This presentation, I really enjoy giving because to me, this is one of those bread and butter talks that we see in our office on a daily basis if you're working in general GI practice. So today we're going to review the definition of diarrhea. We're also going to discuss and differentiate the workup for acute diarrhea and the difference between chronic diarrhea. So the definition of diarrhea is increased liquidity and frequency and decreased consistency of stools. I'll be mentioning the Bristol stool scale in a few slides ahead of us, but I hope everyone has a copy of that laminated in their pocket as they navigate conversations with your patients. If you don't have one, then please get it because it's an amazing visual tool and it will actually save time and have you and your patient be on the same page and talking the same language. So it's a passage of loose and watery stools at least three times in a 24 hour period. Some patients, some people consider diarrhea as increase in the number of stools. However, it really it's the consistency and especially when you work with the IBD patients, the amount of times that they sit on the toilet because of that feeling of tenesmus does not translate in how much liquidity of stool will come out because you may find that they're going to sit on the toilet with the feeling they have to go to the bathroom, but nothing comes out of the rectum and it reflects the increased water content in the stool due to this impaired water absorption and or active watery secretion by the bowel. So this is the algorithm I want you to keep in your mind and take back to work on Monday. Acute diarrhea is 14 days or fewer. Persistent diarrhea is between 14 and 30 days. And then chronic diarrhea is 30 days and patients will judge the amount of workup that you do for them based on the fact that they're having a symptom of diarrhea. But I specifically asked my patients to give me the date when the symptoms first started because that is your playing field that will give you your landscape of how are you going to work this patient up and what they've and how are you going to generate your history of presenting illness and then what workup has been done, what they've tried, et cetera. So acute diarrhea is less than two weeks in duration. Sometimes cases of this acute diarrhea is going to be an infectious etiology and cases may resolve on their own without symptomatic relief. And there's some common infections below. Sometimes when a patient is on my schedule and they've had diarrhea for two days, my first thought is how did you, A, how did you get on my schedule so quickly? And two, this is most likely a self-limiting disease. So I almost have to switch my primary care hat on to get a good history and find out when did the diarrhea first start? Exactly did they go out to eat at a restaurant? Did they go to a potluck? Are there other family members that are infected? And then look at the stool studies that would be appropriate at that time. So you're looking at the duration of symptoms, the frequency and characteristics of the symptoms. And I had mentioned the Bristol Stool Scale. Associated symptoms which include abdominal pain, hematochesia, weight loss or fever. This is a sicker person. This is a much sicker person that you're dealing with. Potential exposures, food. As I mentioned, who in their home may have also had the same exposure. A lot of patients will come in and say, you know, my husband and I and children went out to eat at a restaurant last night. They're fine, but I woke up in the middle of the night with lower abdominal cramping and watery diarrhea. Look at the travel history, look at pet history. Also look at the medical history. So exposure to antibiotics, look to see if they come to you if they're immunocompromised, if they're recently or they've been being treated for multiple myeloma or for other types of cancers, specifically if they're on immune checkpoint inhibitors. And I'll be going over that, what immune checkpoint, immune mediated colitis is. Social history, whether they have receptor anal or intercourse, this also increases risk for bacterial and parasitic infections. The physical examination, you're going to look for volume depletion. Look at that patient, their vital signs. If they have dry mucous membranes, ask them about their urine color. Look at their skin turgor, you know, someone who is in their eighties with that can develop acute onset of diarrhea. They're going to be much more volume depleted than someone say in their twenties or thirties. But it's surprising that when patients start having any type of diarrheal illness, everyone wants to increase their water intake. And it's really our job to make sure you're finding out what fluids that they are increasing, because even increasing a lot of water intake, it's not going to replace the fluid. It's going to replace the fluid, but they're not going to get the electrolytes. So I have to make sure that they're drinking Gatorade or sometimes Pedialyte or vitamin water so they can get in their electrolytes. So the labs that you're going to look at, you're going to look at the infectious stool studies. Generally, you can wait about a week until it's a severe illness of concerned for inflammation. Again, look at the patient, look at their age, look at their, look at what they're compromised by. And then I just mentioned about the electrolytes and renal function. So antibiotic exposure to Clostridioides difficile is your primary concern. Even if patients have not had a specific antibiotic exposure, that is one of the stool tests that I will order. I have seen patients, you know, it's so much more common in the community now, and I've seen patients be exposed to it without telling me that they had a specific antibiotic exposure. Sometimes they may have visited a patient in the hospital or visited an elderly home or gone to someone's home to visit. So I am not dogmatic to not order a C. difficile toxin if a patient has not had an antibiotic exposure. And again, look at your immunocompromised patients. So the management for it is supportive measures, oral hydration, I mentioned, make sure that the oral hydration is going to have electrolytes, a bland diet, avoid bowel stimulants. A lot of patients are taking magnesium on a regular basis. Even a patient last week, she was on, she developed acute, a watery diarrhea, it was most likely a self-limiting process, but she was taking magnesium 500 milligrams a day. And I, before I tell patients to just automatically stop it, I want to find out why, because a lot of times it may be recommended by their cardiologist because they have a magnesium deficiency or sometimes they're taking it on their own. A lot of our patients will take supplements and herbal products that we're not aware of, as we learned in our presentation on elevated liver enzymes. So those are certainly a hidden cause for many problems that we encounter. So empiric antibiotic treatment is only in selected patient population. If it's very severe, if they have a fever, if their bowel movements are six stools a day, volume depletion, if they're requiring hospitalization, then, then you would recommend that you would refer them to the hospital for evaluation. It's mostly fluid therapy. It's not the fact that the etiology of the diarrhea is causing problem, as you'll find as we move forward with chronic diarrhea, but sometimes the condition goes on so long that these especially elderly patients get so weak and depleted and dehydrated. So it's not the fact you're referring them to the emergency room for fluids for the cause, but for what it's done to them. Invasive bacterial infections, bloody or mucoid, stool with fever. Look at your host factors, over 70 multiple comorbid conditions, pregnancy with a potential exposure to listeria and look at your choice of antibiotics, erythromycin or fluoroquinolones such as Cipro or levofloxacin. Unless specific circumstances, then you want to warrant others like you're pregnant women with concern of listeria, recent antibiotic concern, again, C. difficile, traveler's diarrhea. So here's a nice algorithm for ACG clinical guidelines for acute diarrhea. And as John Martin mentioned to us earlier, we can't be dogmatic looking at our guidelines, but certainly this can give us a roadmap. A lot of times I find this helpful explaining it to patients because a lot of times the first thing patients want me to order is a colonoscopy and I have to take a step back and walk them through our thought process and what is it that we're looking at right now? I mean, certainly if they're eligible for a screening colonoscopy and this is an early stages, then it's something that you will end up ordering at some point. But your first and foremost mission is to find out, okay, what is happening right now in the office with you right now, and let me help take care of these symptoms. So persistent diarrhea, 14 to 30 days should be worked up by culture, culture-independent microbiologic assessment, and then antibiotic if it does come up positive. And I think what's been really revolutionized, my practice I know in taking care of patients with chronic diarrhea is the stool test for calprotectin. And that was a test that relatively was not available for our use. I want to say it's probably came up approximately five years ago, and it's really been helpful now when we differentiate, say a 20 year old that comes in with watery diarrhea with rectal bleeding on wiping, helps us differentiate that patient between irritable bowel syndrome and inflammatory bowel disease. So chronic diarrhea is described as persistent alterations of stool consistency from normal with loose stool. And that consistency on the Bristol stool scale is identified as types five to seven. So if you look through the pipe, and type one is the separate hard lumps with severe constipation. And then it goes through different varying grades all the way over to type seven, as your pipe is flushing out, liquid consistency with no solid particles. I'm still impressed how sometimes I can be confused by my patients trying to explain their consistency and frequency. So use this guide. And then the two main questions that I ask is how many times do you sit on the toilet to try to move your bowels? And what is coming out when you do sit to move your bowels? The causes for this for chronic diarrhea are malabsorptive, secretory, exudative, and inflammatory. And then of course, functional bowel disorder as well. So your malabsorptive diarrhea, it's non-absorbable solutes. It increases this fluid movement into the lumen of diarrhea. So you're going to see this when patients have the PEG prep or fleece enemas, that's for your preparation. Think about that for the colonoscopies. Also lactose can cause the same response. Also bile acid diarrhea. So keep on your, on your radar. If you see a patient that comes in to see you post cholecystectomy, then from the fact of having their gallbladder removed, now they have additional bile that's dumping into their gastrointestinal tract. And how I explain it to my patients is that even though the gallbladder is removed, the warehouse is gone that used to hold the, the bile there to help regulate when you would eat a fatty meal. Now you have dysregulation and your liver still produces the bile, but it comes out at different times and you may have more of it. So bile acid diarrhea is a very common condition that I see in my practice. Also pancreatic insufficiency and impaired digestion of those fats, looking at the low pancreatic enzymes and usually it's related to chronic pancreatitis. I just verified a lab last night where my patient's pancreatic elastase was 119, which is on the low level. And as Sarah Enslin mentioned the other day, make sure that when you're ordering that test, that your, your bowel movements have some type of form. So when I removed, when I reviewed my note last night, sure enough, her bowel movements had started to thicken up. She was alternating with some loose stool and some solid stools. So I can pretty much depend on that. That's going to be an accurate, accurate test result. So secretory diarrhea, this is where abnormal movement of electrolytes and persists during fasting and you have this osmotic gap. So cholera, VIPOMA, carcinoid drugs, also some bile acids can also irritate that and cause a secretion. Inflammatory diarrhea. We've all seen this before in our practice. It's when inflammation of the small bowel or colonic mucosa is damaged and the absorption of the surface loses the ability to have this electrolyte transport and regulation causing diarrhea. So our patients with ulcerative colitis and Crohn's disease, chemotherapy-induced mucositis and immune-mediated colitis. I'd be interested in the Q&A if people would let me know if you're seeing this more often. Also invasive infections, but immune-mediated colitis. Now you're seeing it more and more. And it's interesting, the literature is showing that a lot of times the oncologists are treating this. So the oncologists are starting Remicade therapy for their patients. And you wonder, could something be missed as far as some type of mucosal defect and they really need to have a colonoscopy? How are they gonna stage that? And the grading of immune colitis are different various sub-stages and some are not bloody diarrhea. I had a patient yesterday who I was trying to navigate her chronic diarrhea. She was 84, she had Irritable Bowel Syndrome Diarrhea as an underlying condition of her chronic diarrhea. Last year, she had a colonoscopy. She was hospitalized for an episode of ischemic colitis. And I did see where the gastroenterologist had biopsied her descending colon. So I thought, well, maybe I've ruled out microscopic colitis at least, but she was on checkpoint inhibitors. So really the final diagnosis was that she was on immune-mediated colitis. Chronic diarrhea, motility disorder, related diarrhea. This derangement in the motility that affects the absorption of the fluid in these patients that we see are Irritable Bowel Syndrome with diarrhea predominance. Osmotic diarrhea results from poorly absorbed. Osmotic active solutes stops when the patient is fasting. You see this with a carbohydrate malabsorption, magnesium-induced malabsorption. Again, look at your patients. A lot of times they're on high-dose magnesium supplements and they haven't been asked to be on that. Also laxatives are going to cause this effect as well. So you want a meticulous history, a physical examination, and start your diagnostic testing. So you're looking at the duration, whether it's sudden or gradual, frequency, severity, consistency, watery. Is there greasy stools? Is it floating on the top? My patients bring in pictures all the time. My mantra is, if you take the time to take the picture, then I'll take the time to look at it. Blood in the stool, a travel history, nocturnal diarrhea. We all know that if a patient wakes up in the middle of the night with diarrhea, then that's not Irritable Bowel Syndrome. And we need to pay attention to their symptoms. Dietary correlation, weight loss, alcohol, other constitutional symptoms, abdominal pain, flatulence, increased bowel sounds, foul-smelling stool, previous history of abdominal surgery, antibiotic exposure, sexual history, incontinence, aggravating factors, diet, stress, history of radiation. I see patients with radiation proctitis and they can develop chronic diarrhea. Also family history of IBD or celiac sprue. They still say that celiac disease is being underdiagnosed. I keep ordering it, but I did review the article from 2023 last year for the new updated guidelines. So I think everyone should have that. It should be one of reference that you take away also from this presentation, just to update your clinical acumen. Red flags, alarm symptoms, patients with chronic diarrhea, onset of age after 50, rectal bleeding or melanoma, nocturnal pain or diarrhea, progressive abdominal pain, unexplained weight loss, fever or systemic symptoms, lab abnormalities, iron deficiency, anemia, elevated ESR and CRP, elevated fecal calprotectin or fecal occult blood present, first degree relative with IBD or colon cancer. So your common causes are IBS diarrhea predominant, bile acid diarrhea, post cholecystectomy, food malabsorption, looking at those artificial sweeteners, chronic neoplasia, IBD, including microscopic colitis, drugs we mentioned, recurrent clostridium difficile, overflow diarrhea and celiac sprue. Less common is small bowel bacteria overgrowth. I think less common may start to becoming more common. Remember when you're looking at testing, when you're thinking about SIBO, which a lot of my patients will come in specifically with chronic diarrhea, and that's the first thing they want me to test for, I'll say that that is part of the differential, but let's work our way through with more common conditions. And if it's appropriate, then we can go ahead and order the testing for small bowel bacteria overgrowth. Immune mediated colitis, which I've mentioned a few times, mesenteric ischemia, lymphoma, post small bowel resection, fecal incontinence, chronic pancreatitis, radiation endotherapy, and the list goes on, pancreatic cancer. And then also looking at metabolic disorders like diabetes, hyperthyroidism, and giardia specifically and cystic fibrosis. I had a 28 year old that I came in, he had a chronic diarrhea and I was asking him, he had acute on chronic, let me put it that way. And I was asking him his history and he said, I think I have giardia and he said, why? And he said, well, I had it before. So that's the number one, right? Getting your history. And he said, I've had it three times actually. And I said, why do you keep getting giardia? He goes, well, I like to fish. And what I do is when I change my fishing line, I'm biting on it. And I think that's how I'm getting exposed to it. I'm like, okay, I don't think you needed me for anything other than the prescription. So causes of diarrhea, other rare bowel entropithies, looking at Whipple disease, amyloid, hyperthyroidism, Addison's, and factitious diarrhea, Brainerd's diarrhea, which is a rare condition. Physical examination. I think I've repeated this before. You still want to do the same physical examination and head to toe assessment that you would for a patient with acute diarrhea. And diagnostic testing for your chronic diarrhea. You're ordering your CBC and CMP because you're looking for this long-term effect that has affected your patient and you're looking for anemia. That's really going to tell you if this is more acute, more systemic, if you start showing iron deficiency anemia. Then your CMP is so important because you really want to look at your potassium and sodium. It's amazing how long some patients will go on with chronic diarrhea. And it's not until they have a fecal incontinence episode, whether they're standing in the grocery store or at home, will they then make an appointment to come in and be evaluated. Some of them, I've had several patients say, well, it was fine when I stayed at home. Now that I'm back out, then that's why I wanted to come see you. I've had this diarrhea for two years. I've been working from home. Now that I'm out going out to the community, seeing friends, then I had this accident. That's why I decided to come in. So I think a clinical pearl is asking the patients who has chronic diarrhea, what made you decide to come in now? They may have talked to their primary care doctor before and then had a referral or then they were being referred to you to a GI practice. But I always find that fascinating. With a chronic condition, what was it now that brought you in? And it's usually that they've had a fecal incontinence episode. That's what's brought them in this time. Stool studies, you're looking, I don't order a cold blood, but I'll order a ovarian parasite. I'll order WBCs. I'll order culture, giardia, but I'll order the fecal calprotectin. And then of course the clostridium difficile. And only unless a patient has had chronic diarrhea and looks like they have problems with malabsorption, then you'd look at considering ordering electrolytes or osmolality. I will order fecal fat and pancreatic elastase. But you have to be guarded on the accuracy of that test because there is a high incidence of false positive due to liquidity of the stool. So diagnosing, testing for chronic diarrhea, you can do flexible sigmoidoscopy or colonoscopy with biopsies. And what you're looking for is microscopic colitis, collagenous colitis. And visually you're looking for inflammatory bowel disease. And depending on your indication of suspicion, you could choose whether you do a limited exam or the total colon exam. I do diagnostic flexible sigmoidoscopies. And this is a common condition that I'll be referred in my clinic if a patient has chronic diarrhea. And even they may have had a colonoscopy two years ago and it was normal. So this is a good test to use to do left-sided colon biopsies. But some studies show is that you may be missing microscopic colitis or collagenous colitis if you do not do that endoscopic random biopsy starting from the ascending colon and coming through to the hepatic flexure and the transverse colon. And then you're looking at radiologic exams, abdominal X-ray, consider small bowel series, CTE or MRE, depending on what you're looking for. So treat the underlying condition and you're looking at empiric therapy. Now I don't do empiric therapy for small bowel intestinal bacteria overgrowth. There is a breath test that is looking at the three different gases that you're looking for with SIBO, which is your hydrogen, your hydrogen sulfide and your methanogen. And then cholecystermine for bile acid diarrhea that I will do empirically. But meanwhile, the colonoscopy is done. You're ruling out the interluminal abnormality and looking at your biopsies. So case presentation, 68 year old female with over three months of chronic diarrhea and infectious etiology has been ruled out. You did a clustridium difficile. You did OMP, you did WBCs and they're normal. You did Giardia and they're negative. No significant laboratory abnormalities. So she's been stable. So medications she's on, proton pump inhibitor, magnesium sulfate and occasional NSAIDs. No red flags such as anemia, rectal bleeding, weight loss. And she has no family history of Crohn's disease or ulcerative colitis. So management, empiric therapy provided, recommended diagnostic colonoscopy with biopsies. And with the biopsies, so the colonoscopy was normal, normal and patients don't understand how can my procedure be normal? And what would happen is, is that the biopsy results show that it confirmed microscopic colitis. Now microscopic colitis cause remains unclear, but there's association between proton pump inhibitors and SSRIs and NSAIDs. And I'll explain to my patients that there is a correlation, but if you're on a medication that you need to be on, I'm not gonna take you off your Zoloft for major depression. I'm gonna treat the microscopic colitis is what I'm gonna do and give you that supportive care. So risk factors for microscopic colitis people age 50 to 70, it's predominantly found in females. There's a link to autoimmune disease or thyroid disorders, including celiac disease, rheumatoid arthritis, and type one diabetes is a genetic link and there's smoking correlation. The medications I mentioned above, all cholesterol lowering agents and diabetic medications, IntegraTol. So in summary, most acute diarrhea is self-limiting. Most critical therapy in diarrheal illness is volume depletion. I have so many stubborn elderly patients that will wait for months before coming in to have a patient or coming in to see us. And then that day I'll have to send them to the emergency room because they look terrible. They're exhausted and they're dehydrated. Alarm features in patients with chronic diarrhea require endoscopic evaluation and imaging if they do have abdominal pain. Meticulous history is key to aiding that diagnosis, which I reviewed with you. And then most prevalent causes of chronic diarrhea are your IBS, IBD, malabsorption syndromes. And so, and then again, look for lactose intolerance and look for celiac disease in these patients to make sure you're not missing something. And there are some references, please check out. Oh, two polling questions. So categories of chronic diarrhea include all of the following except. Oh, very good. For the other percentage that didn't get this question, it is kind of tricky because you would think of inflammatory. You would think of bloody diarrhea, but it is bloody. It's just not one of the specific categories. And then next polling question. So red flags, alarm features in patients with chronic diarrhea include. Yay, 100%. Awesome. All right, well, very good.

diarrhea

acute diarrhea

chronic diarrhea

evaluation methods

colonoscopy

microscopic colitis