Thank you, Caitlin, and thank you again, Dr. Tiwani, for inviting me to continue to present for the program. If you heard my presentation yesterday, it was on, one of them was on coding and billing, but my day job is full time in a gastro, in a general gastroenterology department. So let me go ahead and over with you some clinical scenarios and just some background on looking at patients with acute and chronic diarrhea. These are my disclosures. So what I'd like to do is define what diarrhea is and specifically differentiate between acute and chronic diarrhea and we'll go over the evaluation and appropriate testing for for both entities. So I think that the devil's in the details. So the definition of diarrhea is going to be liquidity or frequency or decrease in consistency of stools. That passage of loose watery stools that approximately three within 24 hours. Some people actually consider diarrhea as an increase in the number of bowel movements. However, the consistency is the hallmark. And then reflects the increased amount of water that loads into the stool that's part of that impairment of the water absorption. How many of us online today have spent many minutes actually walking through a patient trying to differentiate exactly what type of bowel movement that they're having. And I think that's why it's so important that we spend that time to talk to patients to find out exactly what is the consistency of the bowel movement that they're having because their definition of diarrhea is different from our definition of diarrhea. So an acute episode is going to be considered 14 days or less. And by the time a patient sees me in the office that they've had two days of diarrhea, haven't seen their primary care provider, then my first thought is, how did you get into even see me that quickly. So really walking through that patient and being patient with them and, and, and walking through that self-limiting aspect. Persistent diarrhea is over 14 days, but less than 30 days. And your chronic diarrhea is after 30 days. So I really try to find that, that date when the change in the bowel habits first started. And I kind of start counting my clock when I start looking at the differential diagnoses that I'll be walking you through it. So acute diarrhea is that less than two weeks duration. Most cases of acute diarrhea in adults is an infectious etiology. Actually, it also could be a viral etiology. These are the most common infections that you see the different viruses, bacteria, and protozoa. So really spending that time with patients to find out what were those potential aggravating or triggering factors that could have initiated it. So again, that meticulous history, you want to get from your patient, glean from them, the duration of the symptoms and the frequency and characteristics of the symptoms. The Bristol stool scale, I think is invaluable to our practice. So for anyone who doesn't have a pocket guide, get that in your pocket and your lab coat. And I routinely, all my patients have an iPhone in their hand. So I routinely will have my patients self-engage and have them pull up the Bristol stool scale so I can walk through with them what that metric looks like. So we can start guiding, okay, what is your baseline now? And how can we move you forward? It's also important to identify what is your normal baseline? I mean, sometimes patients want us to make them better, more improved than what their constant bowel movement has been like since their lifetime. So really understanding what you're trying to get them back to. I'm trying to help you get back to your normal. So if they normally had two or three soft to loose stools a day, then it sounds like maybe there's an underlying chronic symptoms that you need to help work them through versus this acute episode on top of a chronic. Look for alarm symptoms. You want to look for abdominal pain. You want to look for rectal bleeding. You want to look for weight loss and fever. You want to look for potential exposure. So potential food, did they go out to eat at a restaurant? What type of living environment are they in? Are they in a skilled nursing facility? Are they in a residence with their immediate family? Have potentially they had exposure to some type of trigger that could be more of an infectious etiology? Again, looking at that medical history is imperative. You want to see if there's been an exposure to antibiotics. I don't know about you, but I've actually been tricked before. Patients have had, I've been able to identify clostridium difficile and I can't identify an exposure to antibiotics. So we have to be mindful of that. Don't be dogmatic about not running a C. diff stool culture if you can't identify antibiotic exposure. Look at the household contacts. Are there elderly in the household? Have they been visiting anyone at the hospital? And this has become more of a community acquired infection than what I've seen in my clinical practice experience. Look at your patients if they're immunocompromised and also if they're on chemotherapeutic agents. I've been seeing more and more patients who have been exposed to immune checkpoint inhibitors that are developing this immune checkpoint colitis. And then look at their sexual history in case there's a potential risk. So your physical examination, you want to look for them or just do the overall gestalt to see, do they look ill? Are they ill appearing? You want to assess for that volume depletion. Look at their dry mucous membranes. You know, when they're talking to you in the office, are they having a hard time forming words? Are their mouth dry? So pick up those subtle changes. You're going to do an abdominal exam and assess if there is an acute abdomen. You know, there are peritoneal signs. Are there pain? Is there rigidity? Is there tenderness? Look at the blood work. Now, infectious stool studies, generally you want to wait approximately a week. That's why I was making a comment about patients having acute diarrhea for two days. You know, we don't need to jump into it right away. The majority of the time it's going to be self-limited. But also look at your patient in front of you. Take that into consideration. Are they elderly patients? Are they compromised? Is this someone that you're going to have to put on your worry list? This is what I describe to my patients. So I'm going to make a certain reminder in my office that this is someone I'm going to check up on in the next week. Or have my medical assistant give them a call in a week to make sure their symptoms have improved. Electrolytes and renal function, you know, watch out for that potential hypovolemia. Our elderly patients, we always want to be cautious, especially if they're on medications. And also look back at their history. Maybe they run a little hyponatremic. Maybe their baseline is 131 of their sodium levels. So you want to keep an extra eye on them because an acute that can turn into a chronic episode can really deplete them. And one of your recommendations may be, you know, volume replacement and even sending to the emergency room to make sure that they can get some fluids. So the antibiotic exposure, you want to make sure the number one thing that you want to rule out, especially in our patients with IBD that are coming in with a flare. First and foremost, we want to make sure that we're ruling out any infectious etiology. And also keep in mind your immunocompromised patients. So management, as I mentioned, is supportive. You want to give them the guidance of oral hydration, go on a bland diet, pull out those spicy foods, you know, pull out the caffeinated beverages, and you want to avoid any type of bowel stimulants. And I don't recommend probiotics and the first flush, but just keep an eye on the patient. If that's something that you feel may be part of your armamentarium that could help that patient. But it's amazing how patients may continue their current regimen, say if they have an underlying history of chronic constipation, they may still continue their laxatives. Look at fluid replacement we talked about. And empiric antibiotic therapy, it has a place but only in a select patients. This is someone who is severe, who has a fever, or if you're concerned that potentially there could be some type of invasive infection. But these types of patients, you really want to consider if they need to be hospitalized. So this is the ACG clinical guidelines for acute diarrhea. So I encourage that you add this to your clinical practice guidelines. And they walk through that persistent diarrhea for 14 to 30 days should be worked up by culture, and culture independent microbiologic assessment, and then consider treatment with antimicrobial therapy if it's directed. The concern is that we have over usage of antibiotics in our community. So we really want to preserve that for documented disorders if our patient needs that. So chronic diarrhea, the definition is persistent alteration of stool consistency from that normal to loose stool. That consistency is between your types five and seven. Again, I can't stress enough to use this as a tool in your office to be able to talk to your patients so we can have the same language. It also increased stool consistency is that three stools daily for at least four weeks in duration. And this is going to account for about 30% of patients in our practice. There are different types of chronic diarrhea that we can differentiate. It's going to be identified as malabsorptive, secretory, exudative, and inflammatory. And then we all know about functional bowel disorder. So again, this history is important because sometimes our patients will come in and they'll describe an acute episode, but it's an acute on top of their chronic. So their chronic diarrhea, their chronic functional bowel disorder may have worsened. So really hone in on their history and try to help them walk through, you know, what has your normal bowel movement been like? Where would you like to be? These are the four categories I described also includes motility related. So malabsorptive, maldigestive, secretory, osmotic, inflammatory, and motility related. So malabsorption is going to be these non-absorbable salutes or increase, which is going to cause an increase in fluid movement in the lumen and diarrhea. So examples of these are going to be your fleets, phosphosoda, your polyethylene glycol, which we use commonly for a chronic constipation. And of course, for the bowel preparations, carbohydrate malabsorption or lactulose, bile acid diarrhea. So we see this very commonly for our patients who have post cholecystectomy diarrhea. And then pancreatic insufficiency, which is impaired digestive fats due to the low pancreatic enzymes, usually due to chronic pancreatitis, which Sarah went over brilliantly in our last presentations. So secretory diarrhea, these are going to be the abnormal movements of the electrolytes from your sodium to water that falls to diarrhea. So this is going to persist even during stages of fasting. And this is, you're going to notice that there's going to be an osmotic gap of less than 0.5 to one liters per day. Examples of this, you're going to see with cholera, which hopefully in our practices, we're not going to see. Carcinoid syndrome, different medications, and then back to the bile acids. So bile acids are going to be irritating the colon, which then causes secretion. It's interesting. I have seen many patients that have been, that I've diagnosed with bile acid diarrhea or post cholecystectomy diarrhea. And these patients have struggled for years. So keep that on your horizon as part of your differential for patients with chronic diarrhea. And it doesn't always determine on when that date is of the surgical date of that post cholecystectomy. I've seen it happen within months to years to then many years where a course of bile acid sequestrants have really been helpful for these patients. So another type of chronic diarrhea is the osmotic diarrhea. So results are this poorly absorbed osmotic active salutes in your gut lumen. So the diarrhea stops when your patients are fasting. So these are two clinical pearls. Ask your patients with their history of diarrhea. Do you find that your diarrhea still persists whether you eat or whether you don't eat, or does your diarrhea stop if you are fasting and you're not eating anything? So examples of this are going to be carbohydrate malabsorption. It can be related to magnesium intake, GI lavage solutions, and laxatives. Think to yourself how many patients come into you and they're complaining of chronic diarrhea, and they're taking 500 to 1000 milligrams of magnesium to help them sleep at night. Now, my clinical practice before I take that away from them or tell them to hold it to see if it can help improve their diarrhea, make sure that they're not being recommended to take magnesium due to documentation say by their primary care provider or their cardiologist for hypomagnesia. So I always ask my patients, did a provider, did a specialist ask you to start taking magnesium on a regular basis? Or is this something that you've started on your own and tell me why? So inflammatory diarrhea, we're familiar with this in our general GI practice or specialty practice. Inflammation of the small bowel and colonic mucosa. This is damaged absorptive surface and the ability of this electrolyte transport and regulation, which can cause diarrhea. So examples of this are inflammatory bowel disease, your ulcerative colitis and Crohn's disease, chemotherapy-induced mucositis, immune-mediated colitis, which I'm seeing more and more in my practice, and then some type of invasive infections. And then motility-related diarrhea. Examples of this are going to be your irritable bowel syndrome or even a post-vagotomy diarrhea or dumping syndrome that can occur. And this is when the motility is off. It's deranged, so it affects the fluid absorption, you get this faster motility, less time, and you have this dumping syndrome, this rapid transport. Meticulous history is so important. It's almost like a detective with patients with acute chronic diarrhea. You really have to find out exactly when did it start, what type of environment they were in, and then look at their surrounding exposures. Doing that physical exam and then the diagnostic testing. Your history, you're going to identify if it's sudden or gradual. Frequency, severity, the consistency. Is there greasy-like stools? Are there fat globulins floating on top of the toilet bowl? Is there blood in the stool, travel history? Also, if there's weight loss or if there's alcohol use. So then you're thinking of, again, what Sarah had mentioned about looking at your acute and chronic pancreatitis. Weight loss is an alarm symptom for us, so you're also going to consider your additional workup, which may include your CT scan finding to make sure you're not ruling out some interabdominal malignancy. And then looking at pain, looking at those greasy, foul-smelling stools. Prior abdominal history, surgical history. Did someone, has someone had a fundoplication? Has someone had partial gastrectomy? Has someone had a history of abdominal trauma and had a small bowel resection? All these are going to come into play affecting the GML absorption and transit time. Also appropriate, look at the sexual history, find out if there's fecal incontinence, and also look at these aggravating factors. History of radiation therapy. And then, of course, if there's a family history of inflammatory bowel disease, if a patient has been specifically diagnosed, or if there's a family history of celiac sprue, to take into your consideration and add that into your clinical testing. So the alarm symptoms, age of onset, if it's after 50, if there's rectal bleeding or melanoma, if these symptoms wake your patient up at night. So this is a concerning for me, if diarrhea will wake them up in the middle of the night, or if they're having abdominal pain. And this progressive abdominal pain and this unexplained weight loss. These types of patients with chronic diarrhea can get very sick very quickly, especially our elderly patients. They can become hyponatremic, hypokalemic very quickly. So you want to look at that blood work to assess for anemias. Look at their SEP rates, that way you can clinically assess, you know, how sick are they? And then also you can look at your fecal calprotectin and your Guaiac testing. And we also mentioned about looking at that family history. If a patient comes into me and they've had a screening colonoscopy, say if they're age 50 and they've had a colonoscopy two years prior, I'm not going to worry about that patient as much unless someone comes in, say at age 60s or 71, and they haven't had any endoscopic evaluation done. So common causes of chronic diarrhea I've mentioned throughout the presentation, bile acid diarrhea. Also think about our patients with functional disorder that may not have been diagnosed and look at those food intakes as well, looking at your FODMAPs. Chronic neoplasm, IBD, looking at the medications. And then less common, we're going to talk about small bowel bacteria overgrowth, which I'll be mentioning more in detail in the next presentation. Immune-mediated colitis, mesenteric ischemia, lymphoma, post-surgery complications or side effects, chronic pancreatitis, pancreatic cancer, hyperthyroidism, your diabetes type one and two, and then giardium, and cystic fibrosis. Other rare causes, think about small bowel enteropathies or hypoparathyroidism, Addison's disease. I had mentioned bipomas, gastronomas, and carcinoid, and autonomic neuropathy and factitious diarrhea. So your physical examination, again, you're going to assess for dehydration. You're going to look if there's other comorbid conditions, look at thyroid mass, you're going to look at other potential signs and symptoms that could trigger you to look at some other more systemic disorders versus an infectious etiology. And then anal rectal exam, if that potentially is helpful. Sometimes, you know, when you're taking your history from your patient, find out how many times patients will go into the restroom. They may only tell you that they've gone to the bathroom and had liquid stool three times. And I'll ask them, well, how many times have you gone into the restroom and sat, feeling like you have rectal urgency? Because they may not include that part of the history because no stool may come out, or else maybe only a small amount of mucoid discharge will come out. So find out how many times they actually have the urgency to make some want to go to the bathroom, to feel like they need to sit down, to have some type of defecatory mechanistic action occur. So depending on how ill the patient is, and depending on their history, how soon they've had recent blood work done, look at ordering your routine blood work at CBC, CMP, and Sedrate. Thyroid function, because you know, hyper or hyperthyroidism can cause GI distress. And then looking at celiac disease. So just a reminder, part of the workup for irritable bowel syndrome would diarrhea predominant. The ACG guidelines do recommend at the minimum that we're checking for Giardia and for celiac disease. I recently had a insurance company deny my celiac panel, and I used that on my medical necessity letter, used that resource from ACG on recommendations by their professional organization, because I had a 32 year old that came in with change in bowel habits, and he was watery, diarrhea, and some bloating. So I included that in my medical necessity letter, that resource. So stool studies, look at the white blood cell count, look at your O and P, your cultures, Giardia, Cryptosporidium, C. difficile A and B, and the Calprotectin. And then fecal lactoferrin is also another inflammatory marker. And then I also will include fecal fat as well. And then also pancreatic elastase, which you don't see here, are listed. And then depending on the patient, then I'll calculate a stool osmotic gap. So you're ordering a stool for sodium, a stool for potassium, and then there's a calculation that you calculate to come up with that value. Also, you can go under MD calculations. You can just Google that calculation, and then type in both of the numbers, and it'll come up, give you a value. And so a secretory diarrhea is gonna be less than 50. Your indeterminants is gonna be 50 to 125, and your osmotic diarrhea is gonna be over 125. Last time I calculated this, it came out to be 100 indeterminant. I'm like, oh, okay. But it's still value exercise, and sometimes I will forget to use that. So think about using that when you're doing your diagnostic evaluation for chronic diarrhea. And I'm glad that one of our attendees mentioned that discoordinates that can happen when you're looking at that, pancreatic elastase and fecal fat. So thank you, Sarah, for answering that question. So that's common. That's a common conversation to navigate with our patients as well, because it doesn't make sense to them, and sometimes it doesn't make sense to us because of that discoordinates. Again, I do the exact same recommendations as Sarah does in my practice pattern. I will counsel my patients, try to bulk up their stool. Let's try to slow it down so we can get a more accurate evaluation for that pancreatic elastase value. Your diagnostic testing, depending on that chronic diarrhea, looking at doing either a flexible sigmoidoscopy with biopsies or a colonoscopy with biopsies, depending on the last time that they had that done. And then your upper endoscopy would be recommended with small bowel biopsies if you're looking for celiac disease as part of your differential. And again, depending on the acuity of your patient and how they present to your office, do you need to do a KUB? Is that something fast and quick that you can get done in your office quickly? Do you need to do any upper additional imaging, your upper GI series or small bowel series or CT, MRI, depending on that patient acuity, how they present to your office. And also if they're of history for potential illness or small bowel obstruction. So management, you want to treat that underlying etiology, empiric therapy. So there's an overlap with small bowel intestinal bacteria overgrowth. You want to look at potentially testing for it. You want to look at restriction of lactose. Lactose intolerance is very common. You want to look at pulling that out of the diet, pulling out products that can cause that promotility agent and looking at prescribing cholecystermine for potential bile acid diarrhea, if that's appropriate in your armamentarium and looking at symptomatic therapy. So case presentation, we have a 68 year old female who's had over three month history of chronic diarrhea. So that falls under our definition of having four liquid watery bowel movements a day. So the infectious etiology has been rolled out and there's no significant laboratory abnormalities. So you review the medication list. So patients on a proton pump inhibitor, they're also on a magnesium supplement and occasionally take anti-inflammatories. No red flags such as anemia or rectal bleeding or weight loss or abdominal pain, no family history of inflammatory bowel disease. So empiric therapy was provided and recommended a diagnostic colonoscopy for random biopsies. So what the random biopsies find is that the patient has microscopic colitis. So part of your differential for chronic diarrhea in an older patient, you wanna look at ruling out microscopic colitis, lymphocytic colitis, collagenous colitis or your inflammatory bowel disease. So what's interesting about the diagnosis microscopic colitis is that the causes remain unclear. They say possibly there's an association between medications. So those associations are going to be linked to proton pump inhibitors. SSRIs are also linked to that and also non-steroidal anti-inflammatories. So your risk factors are 50 to 70 year olds, females, female predominant. There is an autoimmune link to microscopic colitis, associated disorders or thyroid disorders, celiac disease, rheumatoid arthritis and your type 1 DM. And then also there's a genetic link to smoking and medications are associated as well. So if you have a case like this, if you're seeing the patient in follow-up, I would definitely make sure you do a chart review to make sure that a patient has had a celiac panel done to make sure that you're not missing out a comorbid condition that's associated with this disorder which I have seen that before in my general practice. So in summary, most acute diarrhea is self-limited. Most critical therapy in diarrheal illness is volume repletion. Empiric antibiotic therapy for acute diarrhea is not recommended unless your patient is at high risk and the alarm features in patients with chronic diarrhea absolutely require endoscopic evaluation. I, in all my years of experience, I did have one patient who she had just had a screening colonoscopy and I swear three months later, she started to develop in this acute watery diarrhea. And so the recommendation, everything was negatives. The recommendation was to do an endoscopic evaluation with random biopsies, right colon and throughout the colon biopsies. And sure enough, she wasn't happy about the recommendation but she had a diagnosis of microscopic colitis. Meticulous history is key to aiding in this diagnosis and most prevalent causes of chronic diarrhea are gonna be your functional bowel disorder, that inflammatory bowel disease, malabsorption syndromes and examples like lactose intolerance, celiac disease and chronic infections. So make sure that you're again, you're taking that meticulous history. So I do have two polling questions. Categories of chronic diarrhea include all of the following except malabsorptive, secretory, bloody, inflammatory, motility related or osmotic. Very good. So bloody diarrhea was not a specific category. We see patients with bloody diarrhea but that's gonna fall under your inflammatory bowel category. All right, then the next polling question. Red flags or alarm features in patients with chronic diarrhea include the following. Age of onset after 50, rectal bleeding or melanoma, unexplained weight loss or iron deficiency, anemia or all of the above. Excellent, excellent, excellent. So it's all of the above. Everything is gonna be a red flag alarm system. All right, I see some great questions in the chat but what I'm gonna do is I'll go ahead and I'm gonna continue to my next presentation.

acute diarrhea

chronic diarrhea

Bristol stool scale

infection causes

endoscopic evaluation

management strategies