Cairo university

School of medicine
Department of tropical medicine
 Presented by:

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Overview
Diarrhea is defined as change in the bowel habits in which there is an increase
in frequency, amount or fluidity of the stools.
It may be defined as the passage of 3 or more loose stools per day but the first
definition is more accurate and appropriate, as the frequency is variable from
person to another

Its to be noticed that faeces exceeding 200 gm/day with low dietary fiber
content is considered diarrhea

Classification:
Diarrhea may be classified by two methods:

According to the pathogenesis:

o Osmotic diarrhea
o Secretory diarrhea
o Inflammatory diarrhea
o Malabsorptive diarrhea
o Diarrhea duo to motility abnormality(motility disorders)

According to the duration of the disease:

o Acute diarrhea: if less than four weeks
o Chronic diarrhea: more than 4 weeks

More details about this classification are discussed later.

Pathogenesis of diarrhea:
1) Osmotic diarrhea:

In this type of diarrhea there is derangement of the osmotic force that acts in the lumen to
drive water into the gut. Its due to the presence of high concentration of unabsorpable
hypertonic substance ,this will lead to accumulation of fluid in the intestine causing the
stools to be more loose and fluidity

In this case the stool output is proportional to the intake of the unabsorpable substrate and
is usually not massive; diarrheal stools promptly regress with discontinuation of the
offending nutrient, and the stool ion gap is high, exceeding 100 mOsm/kg

The ion gap is obtained by subtracting the concentration of the electrolytes from total
osmolality (assumed to be 290 mOsm/kg), according to the formula: ion gap = 290 [(Na
+ K) 2].

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 e.g. after the ingestion of unabsorpable sugars such as lactulose or lactose in lactose
disaccharidase deficiency

2) Secretory diarrhea

in this type, the epithelial cells ion transport processes are turned into a state of
active secretion of fluid and ions

this type is not related to specific type of food or substances

e.g. enterotoxin-induced diarrhea.

3) Inflammatory diarrhea

In this type there is damage in the intestinal mucosa leading to loss of excessive fluid
and/or blood in the stools with defective absorption of food components which adds
an element of osmosis thats why it may be partially relieved by fasting

e.g. ulcerative colitis and bacillary dysentery

4) Diarrhea duo to motility abnormality (motility disorders)

In this type there may be is hypermotility of the intestine leading to defective time of
absorption and contact between the mucosa and the food

E.g. irritable bowel syndrome and hyperthyroidism

Aetiology:
Acute diarrhea
Its usually associated with constitutional manifestations in the form of fever,
headache and malaise
1) Infective causes:
a) Bacterial: shifella, E.coli, cholera, and food poisoning with staph, salmonella or
clostridium
b) Viral: Rota virus, echo virus and Norwalk virus
c) Protozoal: entameba histolytica, giardia, balantidium coli and malignant malaria
d) Helminthic: ascaris, ankylostoma and strongyloides stercolaris

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 2) Drug-induced:
a) Antibiotic-associated
b) Laxatives
c) Antacids that contain magnesium
d) Opiate withdrawal
3) Food allergies or intolerances:
a) Cow's milk protein allergy
b) Soy protein allergy
c) Multiple food allergies
4) Chemotherapy or radiation-induced enteritis
5) Ingestion of heavy metals or toxins (e.g., copper, tin, zinc)
6) Acute psychological, stress

Chronic diarrhea
The aetiology of this type is better classified according to the pathology as following:

1) Osmotic:
(a) lactose intolerance
(b) Drug-induced: sorbitol and lactulose
2) Secretory:
(a) Hormonal causes: zollinger-ellison syndrome, carcinoid tumor,
thyrotoxicosis
(b) Bile salt: malabsorption, ileal resection
(c) Enterotoxins: cholera

3) Inflammatory: ulcerative colitis, crohns disease, tuberculosis, radiation enteritis,

microscopic colitis
4) Malabsorptive:
(a) Mucosal: celiac disease, eosinophilic gastroentritis
(b) Pancreatic: chronic pancreatitis
(c) Bacterial overgrowth: vagotomy and diverticula
5) Motility disorders: irritable bowel syndrome, diabetes and thyrotoxicosis

N.B. its to be mentioned that the most common complications of diarrhea are
dehydration and electrolyte imbalance.

Clinical approach of a case with diarrhea

Properhistory is mandatory for the diagnosis, the following items should be stressed:
o The duration of the diarrheal attack to determine whether its acute
o The frequency of the attack
o Abdominal pain
o The presence of complications
o Blood, mucus, or pus may be present in the stool when there is damage to the
mucous lining of the intestinal tract.
o History of peptic ulceration: in zollinger-ellison syndrome
o The intake of specific food: as in lactose intolerance and celiac disease
o Drug and radiations therapy history

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 Examination may be normal unless the complicated or the cause may have some signs,
Proper examination has to be done to detect:
o Weight loss
o Fever: in TB, inflammatory bowel diseases
o Neuropathies: in diabetes
o Arthritis: in some cases with inflammatory bowel disease
o The amount. Nature, character of stool: large volume, watery and no relation
to meals in secretory diarrhea, greasy in malabsorption

Investigations:
o In most cases of acute diarrhea, laboratory investigation is unnecessary,
unrevealing, and does not affect treatment or outcome. Microscopic
examination of the stool for leukocytes (white blood cells) distinguishes non-
inflammatory from inflammatory diarrhea. If leukocytes are present, a stool
culture is done to identify the infectious agent. If diarrhea persists for more
than ten days, examinations are done on three consecutive stools to look for
ova or parasites.
o For a case of chronic diarrhea the following should be done:
Therapeutic test:
A diet free of dairy products for 3 weeks will improve a patient
with lactase deficiency
A diet free of wheat for 6 weeks improve a patient with celiac
disease
Broad spectrum antihelminthic
Metronidazole for giardia
A 24-hour stool collection for weight and quantitative fecal fat may be
needed to identify a malabsorption process
stool osmolality may be needed
Routine laboratory tests in the form of complete blood count (CBC),
serum electrolytes, liver function tests, calcium, phosphorus, albumin,
TSH, total T4, beta-carotene, and prothrombin. to diagnose
malabsorption, anemia, and inflammatory diseases include
A sigmoidoscopy with mucosal biopsy is warranted to distinguish
infectious diarrhea from ulcerative colitis.

Treatment:
A. acute diarrhea:
i. usually self-limiting but antibiotics or anti-protozoal according to
culture and sensitivity
ii. fluid and/or electrolyte replacement: oral or parentral according to the
need
iii. loperamide: rarely indicated in severe cases and for short term as it
impairs the clearance of any pathogen from the bowel
B. chronic diarrhea:
i. the treatment is mainly the treatment of the cause

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 ii. correction of fluid deficit and electrolyte imbalances
iii. symptomatic treatment is rarely resorted to

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 References

websites:

http://www.who.int/topics/diarrhoea/en/

http://emedicine.medscape.com/article/928598-clinical

www.medicinenet.com/diarrhea/pag1.htm

http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea

http://www.mayoclinic.com/health/diarrhea/DS00292/DSECTION=cause
s

http://www.nmihi.com/d/diarrhea.htm

Kumar and Clark clinical medicine

current diagnosis and treatment: gastroenterology,hepatology and endoscopy