So to take a step back, I'm going to go ahead and talk about acute and chronic diarrhea. I have no disclosures. So what I'm going to be doing is reviewing the definition of diarrhea and discuss acute diarrhea evaluation appropriate testing and discuss chronic diarrhea evaluation appropriate testing. So you are going to see just a little bit of overlap because usually when patients get to see Kimberly, they're going to come into your office and have some component of diarrhea. So the definition is increased liquidity or frequency and decreased consistency of stools. Passage of a loose or watery stool typically three times in about a 24-hour time period. Some people consider diarrhea as an increase in the number of stools. However, the consistency is a hallmark. It reflects this increase in water content in the stool, whether due to impaired water absorption or an active water secretion. And I can tell you, it takes a few minutes to even just level set the consistency of the bowel movements and what we're talking about in that examination room. This is really important. Acute diarrhea is considered 14 days or fewer. Persistent diarrhea is more than 14, but fewer than 30 days. And then chronic diarrhea is more than 30 days. Because then once you start developing chronic diarrhea, your differential starts to shift. So in acute diarrhea, less than two weeks of duration. Most causes are due to an infectious etiology. And most causes resolve with symptomatic treatment alone. Most common infections are the norovirus, rotavirus, adenoviruses, astrovirus from a bacterial perspective. You see salmonella or camphorbacter, shigella, E. coli, and C. difficile. Protozoa infections would be cryptosporidium, giardia, cyclospora, and entomoeba. So with your acute diarrhea evaluation, you want to make sure you're capturing the duration of symptoms, the frequency and characteristics. Also associated symptoms, abdominal pain, hematochesia, weight loss or fever. Then you start getting into some alarm symptoms. And when you start differentiating with patients, when they're developing hematochesia, you have to start listening to their story. And you have to start imagining, okay, is this diarrhea bloody diarrhea? Is there blood that's mixed in with the liquidity of the stool? Is it coming from a proximal area of the colon? Or is the diarrhea that they're describing to me, is it because of all of a sudden this increase in motility, has it actually increased their hemorrhoids? And is this potentially related to hemorrhoid bleeding? So that's really where important indicators come in and make sure you're getting a CBC and assessing them, and of course, looking at their age and age-appropriate workup. Potential exposures, you've got food exposure, residence, occupation, exposure, travel, pets, medical history, exposure to antibiotics, and if patients are immunocompromised. Now, when we say exposure to antibiotics, first thing we think of is that, oh, potentially a patient could have developed C. difficile, because that's going to be association with their exposed antibiotics. Even if they haven't been exposed to antibiotics, I will still order a C. difficile in case, potentially, they could have been exposed to a family member or a friend, whether they visited someone in the hospital or not in the hospital. So it's, I don't rule out C. difficile completely, just because they haven't had a recent exposure to antibiotics. And then, of course, sexual history. So your physical examination, either by telehealth or in your office, you're really going to look at them to assess if there's an aspect of dehydration. It's interesting. Patients can get dehydrated very quickly, especially if there's someone in your office with chronic diarrhea, an elderly patient, and the diagnosis hasn't been made yet. So really assess, make sure they're not fluid depleted. Look at the lab studies that have been done, and you want to make sure that you're ordering those infectious stool studies and looking at their electrolyte and renal function. So for acute diarrhea evaluation, again, you want to look at antibiotic exposure, specifically C. difficile's primary concern. And I had a group of new NPs in a new residency program that we're developing in our organization, and I reminded them, just because there's a negative C. difficile, say, three months ago, I have seen that all of a sudden become positive before. So don't automatically rule out if this is still a persistent chronic diarrhea. Think outside the box, because look at the immunocompromised patients, like CME, CMV, or noninfectious aspect, these are your really sick, sick patients, though. Your management originally is supportive. Sometimes when a patient's on my schedule, and they've had diarrhea for three days, and it's of acute nature, sometimes I think, well, how did you get on my schedule so quickly? Because you really, you, you, these are self-limited, and you don't want to give empiric antibiotics, again, only unless it's in a very few select patients, unless they're severely ill. Here's a schematic of the ACG clinical guidelines for acute diarrhea, and it goes over this nice graph of persistent diarrhea between 14 and 30 days, and how it should be worked up by culture or not by culture, culture-independent, microbiologic assessment, and then treatment with antimicrobial agent directed to its cause. So I'm going to give you that as a resource to review. Chronic diarrhea, this is the majority of the patients that I'll see in my office, because primary care doctors are great at navigating through a patient who has a new onset of acute diarrhea. So chronic diarrhea is persistent of alteration of stool consistency from the norm, loose stools consistently with your Bristol stool types of five to seven, and I don't know about you, but I have a Bristol stool scale in my pocket, or else I had it on a chart when I was doing more telehealth visits, and I can actually show it to patients and have them share with me what they thought that their stool type was. So it accounts for 30% of patients in our GI practices, malabsorption, and secretory or inflammatory etiologies. We have to make sure that we're ruling out as well as functional diarrhea. And that you're going to get in your history, especially if patients have had it and it's been episodic, chronic and episodic. The categories of chronic diarrhea are malabsorptive or maldigestive, secretory, inflammatory, motility-related, or osmotic. So your malabsorptive diarrhea, these are nonabsorbable solutes. So it's going to increase the fluid movement into the lumen, which will then cause a diarrhea. Examples of this are ingested nonabsorbable solutes like fleets and peg, carbohydrate malabsorption like lactose, your bile acid diarrhea. So say if a patient you're seeing that has had a post cholecystectomy syndrome, and they described to you in their history that they've been having chronic diarrhea since they had their gallbladder out two years ago. So that's going to give you an inclination that could be bile acid diarrhea. Pancreatic insufficiency or impaired digestion of fats due to low pancreatic enzyme levels, usually due to chronic pancreatitis. And Sarah gave us a great presentation on acute and chronic pancreatitis. So secretory diarrhea, abnormal movements of the electrolytes, especially sodium with your water that follows through the diarrhea. This persists during the fasting stage, and this is identified with your osmotic gap. Now, I do not do, I will not, I do not order 24 hour collections of stool unless I really have to. Usually if I'm looking for, really concerned more about carcinoid syndrome, then I will do a 24 hour stool. But look at the drugs that patients are on and especially query the most recent medications that they've started. I can't even tell you how many patients I've cared for where they've had a negative workup, colonoscopy with random biopsies are negative, and come to find out they're taking magnesium 500 milligrams at bedtime to help them sleep, not knowing that it can cause loose stool. So really be a good detective when you're looking at your patient's medication list, but ask them, what are you taking in addition to your prescription medications? What are you taking potentially your multivitamins or supplements? Inflammatory diarrhea, so inflammation of the small bowel, colonic mucoses, damage that absorptive surface, loss of ability of electrolyte transport and regulation of diarrhea. So this is an example that you see when the inflammatory bowel disease, also chemotherapy induced mucus, mucus, mucus, sinusitis and invasive infections. I've been seeing more patients recently on chemotherapy induced inflammation related to malignant melanoma. They'll be referred by the oncologist because they've been on Keytruda and this is a potential reaction of this chemotherapy induced inflammatory bowel disease. Motility related diarrhea. So you have a deranged motility, effective fluid absorption. This occurs a faster motility, less time contact with a fewer or mucosa. We see this in patients with irritable bowel syndrome and also post vagotomy as well. And then also short bowel, we'll see this in also in short bowel syndrome. So asthmatic diarrhea results from this poorly absorbable asthmatic activities in the gut lumen. Evaluation of chronic diarrhea, meticulous history. I've already given you some pearls along the way, physical examination and diagnostic testing. So your history, you're looking at duration, frequency, consistency. Now I'll actually ask patients, if you put your stool in a container and you put a popsicle stick in the top of it, would it stand up straight or tilt over to the side? Because this is the test that I'll tell them to do if I'm looking for C. difficile. If they tell me that the popsicle stick would stand up straight, then that's telling me that the stool is more formed to it. And I can be pretty confident that clostridium difficile is not an organism that I have to worry about. But this is the devil in the detail of trying to identify the consistency of the patient's bowel movements. Blood in the stool, travel history, nocturnal diarrhea. So this is waking them up in the middle of the night. Then you know you have some type of infectious or inflammatory process. Traditionally, patients will not be woken up in the middle of the night if they have functional bowel syndrome. So this is going to be one of those key questions that you're going to ask in your history. Medications over the counter, I included magnesium supplement is a common offender for diarrhea. Diarrhea correlation, weight loss, alcohol, other constitutional symptoms, abdominal pain, excessive flatulence. If they have increase in bowel sounds, foul smelling stools, previous history of abdominal surgery. Now that line of questioning, we could also be looking at small bowel intestinal bacteria overgrowth as well. Antibiotic use, intestinal sexual history, incontinence, aggravating factors, diet and stress, history of radiation or family history of IBD or celiac sprue, which we just heard that presentation from Kimberly. Red flags, alarm features in patients with chronic diarrhea, age of onset after age 50, rectal bleeding or melanoma, nocturnal pain or diarrhea, progressive abdominal pain, unexplained weight loss or fever or other systemic symptoms. These patients you can see in your office, they're sick and you know you need to get additional workup and you need to order them urgently and you need to figure out what's going on with these patients fast. It's interesting how ill patients can present in your office and how long the symptoms have been allowed to go on. And then sometimes within the last 48 hours, they just feel so bad because of the length of time everything has gone on. You're looking at your lab abnormalities, you're looking for iron deficiency anemia, you're looking at your SED rate, your CRPs. And Kimberly was saying that sometimes those aren't good markers though. And then looking at your fecal calprotectin and your fecal occult blood stool test. And then getting that family history to see, okay, are there any first degree relatives that have had inflammatory bowel disease or colon cancer? Causes of diarrhea, common ones are IBSD, bile acid diarrhea, fermented foods, it could also be aggravating symptoms, neoplasm, inflammatory bowel disease, you see Crohn's disease or microscopic colitis. Drugs we talked about, recurrent C. difficile, overflow diarrhea, celiac sprue, less common, small intestine bacterial overgrowth, mesenteric ischemia, lymphoma, post-surgery resections, chronic pancreatitis, radiation andropathy, pancreatic cancer, hyperthyroidism, diabetes, giardia, and cystic fibrosis. Other rare conditions to consider would be other small bowel enteropathies, hypoparathyroidism, Addison's disease, your hormone secreting tumors, autonomic neuropathy, factitious diarrhea, and Brainiard's diarrhea, possibly infectious, but causes are not identified. Again, assess for dehydration, look for rashes or flushing, mouth ulcers, thyroid mass, wheezing, arthritis. Some of these indicators you're going to be thinking about IBD. Diagnostic testing. You're going to do routine blood work and include celiac sprue, which you've learned about earlier. Stool studies, WBCs, look for leukocytes. I don't necessarily do an occult blood for the guaiac cards because if there's, if patients are telling me that they're having rectal bleeding, then I'm not going to do a guaiac testing. I will do OMP though. I'll do cultures and GRD and then check for C. difficile and a fecal calprotectin. Diagnostic testing. We're going to look at doing either a flexible sigmoidoscopy or colonoscopy with biopsies, depending on what services are offered in your community or what's available. If a patient had a colonoscopy just recently, then a flexible sigmoidoscopy with a left-sided biopsy is a great tool to have, not to have to have a patient go through another colonoscopy. However, if you're looking for microscopic colitis, there is an increased incidence. I want to say approximately 30% of incidents. You'll find a sampling of the right side of the colon of microscopic colitis versus the left side of the colon. So you may not have enough geography to be able to get a true sampling. And what the sampling that they're looking for is, they're looking for that thickening of the basement membrane. Radiology studies can be appropriate at that time to look to see if there's some type of small bowel stricture or narrowing. And then of course, an upper GI series to look if there's any abnormalities in your esophagus or your stomach. Usually when someone who's had chronic diarrhea, then I'm not doing a lot of upper endoscopy evaluation. Sometimes it's easy if you're getting a small bowel series, then you can get the upper GI series at that same time. And then CTE and MRE, which Erin talked to us about as well, looking at a more definitive imaging of your small intestine to see basically if you're missing some small bowel lymphoma or tumor that could be causing the chronic diarrhea. So you want to treat the underlying etiology. Empiric therapy for SIBO, lactose restriction, cholestyrene for bile acid diarrhea. So after giving the presentation on SIBO, I really think that we need to focus on testing if it is available. There are different breath testing because these patients, sometimes they'll get better and sometimes they don't. So having that quantifiable data, now I know that I have access to it has been a significant change and game changer in my practice. So here's a case study I want to go over. 68 year old female. She's had over one year of history of intermittent diarrhea. Infectious etiology was ruled out. No significant laboratory abnormalities. Current medications that she's on are a proton pump inhibitor, magnesium supplement, and occasional anti-inflammatories. No red flags were noted. No anemia, no rectal bleeding, no weight loss, no abdominal pain, no family history of Crohn's disease, ulcerative colitis. So empiric therapy was recommended. Since there's no etiology of infection or inflammation or no presence, then I will start patients on Imodium to take it routinely. So they can take one tablet as soon as they wake up in the morning. And that's going to start cutting down that daily burden of, say, three to four water evaluations a day to maybe two per day. And they're not having fecal incontinence. And then of course, recommend a diagnostic colonoscopy with random biopsies. Because what we're looking for, really looking for an inflammatory or microscopic colitis. So the colonoscopy endoscopically appeared normal, which is what you see with microscopic colitis. And the biopsy results did confirm that. So microscopic colitis is when there's an inflammation of the basement membrane. I explain to my patients, you can only see this microscopically. That's why it's important to do this sampling. And previously when I set up the case for her history, it's been associated that people on proton pump inhibitors, specifically Lansoprazole can increase their risk for a microscopic colitis. I had a patient just yesterday that I actually switched her from Lansoprazole back to Omeprazole for her reflex disease to see if that could help with her symptoms. SSRIs are known to have an associated increased risk as well as anti-inflammatories. So the age that it usually originates is 50 to 70. Female is greater than male. There is an autoimmune disease link looking at thyroid disorders, celiac disease, RA and diabetes. Genetic link associated with smoking. Medications that I had mentioned were NSAIDs, PPIs, SSRIs and cholesterol lowering medications. Now I will explain to my patients, because there's an association, some of these medications are important for you and we don't want to stop them unless it is an elective medication or something that you don't need specifically. So in the case of the studies I've shown Lansoprazole, if there's an increased risk for microscopic colitis, then I chose to transition her to a different proton pump inhibitor. So again, if someone's on an SSRI and their mood disorder is well-controlled, whether anxiety or depression, I'm not going to stop that because they have microscopic colitis. And the treatment, which I didn't go over a treatment for, is Budesonide, usually three milligrams, three tablets, Q day for a month, and then you taper down to two tablets and then a day for a month and then one tablet once a day for a month. I have recently read they're recommending, or you can do a shorter taper. So do your three tablets once a day for a month and then you can do a shorter taper two weeks and then two weeks. But I had a patient recently that just her symptoms reoccurred pretty quickly. So I went back to my one month, one month, one month. A post-acute diarrhea is self-limiting. The most critical therapy in diarrheal illness is volume repletion. Unfortunately, I've had patients on my schedule for chronic diarrhea and when they didn't show that day, I find out that they were in the emergency room because of dehydration. And this is before I've even seen the patient. So it just makes me pause how critical these symptoms can be. But also the education is patients are given, are recommended to use Imodium and it usually says you may take one or two after your first bowel movement and then take a second one after that second bowel movement. I tell my patients, I said, don't follow the instructions on the box. I want you to just start taking one the first thing when you wake up in the morning because that's what's going to mitigate the volume of the bowel movements during the day. Again, this is in light of having a negative infectious workup. So they're negative for C. difficile and there's zero or limited white blood cells in the stool. And we mentioned this empiric antibiotic treatment for acute diarrhea is not recommended unless it's a critically ill patient and who's immunosuppressed. Know your alarm symptoms. Meticulous history is key to this diagnosis. And most prevalent causes of chronic diarrhea are IBS, IBD. Thank you, Kimberly, for your amazing talk. Malabsorption syndromes such as lactose intolerance and celiac disease. And your chronic infections, just be mindful, particularly in patients who are who are immunocompromised. OK, so the poll. Question one. OK, categories of chronic diarrhea include all of the following except. Very good, yeah, so bloody diarrhea is is a symptom, but it's not a category. OK, next question. So for red flags, alarm features in patients with chronic diarrhea include age of onset after 50, rectal bleeding or melanoma, unexplained weight loss or iron deficiency anemia. Nice, excellent. All of the above. All of these are our alarm symptoms. Alright, very good. Well, thank you everyone for my presentation. I also want to thank Sarah and Kimberly for joining me for that series of talks. These were great.

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