Investigation Of Chronic Diarrhoea Research Articles

Differential diagnosis and investigation of chronic diarrhea

Chronic diarrhea is defined by a decrease in stool consistency and a bowel frequency of more than 3 times per day, lasting for at least 4 weeks. Multiple underlying causes may be responsible for chronic diarrhea. There are four main pathomechanisms for chronic diarrhea: osmotic diarrhea, secretory diarrhea, infectious diarrhea and bowel dysmotility. Overlaps between these mechanisms may exist. A stool collection over a 72-hour period frequently allows to classify diarrhea into one of these four entities. Such classification finally helps for the identification of underlying cause(s), thereby allowing rational diagnostic measures. It also limits the costs of diagnostic workup. This article aims to present the main causes of chronic diarrhea, the diagnostic steps to perform and to provide a guideline for clinicians in daily practice.

The investigation of chronic diarrhoea: new BSG guidance.

Chronic diarrhoea has an estimated prevalence of about 4–5% in Western populations and is one of the most common reasons for gastroenterology referral.1 There is a myriad of causes for chronic diarrhoea, which can make the investigation and diagnosis of the underlying cause difficult. In 2003, the British Society of Gastroenterology (BSG) released guidelines2 to aid in the investigation of chronic diarrhoea; however, these have since been updated, in April 2018. Below, we provide a brief and focused summary of the new 2018 guidelines1 for primary care, highlight the new changes compared with the 2003 edition, and discuss some limitations of the new guidance. Initial investigations in primary care are aimed at differentiating organic gastrointestinal (GI) disease from functional disease. Routine, screening blood tests are recommended in all patients presenting with chronic diarrhoea, and these include full blood count, ferritin, c-reactive protein, coeliac serology, and thyroid function tests. Faecal calprotectin (FCP) is now recommended as a screening tool to detect inflammatory causes of chronic diarrhoea, and stool cultures remain useful in distinguishing infection from other inflammatory causes of chronic diarrhoea. Faecal immunochemical testing (FIT) is a new method of detecting the presence of blood in faeces and can be used instead of the traditional faecal occult blood test (FOBT) where available. In general, for patients with typical symptoms of functional bowel disease, normal physical examination, and normal screening investigations, a diagnosis of IBS can be made. However, referral should be considered for those with abnormal screening investigations or persistent symptoms that impact the quality of life and do not respond …

The role of fecal markers in the investigation of patients with chronic diarrhea.

Chronic diarrhea often presents a dilemma for a practicing clinician as to whether an endoscopic evaluation would be necessary. The current application of colonoscopy-for-most approach increases the burden on the endoscopy services and is associated with higher costs. Therefore, there is a need for newer tools which are cost-effective, less invasive, and easily accessible, in order to triage patients referred for endoscopic evaluation. In this context, fecal markers are becoming considered as triage tools in clinical practice. Emerging evidence in support of their high performance will certainly influence future practice.

Pathophysiology of diarrhoea

Diarrhoea results when there is loss of the dynamic and finely balanced absorption and secretion of water and electrolytes within the gut. Diarrhoea remains a major cause of morbidity and mortality worldwide and it is important for those who care for children to have a clear understanding of the pathophysiology of diarrhoea. Diarrhoea can be considered to be either osmotic or secretory. Osmotic diarrhoea occurs when excessive osmotically active particles are present in the lumen, resulting in more fluid passively moving into the bowel lumen down the osmotic gradient. Secretory diarrhoea occurs when the bowel mucosa secretes excessive amounts of fluid into the gut lumen, either due to activation of a pathway by a toxin, or due to inherent abnormalities in the enterocytes. The management of acute diarrhoea is based on assessment of fluid balance of the child and rehydration. Oral rehydration solution is extremely effective and has significantly reduced childhood mortality from acute infective diarrhoea over the past 40 years. Chronic diarrhoea has a number of infective and non-infective causes, careful history and specific investigation and management in secondary or tertiary care is often necessary. This update contains new details on the investigation of chronic diarrhoea and in particular use of imaging, the ‘non-GI’ causes of diarrhoea, updates on the changing prevalence of infective pathogens and research into the use of probiotics.

Investigation of chronic diarrhoea

Abstract Chronic diarrhoea occurs, by definition, when there is an excessive intestinal loss of water and electrolytes with increased stool frequency, reduced consistency and larger volume over more than 14 days. While in developing countries often resulting from persisting infectious gastroenteritis in high incidence, in industrialized countries chronic diarrhoea is mainly related to anatomical, functional, and immunological causes. As the spectrum of aetiology is variable, flow charts for different age groups are useful in determining key features of disease severity and diagnostic criteria. The knowledge of common and rare aetiologies enables a structured approach to investigation, and facilitates critical interpretation of results in awareness of diagnostic pitfalls. Comprehensive history, physical examination, inspection and collection of stool samples of sufficient volume are pivotal to devise appropriate referral modes for diagnostic and therapeutic management, as particularly newborn and infants are susceptible to severe dehydration and metabolic disturbances.

PTU-065 Is There A Role For Faecal Calprotectin In The Investigation Of Diarrhoea In Patients With Hiv?

IntroductionDiarrhoea is the most common gastrointestinal symptom in patients with HIV. Faecal calprotectin (FCP) is a useful test in the investigation of chronic diarrhoea in the general population.1 The sensitivity...

The British Society of Gastroenterology guidelines for the investigation of chronic diarrhoea, 2nd edition

The prevalence of chronic diarrhoea has been estimated at 4-5% in Western populations and is one of the most common reasons for referral to a gastroenterological clinic. Investigation of patients was rationalized in 2003 with the publication by the British Society of Gastroenterology of guidelines for the investigation of chronic diarrhoea. The guidelines may also be viewed at www.bsg.org.uk/clinical_prac/guidelines/chronic_diarr.htm.

Microscopic colitis: an underdiagnosed cause of chronic diarrhoea--the clue is in the biopsies.

Microscopic forms of colitis (collagenous colitis and lymphocytic colitis) are uncommon but important causes of chronic diarrhoea that are often overlooked. The clinical features of these disorders are similar, and they are more common in middle-aged females, although the female predominance is greater in collagenous colitis. Although their cause is unclear, both are associated with a variety of autoimmune diseases. Colonoscopy and barium enema are typically normal, so that the diagnosis depends on the demonstration of characteristic changes on histopathological examination of colorectal biopsies. These should be taken in all patients undergoing colonoscopy for the investigation of chronic diarrhoea. There are no large controlled trials of therapy available. Treatment is empirical, generally using the same agents as for inflammatory bowel -disease. Assessment of therapy is also difficult as spontaneous remissions occur often.

780 The value of colonoscopic and ileoscopic biopsies in the investigation of chronic diarrhoea

Introduction Colonoscopy is advocated in the investigation of chronic diarrhoea. Previous studies have supported the use of routine colonoscopic biopsy in those with normal endoscopic appearances. We assessed the additional value of colonic and ileal biopsies compared with endoscopy alone in the investigation of a cohort of patients with chronic diarrhoea attending a tertiary referral centre. Methods A retrospective search of the endoscopy database was carried out, amongst patients that underwent colonoscopy, ileoscopy, colonic and ileal biopsies in the investigation of chronic diarrhoea. The histological reports from all biopsies were then retrieved, and the data examined. Results 40 endoscopy and histology reports were reviewed and compared. There were 23 males and 17 females in the group, the age range was 6-77 years. 31 had normal endoscopic appearances. Discussion Seven out of 40 (17.5%) had abnormal colonic or ileal histology with normal endoscopic appearances. These data support the use of routine colonic and ileal biopsy in the investigation of patients with chronic diarrhoea and normal colonoscopy.

Prognosis of Adult-Onset Idiopathic Bile Acid Malabsorption

Background: From 1986 to 1993, 150 patients were investigated with the 75Se-homocholic acid taurine (SeHCAT) test as a late step in the investigation of chronic diarrhoea. On basis of low SeHCAT values and response to cholestyramine treatment, 33 patients were initially classified as having idiopathic bile acid malabsorption (IBAM). The aim was to describe the long-term clinical course of the disease and to assess the reliability of the SeHCAT test in diagnosing IBAM. Methods: The methods included 1) clinical follow-up with patient interview combined with information from medical records and 2) repeated SeHCAT test. Results: The diagnosis of IBAM had to be revised in three cases (inflammatory bowel disease in two patients, Clostridium difficile infection in one). Six patients were lost to follow-up and a further four patients were excluded from re-examination either because of old age (>80 years) or bowel resection, leaving 20 patients for re-examination, of which 16 completed both clinical follow-up and a new SeHCAT test. The median duration of symptoms before initial SeHCAT test was 2.5 (1-30) years. In 13 of 16 patients symptoms persisted, and SeHCAT values remained low and almost identical to the initial value after a median observation time of 88 (51-113) months. Despite initial response to treatment with cholestyramine, six patients had to discontinue treatment because of adverse effects or other compliance problems. In three patients the SeHCAT value showed a considerable increase, and bowel function had correspondingly normalized in these cases. Conclusion: The study confirms the reliability of the SeHCAT test in diagnosing IBAM. Despite adult onset of symptoms, only a few patients improve after several years' observation. Treatment with cholestyramine is generally effective but not always tolerated.

Investigation of chronic diarrhoea in acquired immunodeficiency syndrome. A prospective study of 155 patients.

The optimum diagnostic investigation for patients with acquired immunodeficiency syndrome (AIDS) and diarrhoea is not known. Often no pathogen is detected and it is unclear whether this is because pathogens are absent in some patients or the investigations used fail to detect them. The hypothesis that AIDS related diarrhoea is usually due to an infection, which can be identified by a simple diagnostic strategy based on the results of intensive investigation of a cohort of such patients, was investigated. 155 patients with AIDS and chronic diarrhoea underwent contemporaneous examination of stools, duodenal, jejunal, and rectal biopsy specimens and duodenal aspirate for bacterial, protozoal, and viral pathogens. A decision tree analysis was used to determine the best sequential diagnostic strategy for clinicians. 128 of 155 patients investigated (83%) had at least one potential pathogen. The presenting clinical features could not predict the presence or site of the pathogens. Stool analysis identified the most pathogens (93 of 199, 47%). Rectal biopsy was essential for the diagnosis of cytomegalovirus and adenovirus. Duodenal biopsy was as helpful as jejunal biopsy and detected some treatable pathogens missed by other methods. Electron microscopy, impression smears, and duodenal aspirate yielded little extra information. If gut biopsy was reserved for patients without a stool pathogen, some treatable pathogens would have been missed. Most patients with AIDS and chronic diarrhoea have at least one gut pathogen, which can be identified by stool analysis and light microscopic examination of duodenal and rectal biopsies. Some pathogens will be missed unless all these investigations are done on all such patients.

Investigation of chronic diarrhoea

Chronic diarrhoea may be best defined as a parental perception of persistently increased looseness and frequency of stools, as this is the problem which presents itself to the paediatrician. A knowledge of the normal patterns of bowel action in children is essential to enable the paediatrician to decide whether true diarrhoea is present. In the infant, up to one bowel action per feed may be regarded as normal, and the consistency may often be semi-liquid. This is particularly so in breast fed infants who tend to have softer, more frequent, less malodorous, and more acidic stools than their bottle-fed counterparts. In the older child, four or more loose stools per day may be considered to be abnormal, though less frequent and markedly loose stools may also be abnormal. At this point, it is convenient to differentiate the problem into one of the following clinical entities: (4 (b) (cl spurious diarrhoea resulting from chronic constipation with overflow incontinence; protracted diarrhoea, associated with failure to thrive or other symptoms; chronic non-specific diarrhoea of infancy or childhood, associated with good growth (often called toddler diarrhoea).

La clairance de l'alpha-1-antitrypsine dans les diarrhées chroniques et les hypoalbuminémies

Intestinal clearance of alpha-1-antitrypsin appears to be a good test in the investigation of chronic diarrhea and hypoprotid˦mia of obscure origin. In 8 of 30 patients, it was the only fecal test to be abnormal.