When a patient comes to the doctor for chronic diarrhea, what causes to think?
What can chronic diarrhea depend on? Are there any medications that cause
chronic diarrhea? How long has diarrhea lasted?
The anamnesis is a fundamental element in the evaluation of the patient
suffering from diarrhea. The duration of the symptomatology may already be an
important element, since it orients and allows to divide the diarrhea into:
- acute diarrhea = discharges for less than 4 weeks;
- chronic diarrhea = discharges and symptoms for more than 4 weeks, but
also months, in general, for six months or more.
In addition, the doctor must ask his patient some questions in order to
reconstruct the patient's clinical history.
The doctor should carefully consider the patient's medical history and ask these
questions: has there been weight loss (severe diarrhea)? Is the patient
hypothesized? Did you lose potassium? (see hypokalemia)? Did you lose volume?
Other questions that must be asked:
- what is the mode of discharges by frequency and type?
If there is blood in the stool, it is necessary to think, that is, to chronic
inflammatory diseases or neoplasia! Or only to hemorrhoidal to a simple
inflammatory proctitis? (see rectorrhagia and melena)
-Is there the presence of mucus, pus, fat, food residues in the stool?
-Are the stools oily (malabsorption syndrome)?
- Are faeces immediately after a meal (for example, for an exaggerated
gastro-colic reflex, as in irritable bowel syndrome)?
- Is there a rectal tenesmus (ie a weight to the rectum and the need to evacuate
as an insatiable, irritating stimulus?) Is there an urgency to evacuate (or I
run away or do it)?
- Does diarrhea wake up the patient at night? So I think about inflammatory
diseases (see Inflammatory Bowel Diseases)
- Does the patient have abdominal pain? Cramps? Flatulence?
- Is there a fever? Does the patient vomit?
- Is he hyperthyroid?
- One patient has taken medication and has diarrhea (for example, many patients
come to me after taking metformin or beta blockers or hydroquinidine)
- The patient takes laxatives and does not know?
- Does he consume laxative waters (cf. Fonte di Venere, Tettuccio water, Acqua
Uliveto)?
- Did you travel abroad? Did you drink spring water outdoors?
- Does it keep water in plastic bottles (!) that takes from fountains around,
even from streams in the mountains?
- He also drank water from my fountain, but I have an autoclave that has been
holding water for a long time and it has never been cleaned, maybe it is without
a lid, on the terrace and we drink the doves.
-Is it affected by celiac disease?
-Do you have lactose intolerance? Does it disturb if you drink fresh milk or
dairy products?
- Does he have a cat and / or a dog at home (has taken toxoplasmosis)? A
patient recently visited by me, had the salmonella who had also contracted the
cat, before her!
After answering these simple questions, the doctor begins to get an idea of
the problem and immediately make a differential diagnosis with irritable bowel
syndrome. This is a disease that affects women more often and among them, the
most sensitive, with anxiety problems, perfectionists who are stressed at work,
have problems at home, and with her husband (!), Especially if they are
hyperthyroid! In these cases diarrhea is an expression of the internal
discomfort that occurs with irritable bowel, and then borborigmi, evacuations
after the meal, urgency to go to evacuate, pains and cramps in the abdomen,
especially in the left iliac fossa, sometimes after taking drinks cold or a
simple ice cream or just some milk in the morning, or a pizza in the evening,
even if it was a simple daisy, maybe with a sip of coca-cola and immediately
warn "today the colic (!)", those colic that put in embarrassment especially if
to invite them to dinner was the boyfriend and that was the first exit! I have
successfully treated a lady, whom I have returned several times, even without
making me pay, of course, to reassure her, until finding the solution in the
cure, prescribing as well as antispasmodic and regulators of gastrointestinal
motility, also anti-depressants and mild sedatives ! If, on the other hand, the
blood appears in the stool, there is a sensation of a weight in the rectum (rectal
tenesmus), if the stools are voluminous, even 400 g / day, if the ferritin is
low, if the sideremia has fallen, if PCR and ESR are elevated, I no longer think
of irritable bowel syndrome, but a specific pathology of the digestive tract,
usually an intestinal inflammatory disease, which can begin with a
proct-sigmoiditis. And if instead it was a patient suffering from a villous
cancer adenoma to the right parts of the colon?
Infections
Bacteria
Virus
Protozoa
Multi-cell parasites
Food poisoning
Food allergy, with high IgE and specific food intolerances, or lactase
deficiency and intolerance to fresh dairy products,
or strawberries, proteins of fish, eggs, crustaceans etc.
drugs:
antibiotics, almost all
anti-inflammatories, e.g. NSAIDs, gold derivatives, 5-aminosalicylates
antihypertensive, e.g. beta blockers.
metformin
colchicine
prostaglandins
theophylline
antiarrhythmics, e.g. hydroquinidine
herbal products, various teas
Heavy metals
Watery diarrhea
Osmotic diarrhea
osmotic laxatives such as magnesium and sulphate, phosphate
secretory diarrhea
congenital syndrome with chloriddorrea
malabsorption of bile acids
inflammatory bowel diseases
diverticulitis
vasculitis
drugs
abuse of laxatives
diabetes diarrhea
autonomic neuropathy
irritable bowel syndrome
Endocrine diarrhea
hyperthyroidism
addison disease
gastrinoma
vipoma
somatostatinoma
carcinoid syndrome
medullary thyroid carcinoma
pheochromocytoma
colon tumors
lymphoma
villous adenoma
Chronic inflammatory disease
Ulcerative colitis
Crohn's disease
diverticulitis
digiunoileite
pseudomembranous colitis
invasive bacterial infections ex. tuberculosis
viral cytomegalovirus infections, herpes simplex
parasitic infections, amoebas, strongyloides
ischemic colitis
ray colitis
colon carcinoma
lymphoma
Whipple
Short bowel syndrome
Bacterial proliferation
Mesenteric ischemia
Pancreatic insufficiency
Celiac disease
The patient is always the best doctor of himself and will be able to direct us towards the right diagnosis if we have known how to listen to him. Clinical signs, therefore, are useful for establishing the etiology of a diarrhea. It is necessary to evaluate the hydration of the subject, to evaluate his blood pressure, through the proof of orthostatism; check the tongue if it is dry and impatient, if the pressure and the consistency of the eyeballs is reduced, evaluating it with the simple digito-pressure; it is still necessary to evaluate if the abdomen is treatable, if there is the sign of Murphy, or rather the abdominal pain pertaining to the chirp (cfr abdominal pain surgical abdominal pain); it has been evaluated whether peristalsis is present, if there is abdominal distension, if there is hepatosplenomegaly and orthostatic hypertension we think of amylodosis, in which the liver and parenchyma are filled with amyloid substance; if there are changes in the skin we think of mastocytosis, glucagonoma, Addison's disease, carcinoid syndrome, degos and celiac disease. The presence of multinodular goiter and blocked TSH orientate for hyperthyroidism associated with hyperperistaltism and diarrhea, with suspicion of medullary thyroid carcinoma or thyroid adenoma. In chronic intestinal inflammatory diseases, in Whipple's disease it is possible to find signs of arthritis, presence of lymphadenopathy and AIDS or of lymphoma. Are there food intolerances? Are there IgE increased, expression of food allergies? Still at the blood count, is there a high white blood cell count? If yes, we think of bacterial infection, if not viral infection; in salmonellosis, however, neutropenia is always present. Have we evaluated the electrolytes? Are they normal, is potassium adequate? Did we do the copracultural exam? The serodiagnodes of Vidal and Wright, for the research of salmonella and shighelle? The ELISA test for giardiasis? The search for eggs and parasites in the feces? Has the patient been treated with broad-spectrum antibiotic therapy? Is there bloody diarrhea? Is the patient suffering from AIDS? So it is good to perform a colonoscopy and think of lymphomas that can be found on the ascending colon. If the patient is a subject with faecal discharges of 4-5 times / day, mucous and bloody, then at the colonoscopy if we see ulcerated lesions, we think of the RCU and Crohn's disease; it will be opportune to perform targeted biopsies and wait for the diagnosis of the anatomopathologist.
On the stool are to be searched:
- Osmolality
- Fecal pH: provides information about malabsorption of carbohydrates, which are
fermented with the production of short-chain fatty acids.
- occult blood: neoplasia, inflammation with serum-mucous and hematic exudate,
only hemorrhoids
- leukocytosis
- fecal lactoferrin
- fats with the coloring of sudan: if> 10%, then insufficiency of the pancreas
-measurement of faecal electrolytes and osmotic gap.
The parameter is calculated by subtracting twice the sodium and potassium concentration from 290 mosm / kg. When the osmotic gap is limited (<50 mosm / kg) the osmolality of faecal water is mainly linked to electrolytes (especially sodium, potassium and associated anions), indicating that in the stool there is excess water due to a incomplete electrolyte absorption, indicating secretory diarrhea. When the osmotic gap is important, then the fecal osmolality is due to the presence of some poorly absorbed substance.
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