chronic diarrhea kuliah 06

8/9/2019 Chronic Diarrhea Kuliah 06

1/27

Chronic Diarrhea Erwin Budi Cahyono


2/27

Defnition o chronic diarrhea

• Diarrhea that lasts for more

than 2 weeks

• The most reliable assesment : stool weight > 200 gram/day


3/27

PathophysiologyPathophysiology

• oorly absorbable• !"ti#e ion se"retion

• Deranged intestinal motility• !ltered mu"osal mor$hology• %is"ellaneous


4/27

Classifcation o chronic diarrheaor clinical used

• &teatorrhea• 'atery diarrhea

( that res$ond to fast

( that may or may not res$ond to fast

( that not res$ond to fast• )nflammatory diarrhea


5/27

Steatorrhea ( Malabsorptivedisease )

• )ntraluminal maldigestion

Cirrhosis and bile du"t obstru"tion

Ba"terial o#ergrowth

a"reati" e*o"rine insuffi"ien"y

• %u"osal malabsor$tion Drug )nfe"tious diseases

)mmune system diseases

Tro$i"al s$rue

Colia" s$rue

Dermatitis her$etiformis

'hi$$le+s disease

!betali$o$roteinemia


6/27

Steatorrhea

• ost mu"osal obstru"tion

)ntestinal lym$hangie"tasis

• %i*ed "auses of steatorrhea

&hort bowel syndrome


7/27

Watery diarrhea, respond to ast

• maldigestion

• Carbohydrate malabsor$tion

• Bile a"id diarrhea

• ost#agotomy diarrhea


8/27

Watery diarrhea, may or may notrespond to ast

• )rritable bowel syndrome

• ,ood allergy

• %i"ros"o$i" "olitides

Collagenous and mi"ros"o$i" "olitis

eri"ry$t eosino$hili" entero"olitis


9/27

Watery diarrhea, do not respond toast ( Secretory )

• Carcinoid syndrome

• Gastrinoma

• Vipoma ( pancreatic cholera syndrome )

• Medullary carcinoma of the thyroid• Glucagonoma

• Villous adenoma

• Systemic mastocytosis

• Factitious diarrhea

• Diabetic diarrhea


10/27

n!ammatory diarrhea

• )nflammatory bowel disease

• Eosino$hili" gastroenteritis

• %ilk and soy $rotein allergy

• rotein(losing entero$athy

• -adiation "olitis

• %is"elaneous disease


11/27

"esult o colonoscopy in chronicdiarrhea (Semarang)

• Colitis• Colore"tal "an"er • )nflammatory bowel disease

• Colore"tal $oly$• -adiation "olitis• )s"hemi" "olitis

• .ormal


12/27

Diagnosis

&ym$tom and sign

Stool are consistently large in

volumeSmall bo#el or pro$imal

Small volume diarrhea with

Freuent urges to defecate%sually let colon and re

!lood mi"ed diarrheal stool

more li&ely due to

in!ammation othe mucosa orneoplasmSmall volume diarrhea# mucus

alternating with constipation

and abdominal pain

Consider 'S ( "M )


13/27

&ym$tom and sign

Visible oil or fat mi"ed stool ndicate steatorrhea

$ther special medical history• Febrile• Drug inta%e• &revious history of surgery• Symptom of systemic illness


14/27

Physical e$amination

-elated to :

• %alnutrition

• Dehydration

• itamin and tra"e element defi"ien"y

• )mmunologi"al alteration


15/27

*aboratory fndings

"outine e$aminationo the stool

'arge number of !C pusnection orin!ammation+nection byviruses, giardia or

organismenteroto$ineproducer are notassociated #ith pus$ccult blood %sually has thesame signifcant#ith pus in stool+

'lood #ithout pusconsider neoplasm,sprue or #hipples D

&arasite and helminths


16/27

Special e$amination o stool

Sudan test &teatorrhea giardiamalabsor$tion syndrome

*l%alini+ation )ngestion of $henol$hthalein

,wenty-four hours stool

volume-ery large volume,consider pancreaticcholera syndrome

Stool fat &teatorrhea

Culture of stool thiology o inective diarrhea

Di i h i di h


17/27

Diagnosis o chronic diarrhea

Chronic diarrhea

Medical history , Physical ERoutine Lab

Steatorrhea Watery diarrhea Infamatory

Respondto ast

May/maynot

respondto ast

Diagnosis

&$e"ifi" test &$e"ifi" test

&$e"ifi" test

otrespondto ast


18/27

Specifc laboratory tests orsteatorrhea

• ,e"al fat test

small intestine bio$sy 1#ia endos"o$y

malabsor$tion test

$an"reati" fun"tion test

Test for ba"terial o#er growth


19/27

Specifc laboratory test or #aterydiarrhea

• Breath test : 32 breath test

• 4a"tose tolerant test• Test for bile a"id malabsor$tion

• 3ormone le#el in urine and blood

• Colonos"o$y


20/27

Specifc test or in!amatorydiarrhea

• "olonos"o$y• labeled leuko"yte test

• Test for enteri" $rotein lost ( albumin labeled "learan"e


21/27

.reatment

• &u$$orti#e thera$y5

• &ym$tomati" treatment

!meliorate the disease

-edu"e the se#erity of the disease5

• Cure the underlying disease


22/27

Supportive treatment

• re#ention and "orre"tion of salt and water de$letion

Symptomatic treatment

• 6$iates lo$eramide

-edu"e bowel mo#ement fre7uen"y urgen"y and stool

#olume

&hould not be used in "ase of se#ere )BD indu"tion of to*i" mega"olon5


23/27

piate/loperamide

• 6$iate / 4o$eramide

( may redu"e urgen"y fre7uen"y of stool

and bowel mo#ement ( &hould not be used :

&e#ere )BD

&higellosis

6ther in#asi#e ba"teria

!ntibioti" asso"iated diarrhea


24/27

0nti secretory drugs

• .&!)D/!s$irin redu"e $rostaglandin mediated diarrhea

• 8lu"o"orti"oids

redu"e mu"osal inflamation and enhan"e.aCl absor$tion

• .i"otini" a"id Clonidine lithium "arbonate

Enhan"e intestinal absor$tion

• &tomatostatin analog/syntheti"

may redu"e diarrhea mediated by tumor


25/27

Cure the underlying disease

• )nfe"ti#e diarrhea

antimi"robial "hemothera$y

proven efficacy : 5 Cholerae 1ba"terial ETEC

&higellosis 1dysenteri"

se#ere &almonellosis

C5 Diffi"ile 9ersinia

Cam$yloba"ter dysentri


26/27

!ntimi"robial "hemothera$y

&roven efficacy : 8iardia intestinalis

1$rotooa En"e$halitooon intestinalis

)sos$ora belli

Cy"los$ora "ayetanensis

Entamoeba histolyti"a

Balantidium "oli


27/27

chronic diarrhea kuliah 06

Documents