a bit of increased alcohol intake across the board, and alcohol can cause more diarrhea. In addition, if you have, like I said, going back to those pancreatic patients, maybe a chronic alcoholic with chronic pancreatitis, you're thinking about malabsorption. Moving on to abdominal pain, foul-smelling stools, antibiotic use. Like I said in the beginning, the sexual history, including HIV risk factors. Asking about sexual history can be helpful and can lead to some information in respects to possible proctitis. Other aggregating factors, does stress or a particular diet make it worse? History of radiation is also a great question to be asking with diarrhea. Does someone have a history of a prostate cancer or uterine cancer? Have they been radiated in the pelvis in the past? Are you thinking about possibly a radiation proctitis? Something to think about. Family history of inflammatory bowel disease or celiac screw, in addition to colon cancer, are also very good to note. Red flags. This is something you need to remember and always make sure that you act on these. So in patients with chronic diarrhea, alarm features or red flag symptoms. Age of onset after 50 needs to be evaluated. Rectal bleeding or melanin needs to be evaluated. Nocturnal pain or diarrhea. Like I said, majority of the time, these patients aren't waking up in the middle of the night with diarrhea. They just have IBS. But if there's an invasive bacterial infection or IBD, they are. Unexplained weight loss, fever. People don't lose weight. You know, it's very hard. We're constantly preaching to patients to diet lifestyle, lose weight. So unexplained weight loss is a red flag and must be evaluated. Lab abnormalities such as iron deficiency and medium. Is this an issue with inflammatory bowel disease? Is there a neoplasm? Elevated inflammatory markers such as ESR or CRP. We're thinking about inflammatory bowel disease in addition to elevated fecal calprotectin. And fecal cool blood, if this is present. Once again, you need to have action. Have they had a recent colonoscopy? Getting them in for a look. And a first degree relative with inflammatory bowel disease or colon cancer. Through a physical exam, just as with acute diarrhea, you're assessing for dehydration and making sure the patient is able to stay hydrated. Is there presence of rash or flushing? So rashes, you're kind of thinking, is this an extra intestinal manifestation that could be related to inflammatory bowel disease? Is this a dermatitis related to celiac disease? Flushing, you're thinking about, is this maybe a neuroendocrine tumor? Mouth ulcers can also be an extra intestinal manifestation of inflammatory bowel disease. Is there a thyroid mass? Are you thinking of thyroid dysfunction that could be causing the diarrhea? Is there wheezing? Are you thinking about carcinoid here? Is there arthritis? Once again, looking at extra intestinal manifestations related to IBD. Anal rectal exam can be helpful, but not always. Diagnostic testing for chronic diarrhea. So the first two kind of blood tests and stool tests are something you want to make sure have been completed. Possibly by the time they've gotten to you, those infectious stool studies that have been rolled out. Making sure that the blood work is up to date, doing a CBC, checking for anemia, CMP, checking for electrolyte abnormalities, inflammatory markers, of course, thyroid functions and celiac screw. The quantitative diagnostic testing, such as measuring osmotic gap, fecal electrolytes, fecal fat, maybe this wouldn't be in your initial testing, but it would be kind of in your secondary testing, especially with the fecal elastase, if you're suspicious of any kind of malabsorption due to chronic pancreatitis, or if someone has a pancreatic cancer, or they've had a Whipple procedure, in addition to, of course, if there's any cystic fibrosis, et cetera. Diagnostic testing for chronic diarrhea. The majority of these patients are going on to endoscopy. A flexible sigmoidoscopy, if they've had a recent colonoscopy is acceptable with biopsies, but generally they'll have a full colonoscopy with biopsies to rule out microscopic colitis, in addition to possible CMV, if they're immunocompromised or you're concerned. An upper endoscopy with small bowel biopsies of the duodenum to investigate for celiac screw can be helpful. Aspiration of bacterial counts in parasites is not routine, but can be done if there's high concern, and the stool studies are inconclusive, but there's significant factors in the history that makes you concerned. So plain radiographs, upper GI, small bowel series, and I would also consider other small bowel imaging, such as the CTE or an MR enterography. Those can be completed, of course, if there's abdominal pain persisting, and you're concerned about, of course, if you're concerned about neoplasm associated with weight loss or inflammatory bowel disease. So management. You're treating the underlying etiology. You're treating what you've uncovered from the diagnostic workup or in your meticulous history. You can consider some empiric therapy. So say that you've done the workup. Everything's pretty negative. You can definitely try a trial of Rifaximin for treating possible SIBO. It's an expensive drug, and sometimes very hard to get covered, but a two-week course to see if that helps. You could also do the SIBO testing and do the breath testing to see if this is truly SIBO. In addition to making sure that, are there risk factors for SIBO? Is the patient diabetic? Have they had a small bowel resection? Do they have significant GI dysmotility? Increasing that risk for SIBO. Lactose restriction. Easy enough to, when you meet your patient, and what I tell them frequently is, let's go on a lactose-free diet for two weeks and reevaluate your symptoms. Many times people say, oh, I don't eat lactose or drink lactose often, but truly they're having a glass of milk with every meal. As we age, lactose intolerance goes up. You can consider a trial of cholestyramine for bile acid diarrhea. We also sometimes call this post-cholecystectomy diarrhea. Some data shows that up to 15% of patients, after their gallbladder's removed, will have diarrhea. Cholestyramine is a fairly low risk and not always the easiest medication to take, because it has to be taken away from other medicines, but it can be helpful if you're suspicious of a bile salt diarrhea, such as, like I said, a cholecystectomy, or if they've had a TR resection. And of course, symptomatic therapy. So if the patient has had the workup and everything has been ruled out, you can consider a trial of Imodium, scheduled Imodium, to see if that's helpful. Fiber to bulk up the stools. Many times we think of fiber for constipation only, but to be honest, many times it can make our constipation worse, because it can be a motility issue, but it can be very helpful in this setting of diarrhea to provide some bulk to the stools. And then, like I said, making sure that you're avoiding those possible medications that are trying to take a break from those possible medications that could be offenders, such as like PPIs, magnesium, NSAIDs, and then those diabetic medications. So our practice pearls. Most of the time, acute diarrhea is self-limited. The most critical therapy in diarrheal illnesses is volume repletion. Empiric antibiotic treatment for acute diarrhea is not recommended unless high-risk features or a high-risk host. Know the alarm features, the red flag symptoms in those patients with chronic diarrhea, such as weight loss, anemia, hematochesia, ongoing abdominal pain. Those patients need an expedited endoscopic evaluation. And then also, if they're having significant abdominal pain, need to get imaged. Meticulous history is key to aiding to this diagnosis. Those really cluttered slides I had on all the differential diagnosis of diarrhea, in addition to the questions to ask, that's what you need to be going through in your mind when you're seeing a patient with chronic diarrhea, checking off all those boxes. Most prevalent causes of chronic diarrhea in the general GI realm is IBS, IBD, malabsorption syndromes, such as lactose intolerance and celiac disease, and chronic infections, particularly in a patient who is immunocompromised and at increased risk. Here's my references. I have a couple polling questions here. So categories of chronic diarrhea include all of the following except malabsorptive, secretory, bloody, inflammatory, motility-related, or osmotic. Great, great. This was kind of a trick question because bloody diarrhea goes into the inflammatory category. So I'm really happy that majority of the patients, or majority of the attendees today caught on to that. So the next polling question, red flag alarm features in patients with chronic diarrhea include age of onset after 50, rectal bleeding or melanoma, unexplained weight loss, iron deficiency, anemia, or all of the above. Great, 100%, you guys are done for the day. All right, so thank you so much. So thank you so much, everyone.

diarrhea

evaluation

management

inflammatory bowel disease

acute diarrhea

chronic diarrhea