Diarrhea
Definition
? increase in the frequency of bowel
movements
? increase in stool liquidity
? in some cases increase in daily stool weight
(>200g/d)
Pathophysiological mechanisms
? secretory diarrhea (increased intestinal
secretion)
? Osmotic diarrhea
? Decreased intestinal surface area and/or
intestinal absorption
? Rapid transit of intestinal contents (shortened
transit time)
Pathophysiological mechanisms
? secretory diarrhea (increased intestinal
secretion)
? infections (cholera toxin,E-col,salmonella,
staphylococcal)
? Hormonal (Gut Hormones,ZES,VIP),
cancer (calcitonin,Prostaglandins)
? miscellaneous (laxatives abuse,villous
adenoma of the rectum)
agents Adenylate cyclase cAMP system secretory
diarrhea
active NaCl?
Pathophysiological mechanisms
? Osmotic diarrhea
It caused by accumulation of the followings in
the gut lumen
water
salts
poorly absorble solutes
maldigestion of ingested food
failure to transport an osmotically
active dietary nonelectrolyte
(E,glucose)
intestinal Lumen
being osmotically active
diarrhea
Causes of diarrhea in enteral nutrition
Pathophysiological mechanisms
? Decreased intestinal surface area
and/or intestinal absorption
E,surgical removal; malabsorption
syndrome
Pathophysiological mechanisms
? Rapid transit of intestinal contents (shortened
transit time)
E,irritable bowel syndrome [Functional diarrhea]
laxatives abuse
post vagotomy diarrhea
post gastrectomy dumbing syndrome
stool
volume
liquidity contact time? increase small bowel mucosa
contents
increase in intestinal motility (intestinal hurry)
reduce
Calculation of osmotic gap
Etiology
Acute Diarrhea
? infection
? Food poisoning
? Systematic diseases (influenza,sepsis,
measle,etc)
? Miscellanous
Etiology
Acute Diarrhea
? infection
(A) viral
(B) bacterial
? campylobacteria
? Shigella
? E,Coli
? Salmoneila
? etc
(C) fungal
(D) parasitic (amebic Trophozoites,Giardia)
? Food poisoning
? bacterial,plants,chemical poison(arsenic,...)
? Systematic diseases (influenza,sepsis,
measle,etc)
? Miscellanous
? Allergic diseases
Allergic purpura,enteropathy.,
? endocronic diseases (ZES,etc.)
? Drugs,laxatives,5-Fu,etc,
Etiology
Chronic Diarrhea
? Intestinal
? Gastric(chronic gastritis,subtotal gastrectomy,
etc.)
? Pancreatic (Chronic Pancreatitis,Pancreatic
Cancer,etc.)
? Hepatobiliary(liver cirrhosis,obstructive
jaundice)
? Endocronic (Hyperthyroids crisis,ZES,
Carcinoids)
? Drugs (Reserpin,Ismelin,Laxatives,etc.)
? Others (uremia,hypogammaglobulemia,etc.)
Chronic Diarrhea
? Intestinal
? infections(T.B.,Chronic bacteria dysentery,
etc.)
? parasitics (Amebia dysentery,Giardiasis,
etc.)
? IBD (ulcerative colitis,Chron’s,etc.)
? malabsorption synd,(lactase deficiency,etc.)
? tumors
Mechanisms and causes of secretory
diarrhea
T A B L E 4 - 6, M E C H A N I S M S A N D C A U S E S O F S E C R E T O R Y D I A R R H E A
R e d u c t io n i n m u c o s a l s u r f a c e a r e a
P o s t r e s e c t i o n d i a r r h e a
S h o r t - b o w e l s y n d r o m e
E x t e n s i v e m u c o s a l d is e a s e a n d I n f l a m m a t i o n
V i r a l g a s t r o e n t e r i t is
C e l i a c d is e a s e
W h i p p l e ' s d is e a s e
C r o h n ' s d is e a s e
L y m p h o m a
A b s e n c e o f i o n t r a n s p o r t m e c h a n is m
C o n g e n i t a l c h l o ri d o r rh e a
B a c t e r i a l t o x i n s
C h o l e r a
E n t e r o t o x i g e n i c E s c h e r i c h i a c o l i
S h i g e l l a
S t a p h y l o c o c c u s
C l o s t r i d i u m p e r f r in g e n s
L u m i n a l s e c r e t a g o g u e s
B i l e a c i d s
F a t t y a c i d s,h y d r o x y - f a t t y a c i d s
P h e n o l p h t h a l e i n,r i c i n o l e i c a c i d,b is a c o d y l
C i r c u la t i n g s e c re t a g o g u e s
G a s t r i n ( Z o l l i n g e r - E l l is o n s y n d r o m e )
V a s o a c t i v e i n t e s t i n a l p o l y p e p t i d e ( V I P o m a,g a n g l i o n e u ro m a,n e u ro b la s t o m a,p h e o c h r o m o c y t o m a )
C a l c i t o n i n,p r o s t a g l a n d in s ( m e d u ll a r y c a r c i n o m a o f t h e t h y r o i d )
S o m a t o s t a t i n (s o m a t o s t a t in o m a )
G l u c a g o n ( g l u c a g o n o m a )
S e r o t o n i n,k i n i n s ( c a r c i n o i d t u m o r )
T h y r o x i n e ( h y p e r t h y r o i d i s m )
H i s t a m i n e ( m a s t o c y t o s is )
D r u g s a n d p o is o n s
M i s o p r o s t o l
O l s a l a z i n e
C o l c h i c i n e
P r o p r a n o l o l
Q u i n i d i n e
H e a v y m e t a l s
A b n o r m a l c i r c u la t i o n
R a d i a t i o n e n t e r i t is
M e s e n t e r i c is c h e m ia
M e s e n t e r i c v e n o u s t h r o m b o s is
L y m p h a n g ie c t a s i a
D is o r d e r e d r e g u la t i o n
P o s t v a g o t o m y d i a r r h e a
P o s t s y m p a t h e c t o m y
Endoscopic image,infectious colitis in 7-
year-old girl
Cholera,the simplified version
Symptoms
Acute diarrhea
duration less than 2 weeks
? onset,
Abrupt frequent,small fecal discharge
Cramping abdominal pain,tenesmuse
? stool,increased
Routin Ex
? severe cases,dehydration,electrolyte disturbances,
metabolic acidosis,collapse hypovolumia,tetany,
Symptoms
volume
liquidity
flecks of blood,mucus
WBC,RBC,pus,
destroyed epithelium
Symptoms
Chronic diarrhea
duration more than 2 months
Symptoms
? Onset,
gradual/insidious
Diarrhea of variable severity
Diarrhea alternate with constipation
Colicky abdominal pain,distention
? stool
watery,bloody,steatorrhea
contains,
inflammatory cells/mucus/pus/indigested food
? severe/long-standing cases,
weight loss,malnutrition,edema,multy vits
deficiency,malabsorption,wasting,edema,
bone pain
Accompanied Symptoms
? severe dehydration
(cholera,pancreatic cholera-WDHA,etc.)
? fever
(Acute bacillery dysentery,Typhoid,TB enteritis,etc.)
? tenesmus (Acute dysentery,proctitis,etc.)
? markedly weight loss
(cancer of gut,malabsorption,etc.)
? Arthralgia/Arthritis
(IBD,connective tissue diseases,etc.)
? masses (malignant cancer of GI,TB,peritonitis,etc.)
Diagnostic Procedures
Information
P.E,Findings
fever,dehydration,malnutrion,anemia,
ulticaria,jaundice,arthralgia,abdominal
masses,Tenesmus,digital rectal examination,
Lab findings
Diagnostic Procedures
information
? in epidemics (Dysentery,v,Cholerae,Typhoid,
food poisonning,enteritis)
? food allergy
? past illness(antibiotic related diarrhea,etc.)
? medication take(corticosteroids,laxatives,etc.)
? predisposing conditions (surgical resection,
parasitic infection,etc.)
Lab findings
?Blood
?Urine
?Stool
?Microscopy
?Tolerance tests
?Breath tests
?Culture of Jejunal aspirates
?5 HIAA (urinary excretion)
?Vit B12 absorption test
?X-ray Barium
?Endoscopy
?Suction biopsy technique (Jejunal
mucosa histology
? blood
? RBC
? WBC
? Culture
? Specific Antigen/Antibody (widal test,etc.)
? Serum testings
(carotin/iron,Ferritin/albumin/folic acid)
(vitB12/glucose/gut hormone/Ca2+,K+,Cl-,
Na+)
Lab findings
Lab findings
? Urine
? Protein
? cast
? Stool
? appearance
(watery,bloody,bulky,sticky,
malodorous,steaterrhea,
foul-smelling)
Lab findings
? Microscopy
RBC,WBC
polymorphonuclear (PMN):Shigella,solmonella,
E coli
mononuclear (M)
motile amebic trophozoites
? Gram’s stain (+) staphylococcal enteritis
? Culture,salmonolla,shigella,v,cholera
? Fat determination
Lab findings
? Tolerance tests
? (d-xylose; Glucose/lactose/sucrose)
? Breath tests
? 14C Glycine-cholate,xylose
? Culture of Jejunal aspirates
? (Bacterial overgrowth)
? (increased Bile and deconjugation)
? 5 HIAA (urinary excretion)
? Vit B12 absorption test
Lab findings
? X-ray Barium
? meal
? enema
? Endoscopy
? Duodenoscopy (ERCP)
? Colonoscopy
? Sigmoidoscopy
? Suction biopsy technique (Jejunal
mucosa histology)
Definition
? increase in the frequency of bowel
movements
? increase in stool liquidity
? in some cases increase in daily stool weight
(>200g/d)
Pathophysiological mechanisms
? secretory diarrhea (increased intestinal
secretion)
? Osmotic diarrhea
? Decreased intestinal surface area and/or
intestinal absorption
? Rapid transit of intestinal contents (shortened
transit time)
Pathophysiological mechanisms
? secretory diarrhea (increased intestinal
secretion)
? infections (cholera toxin,E-col,salmonella,
staphylococcal)
? Hormonal (Gut Hormones,ZES,VIP),
cancer (calcitonin,Prostaglandins)
? miscellaneous (laxatives abuse,villous
adenoma of the rectum)
agents Adenylate cyclase cAMP system secretory
diarrhea
active NaCl?
Pathophysiological mechanisms
? Osmotic diarrhea
It caused by accumulation of the followings in
the gut lumen
water
salts
poorly absorble solutes
maldigestion of ingested food
failure to transport an osmotically
active dietary nonelectrolyte
(E,glucose)
intestinal Lumen
being osmotically active
diarrhea
Causes of diarrhea in enteral nutrition
Pathophysiological mechanisms
? Decreased intestinal surface area
and/or intestinal absorption
E,surgical removal; malabsorption
syndrome
Pathophysiological mechanisms
? Rapid transit of intestinal contents (shortened
transit time)
E,irritable bowel syndrome [Functional diarrhea]
laxatives abuse
post vagotomy diarrhea
post gastrectomy dumbing syndrome
stool
volume
liquidity contact time? increase small bowel mucosa
contents
increase in intestinal motility (intestinal hurry)
reduce
Calculation of osmotic gap
Etiology
Acute Diarrhea
? infection
? Food poisoning
? Systematic diseases (influenza,sepsis,
measle,etc)
? Miscellanous
Etiology
Acute Diarrhea
? infection
(A) viral
(B) bacterial
? campylobacteria
? Shigella
? E,Coli
? Salmoneila
? etc
(C) fungal
(D) parasitic (amebic Trophozoites,Giardia)
? Food poisoning
? bacterial,plants,chemical poison(arsenic,...)
? Systematic diseases (influenza,sepsis,
measle,etc)
? Miscellanous
? Allergic diseases
Allergic purpura,enteropathy.,
? endocronic diseases (ZES,etc.)
? Drugs,laxatives,5-Fu,etc,
Etiology
Chronic Diarrhea
? Intestinal
? Gastric(chronic gastritis,subtotal gastrectomy,
etc.)
? Pancreatic (Chronic Pancreatitis,Pancreatic
Cancer,etc.)
? Hepatobiliary(liver cirrhosis,obstructive
jaundice)
? Endocronic (Hyperthyroids crisis,ZES,
Carcinoids)
? Drugs (Reserpin,Ismelin,Laxatives,etc.)
? Others (uremia,hypogammaglobulemia,etc.)
Chronic Diarrhea
? Intestinal
? infections(T.B.,Chronic bacteria dysentery,
etc.)
? parasitics (Amebia dysentery,Giardiasis,
etc.)
? IBD (ulcerative colitis,Chron’s,etc.)
? malabsorption synd,(lactase deficiency,etc.)
? tumors
Mechanisms and causes of secretory
diarrhea
T A B L E 4 - 6, M E C H A N I S M S A N D C A U S E S O F S E C R E T O R Y D I A R R H E A
R e d u c t io n i n m u c o s a l s u r f a c e a r e a
P o s t r e s e c t i o n d i a r r h e a
S h o r t - b o w e l s y n d r o m e
E x t e n s i v e m u c o s a l d is e a s e a n d I n f l a m m a t i o n
V i r a l g a s t r o e n t e r i t is
C e l i a c d is e a s e
W h i p p l e ' s d is e a s e
C r o h n ' s d is e a s e
L y m p h o m a
A b s e n c e o f i o n t r a n s p o r t m e c h a n is m
C o n g e n i t a l c h l o ri d o r rh e a
B a c t e r i a l t o x i n s
C h o l e r a
E n t e r o t o x i g e n i c E s c h e r i c h i a c o l i
S h i g e l l a
S t a p h y l o c o c c u s
C l o s t r i d i u m p e r f r in g e n s
L u m i n a l s e c r e t a g o g u e s
B i l e a c i d s
F a t t y a c i d s,h y d r o x y - f a t t y a c i d s
P h e n o l p h t h a l e i n,r i c i n o l e i c a c i d,b is a c o d y l
C i r c u la t i n g s e c re t a g o g u e s
G a s t r i n ( Z o l l i n g e r - E l l is o n s y n d r o m e )
V a s o a c t i v e i n t e s t i n a l p o l y p e p t i d e ( V I P o m a,g a n g l i o n e u ro m a,n e u ro b la s t o m a,p h e o c h r o m o c y t o m a )
C a l c i t o n i n,p r o s t a g l a n d in s ( m e d u ll a r y c a r c i n o m a o f t h e t h y r o i d )
S o m a t o s t a t i n (s o m a t o s t a t in o m a )
G l u c a g o n ( g l u c a g o n o m a )
S e r o t o n i n,k i n i n s ( c a r c i n o i d t u m o r )
T h y r o x i n e ( h y p e r t h y r o i d i s m )
H i s t a m i n e ( m a s t o c y t o s is )
D r u g s a n d p o is o n s
M i s o p r o s t o l
O l s a l a z i n e
C o l c h i c i n e
P r o p r a n o l o l
Q u i n i d i n e
H e a v y m e t a l s
A b n o r m a l c i r c u la t i o n
R a d i a t i o n e n t e r i t is
M e s e n t e r i c is c h e m ia
M e s e n t e r i c v e n o u s t h r o m b o s is
L y m p h a n g ie c t a s i a
D is o r d e r e d r e g u la t i o n
P o s t v a g o t o m y d i a r r h e a
P o s t s y m p a t h e c t o m y
Endoscopic image,infectious colitis in 7-
year-old girl
Cholera,the simplified version
Symptoms
Acute diarrhea
duration less than 2 weeks
? onset,
Abrupt frequent,small fecal discharge
Cramping abdominal pain,tenesmuse
? stool,increased
Routin Ex
? severe cases,dehydration,electrolyte disturbances,
metabolic acidosis,collapse hypovolumia,tetany,
Symptoms
volume
liquidity
flecks of blood,mucus
WBC,RBC,pus,
destroyed epithelium
Symptoms
Chronic diarrhea
duration more than 2 months
Symptoms
? Onset,
gradual/insidious
Diarrhea of variable severity
Diarrhea alternate with constipation
Colicky abdominal pain,distention
? stool
watery,bloody,steatorrhea
contains,
inflammatory cells/mucus/pus/indigested food
? severe/long-standing cases,
weight loss,malnutrition,edema,multy vits
deficiency,malabsorption,wasting,edema,
bone pain
Accompanied Symptoms
? severe dehydration
(cholera,pancreatic cholera-WDHA,etc.)
? fever
(Acute bacillery dysentery,Typhoid,TB enteritis,etc.)
? tenesmus (Acute dysentery,proctitis,etc.)
? markedly weight loss
(cancer of gut,malabsorption,etc.)
? Arthralgia/Arthritis
(IBD,connective tissue diseases,etc.)
? masses (malignant cancer of GI,TB,peritonitis,etc.)
Diagnostic Procedures
Information
P.E,Findings
fever,dehydration,malnutrion,anemia,
ulticaria,jaundice,arthralgia,abdominal
masses,Tenesmus,digital rectal examination,
Lab findings
Diagnostic Procedures
information
? in epidemics (Dysentery,v,Cholerae,Typhoid,
food poisonning,enteritis)
? food allergy
? past illness(antibiotic related diarrhea,etc.)
? medication take(corticosteroids,laxatives,etc.)
? predisposing conditions (surgical resection,
parasitic infection,etc.)
Lab findings
?Blood
?Urine
?Stool
?Microscopy
?Tolerance tests
?Breath tests
?Culture of Jejunal aspirates
?5 HIAA (urinary excretion)
?Vit B12 absorption test
?X-ray Barium
?Endoscopy
?Suction biopsy technique (Jejunal
mucosa histology
? blood
? RBC
? WBC
? Culture
? Specific Antigen/Antibody (widal test,etc.)
? Serum testings
(carotin/iron,Ferritin/albumin/folic acid)
(vitB12/glucose/gut hormone/Ca2+,K+,Cl-,
Na+)
Lab findings
Lab findings
? Urine
? Protein
? cast
? Stool
? appearance
(watery,bloody,bulky,sticky,
malodorous,steaterrhea,
foul-smelling)
Lab findings
? Microscopy
RBC,WBC
polymorphonuclear (PMN):Shigella,solmonella,
E coli
mononuclear (M)
motile amebic trophozoites
? Gram’s stain (+) staphylococcal enteritis
? Culture,salmonolla,shigella,v,cholera
? Fat determination
Lab findings
? Tolerance tests
? (d-xylose; Glucose/lactose/sucrose)
? Breath tests
? 14C Glycine-cholate,xylose
? Culture of Jejunal aspirates
? (Bacterial overgrowth)
? (increased Bile and deconjugation)
? 5 HIAA (urinary excretion)
? Vit B12 absorption test
Lab findings
? X-ray Barium
? meal
? enema
? Endoscopy
? Duodenoscopy (ERCP)
? Colonoscopy
? Sigmoidoscopy
? Suction biopsy technique (Jejunal
mucosa histology)
