What is Diarrhea

The term diarrhea is a Greek origin and includes two main components: (1) stool consistency lose and (2) increased frequency of bowel movements than 2 times per day. Some authors include in the definition and the third component: increase the weight of stool over 200 grams / day.

Diarrhea is classified as “acute” or “chronic” based on the duration of symptoms. Acute diarrhea is the duration of the symptoms below 2-4 weeks. Chronic diarrhea has a duration of symptoms for at least 4 weeks.

I Acute diarrhea

Most forms of acute diarrhea is self-healing, and are caused by infectious phenoxy (rotaviruses, adenoviruses, parasites such as Gambia, amoebiasis, etc.); common etiological cause, however, and bacteria (Salmonella, Shigella and Escherichia coli).

Tentative diarrhea caused by viruses and bacteria lasts less than a week until the diarrhea caused by parasites have a longer duration.

The possible etiologic factors for acute diarrhea are:

Osmotic diarrhea

  • Osmotic laxatives
  • carbohydrate malabsorption

Secretory diarrhea

  • Bacterial toxins
  • Malabsorption of bile acids
  • inflammatory bowel disease
  • Ulcerative colitis
  • Bolesta on Krohn
  • Microscopic colitis
  • Diverticulitis
  • Vaskuliti
  • Drugs
  • Colchicine
  • NSAIDs
  • Kalцitonin
  • Srdechni glucoside
  • Prostaglandins
  • Stimuliraŝi laxatives
  • Diseases motility
  • Inflammatory bowel disease
  • vagotomy Post
  • Diabetic autonomic neuropathy
  • Endocrine diarrhea
  • Xipertiroidiz’m
  • Addison’s Disease
  • Gastrinoma
  • VIPOM
  • somatostatinoma
  • carcinoid syndrome
  • Medullary carcinoma tiroideяta
  • Mastocytosis
  • pheochromocytoma
  • Other tumors
  • colon carcinoma
  • Vilozen adenomas
  • Limfoma
  • Idiopathic secretory diarrhea

Inflammatory diarrhea

  • Inflammatory bowel disease
  • Ulcerative colitis
  • Bolesta on Krohn
  • Microscopic colitis
  • Diverticulitis
  • Ischemic colitis
  • Radiation colitis
  • Neoplasia
  • colon cancer
  • Lymphoma

Fatty diarrhea or malabsorption syndromes

  • mucosal disease
  • celiac disease
  • Болест на Whipple
  • syndrome short bowel loop
  • Bacterial svrahrazstezh in the small intestine
  • mesenteric ischemia
  • maldigestion
  • Pancreatic exocrine insufficiency
  • Drugs
  • aminoglycosides
  • Tetracyclines
  • Xolestiramin
  • Orlistat
  • Polimiksini
  • immunosuppressants
  • antineoplastic

History

As in addressing other medical problems careful history taking is a key element of the diagnostic process.

The burden of diarrheal process must be defined first. Frequency of defecation is the easiest parameter to determine, but it should be borne in mind that the frequency of the stools did not correlate with the weight of the stool.

The large volume of stools (more than 750 ml per day) are characteristic of secretory diarrhea and enteric disease, while feces with volume of about 350 ml are typical of the column diseases and functional gastrointestinal diseases.

The secretory diarrhea is predominantly liquid while functional diarrhea with soft or semi soft consistency of faeces.

Loose bowel movements accompanied by copious flatulence are characteristic of carbohydrate malabsorption.

Fatty diarrhea can not be confused with anything else. The term “celiac disease” describes the gray, greasy, disgusting smelling stools that may contain undigested food particles. The presence of celiac disease suggests pancreatic disease, celiac disease, gardiaza or bacterial overgrowth in the small intestine.

You have to pay attention for signs of dehydration, weight loss, decreased skin turgor, orthostatism.

The characteristics of the feces are also important. The presence of blood or pus in stools suggesting the presence of inflammatory diarrhea caused by or inflammatory bowel disease or enteroinvasive bacteria. The absence of macroscopic blood does not exclude the inflammatory nature of diarrhea. Watery stools are inherent in the secretory processes.

Should be sought accompanying symptoms such as diarrhea, abdominal pain, usually calms after a bowel movement or cramps, flatulence, bloating, fever, dry tongue and weight loss.

The patient should be questioned also about recent travel, medication, conducting radiation therapy or surgery.

History must be distinguished from diarrhea “psevdodiariyata” where there is only reinforced urge defecation without increasing the volume of stool. Psevdodiariya observed primarily in irritable bowel. Often the term “diarrhea” patient understands the occurrence of incontinence.

Physical Examination

It helps to identify the severity of diarrhea and the underlying disease. Rarely, however, he alone can establish the etiological cause.

Looking for signs of dehydration. Orthostasis suggesting the presence of volume depletion or autonomic dysfunction (possibly diabetes or adrenal insufficiency).

Some skin lesions associated with diarrhea, dermatitis herpetiformis (celiac disease), erythema nodosum and pyoderma gangrenosum (irritable bowel), hyperpigmentation (Addison’s disease), flash syndrome (underlying malignancy), necrotizing migratory erythema (glucagonoma).

Abdominal examination is usually nonspecific. You should be looking scars from surgery, intra-abdominal masses and hepatosplenomegaly. Borborizma in auscultation suggests malabsorption, bacterial svrahrazstezh, obstruction or intestinal quick transport. Palpable sensitivity is a nonspecific finding.

Perianal, rectal and anal examination is very important. We look for signs of incontinence and weakened anal tone. Crohn’s disease is associated with perianal ulcers, fissures, abscesses, and stenoses.

Other associated physical signs include exophthalmos (thyrotoxicosis), aphthous ulcers (celiac disease and irritable bowel), annular cheilitis, lymphadenopathy (disease of Whipple’s , infection or malignancy), enlarged thyroid (cancer tiroideyata, teroidit), arthritis (disease Whipple or irritable bowel), wheezing or right-sided cardiac murmur (carcinoid syndrome) and drum your fingers (malignancy, irritable bowel, abuse of laxatives, liver disease).

Blood Tests

Extensive laboratory tests have not indicated for all patients with acute diarrhea and should be reserved for those with toxic diarrhea, dehydration or massive presence of diarrhea lasting more than expected. PKK gives information about hemoconcentration, the presence of anemia and leukocytosis. Patients with viral diarrhea usually have leukocytosis, but have lymphocytosis. Bacterial infections are usually accompanied by leukocytosis accompanied by immature leukocytes, although the salmonella can cause lymphopenia.

Serum electrolytes, renal and metabolic tests define aspect of diarrhea.

Analysis of feces

This assay has been shown in patients with blood in diarrhea, dehydration and diarrhea in patients with prolonged diarrhea.

This assay is sensitive and specific, but is expensive.

Polymerase reaction ( PCR ) analyzes bacterial or viral DNA and allows specific diagnosis.

ELISA establishing gardiaza and serological testing for amebiasis are more specific analysis of feces.

Patients who have received antibiotics three months prior to the onset of diarrhea, as well as patients who develop nosocomial diarrhea should be tested for the presence of Clostridium difitsile toxin in feces.

Imaging and endoscopic tests

In patients who are intoxicated, having blood in the stool or in those with persistent acute diarrhea sigmoidoscopy or colonoscopy should be discussed.

In patients without rectal bleeding sigmoidoscopy is an adequate method to study because colic changes in most cases are located in the left column. In patients with bleeding or AIDS colonoscopy is the preferred method because opportunistic infections or lymphoma engagement mostly right column.

Mucosal biopsy should be done in some cases, especially if zaangazhiran entire colon.

In intoxicated patients should be performed graphy overview of the abdomen to exclude ileus or megacolon.

II Chronic diarrhea

There are 3 categories of chronic diarrhea: osmotic (malabsorptive) diarrhea, secretory diarrhea and inflammatory diarrhea.

Possible etiologic factors for chronic diarrhea

Dyetarny factors

  • Ektsesiven reception on caffeine
  • Ektsesiven food intake
  • Ektsesiven intake of food containing sorbitol

diverticular disease

Drugs and other substances

  • Alcohol
  • Antacids containing magnesium
  • Antibiotics
  • Colchicine
    • of        Digitalis
    • of        lactulose
  • Laxatives
  • Propranolol
  • Xinidin
  • Teofilin
  • Tiroksin

idiopathic secretory diarrhea

  • collagenous colitis
  • Microscopic colitis

Infections

  • amebiasis
  • Gardiaza
  • Other opportunistic infections associated with immunodeficiency

inflammatory bowel disease

  • Antibiotic associated colitis
  • Bolesta on Krohn
  • Ulcerative colitis

colon iritaʙile

Malaʙsorʙцija

pancreatic insufficiency

Diseases of the small intestine

  • celiac disease
  • Болест наWhipple
  • syndrome short bowel loop

Mehanychny factors

Metabolic Diseases

Addison’s Disease

Diabetes

Xipertiroidiz’m

Tumori

  • colon cancer
  • Ekzokrinin tumors such as carcinoid and gastrinoma
  • intestinal lymphoma
    • Medullary carcinoma tiroideяta
  • pancreatic cancer
    • Vilozen adenomas

Research

First, it is useful to identify the type of stool. The presence of voluminous diarrhea or suggests malabsorption or secretory diarrhea. Grey disgusting smelling stools are characteristic of malabsorption. The presence of blood or pus in stools suggests or inflammatory bowel disease or a tumor, while the presence of mucus or suggesting the presence of inflammatory bowel disease or irritable bowel.

If the patient has a small volume of diarrhea, associated with defecation urgency urgency or abdominal cramps and these symptoms were sedated by defecation, may be available column or rectal disease.

A history of diarrhea, alternating with constipation or defecation urgency early in the morning, they are available only a few stools in this part of the day is typical for functional disease as “colon iritabile.”

Night diarrhea is almost always of organic aetiology.

Positive recent history of antibiotics suggests damage to the gut flora even the presence of pseudomembranous colitis.

The relationship between the occurrence of diarrhea after taking milk or milk products may suggest the presence of lactose intolerance or ulcerative colitis.

We should be aware of the presence of other associated symptoms / disorders which can cause diarrhea (table below). For example, diabetic patients especially those with Autonomic Neuropathy are at risk of developing diabetic diarrhea. Immunocompromised patients are prone to developing chronic infectious diarrhea.About 50% of patients infected with the HIV virus have diarrhea and weight loss often in the absence of opportunistic infections.

etiologic guidelines Diagnosis for discussion
arthritis Ulcerative colitis, Crohn’s disease, Whipple’s disease
liver disease Ulcerative colitis, Crohn’s disease, malignancy with liver metastases
fever Ulcerative colitis, Crohn’s disease, amebiazis, tuberculosis, lymphoma
Weight loss Ulcerative colitis, Crohn’s disease, malabsorption, thyrotoxicosis, malignancy
eosinophilia Eosinophilic gastroenteritis, parasitosis
lymphadenopathy Disease Whipple, lymphoma, AIDS-
neuropathy Diabetic diarrhea amyloidosis
hypotension Diabetic diarrhea, Addison’s disease, idiopathic orthostatic hypotension
flash syndrome Carcinoid diarrhea, pancreatic cholera
proteinuria amyloidosis
Perianal disease or abdominal mass in the right lower abdominal quadrant Crohn’s disease
purpura celiac disease
peptic ulcer Zollinger Ellison syndrome, antacid therapy gastrokolonna fistula
Sled holetsystektomyya Malabsorption of bile acids
after gastroektomiya dumping syndrome
honor infection Imunoglobulinov built deficit, KhIV
immunodeficiency Gardiaza, nodular lymphoid hyperplasia, celiac disease, HIV
hyperpigmentation Disease Whipple, Addison’s disease, celiac disease
Good response to corticosteroids Ulcerative colitis, Crohn’s disease, Whipple, eosinophilic enteritis
Good response to antibiotics Bacterial overgrowth in the small intestine

laboratory tests

They should be individualized or, for example when the history and physical examination show that dietarniya factor or medicinal effects are responsible for diarrhea are not necessary because the adjustment of diet or discontinuation of the drug cease diarrhea.

However, most patients with chronic diarrhea require placing of basic laboratory tests.

Blood tests though useful are rarely diagnostic. From the hematocrit we can possibly judge the presence of dehydration. The presence of anemia suggests or inflammatory bowel disease or neoplasia, while leukocytosis suggests an inflammatory process. Electrolytes, urea and creatinine should be tested to reject the secondary consequences of diarrhea.

Biochemical profile vkl.kaltsiy, albumin, liver function tests, and glucose are needed for screening nutritsionalni abnormalities, diabetes and hepatobiliary disease.

You may need the release of additional tests, depending on medical history and physical examination. For example thyroid tests are needed in patients with tiromegaliya and gastrin levels is reasonable to release water in patients with diarrhea and peptic ulcer.

The study of feces for the presence of blood and leukocytes are needed in almost all patients with chronic diarrhea. The study of feces with Sudan black for the presence of fat is a good screening for malabsorption. While bacterial infections rarely cause chronic diarrhea is reasonable to run at least one microbiological testing because Yersinia and Campylobacter occasionally cause chronic diarrhea. Microscopic examination of fresh faeces for eggs and parasites should be taken at least 2-3 times.

While the initiating tests may give a diagnosis sigmoidoscopy is shown earlier in the work envelope. Sigmoidoscopy allows a direct view of the rectum and colon for ulceration, inflamatsii and tumor masses. Fresh stains mucous in the stool suggests the presence of amoebiasis. Even in normal mucosa seemingly must take a biopsy, so as not to miss the diagnosis as amyloidosis.

Additional tests depend on clinical suspicion.

Radiological studies with barium and abdominal CT scans are useful for identification of anatomical abnormalities, Regional Museu enteritis, fistulas or tumors.

In difficult diagnostic cases the performance of other tests like stool electrolytes and osmolarity of the same, which will give the differential diagnosis between osmotic and secretory diarrhea. Serum levels of vasoactive interstitial peptide, calcitonin and gastrin examined for chronic secretory diarrhea of ​​unknown origin.

The presence of osmotic diarrhea suggests bacterial svrahrazstezh, bile acid-induced diarrhea, lactose intolerance and excessive use of laxatives.

Complete colonoscopy with multiple biopsies need to be performed for the diagnosis of microscopic colitis and collagenous colitis. Endoscopy with intestinal biopsy needs to be performed to diagnose celiac disease, intestinal lymphoma disease, Whipple or gardiaza not identified by testing stool.

In some cases the performance of the culture of small intestine aspirate for diagnosing abnormalities other gastointestinalni including diabetic neuropathy, scleroderma or surgically connected loops which can take place by intestinal stasis and massive bacterial overgrowth.

Laktozotoleransen test or endoscopic retrograde cholangiopancreatography can also assist in the diagnostic process in difficult cases. If therapeutic test with pancreatic enzymes does not provide conclusive evidence of pancreatic inzufitsientsiya, secretin stimulation test or test bentiromid can confirm the diagnosis.
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