Diarrhea (eBook)

Preface 5
Contents 6
Contributors 8
1 Definition, Epidemiology, Pathophysiology, Clinical Classification, and Differential Diagnosis of Diarrhea 11
Introduction 12
Definition 13
Epidemiology 14
Acute Diarrhea 14
Community-Acquired Diarrhea 14
Hospital-Acquired Diarrhea 16
Traveler's Diarrhea 17
Persistent Diarrhea 18
Chronic Diarrhea 19
Pathophysiology of Diarrhea 19
Normal Physiology 19
Physiological Disturbances in Diarrhea 20
Secretory Diarrhea 21
Infections 22
Noninfectious Causes of Secretory Diarrhea 22
Osmotic Diarrhea 23
Inflammatory Diarrhea 24
Iatrogenic-/Drug-Induced Diarrhea 25
Functional Diarrhea 26
Clinical Classification And Differential Diagnosis 26
Other Considerations in Chronic Diarrhea 33
References 34
2 Infectious Gastroenteritis and Colitis 42
Introduction 43
Etiology 43
Clinical Presentation 44
Specific Infections 45
Small Intestinal Pathogens 45
Viruses 45
Bacteria 46
Parasites 48
Ileocolonic Pathogens 50
Bacteria 50
Parasites 57
Viruses 58
Clinical Evaluation 59
Diagnostic Evaluation 61
Fecal Leukocytes and the Lactoferrin Assay 61
Stool Culture 62
Treatment 62
Rehydration, Nutrition, Electrolytes 62
Antidiarrheals 62
Antimicrobials 62
Conclusion 63
Acknowledgments 63
References 64
3 Inflammatory Bowel Disease 69
Introduction 70
Epidemiology 71
Pathophysiology 71
Diarrhea in IBD 72
Diarrhea as a Side Effect of Medication 73
Differential Diagnosis 73
Clinical Presentation 75
Evaluation 75
Physical Examination 76
Laboratory Evaluation 76
Imaging Studies 77
Endoscopy 78
Treatment 79
Aminosalicylates 82
Antibiotics 82
Glucocorticoids 82
Immunomodulators 83
Biologic Agents 83
Surgical Management 84
The Role of Probiotics 85
General Dietary Considerations 85
Specific Antidiarrheal Treatments 85
Prognosis 86
References 86
4 Eosinophilic Enteritis 88
Introduction 89
Epidemiology And Natural History 89
Clinical Presentation And Complications 90
Differential Diagnosis And Diagnostic Criteria 91
Evaluation 94
Treatment 95
Pathogenesis And Future Directions 96
Summary of Key Points 97
References 97
5 Microscopic Colitis 99
Introduction 100
Background 100
Epidemiology 100
Clinical Features 101
Histopathology 103
Pathophysiology 103
Treatment 104
Conclusion 105
References 106
6 Food Allergy 110
Introduction 110
Pathophysiology 111
Clinical Presentation 114
History 114
Signs and Symptoms 114
Diagnosis 117
References 120
7 Protein-Losing Enteropathies 122
Introduction 123
Normal Protein Absorption 123
Protein Malabsorption And Protein Loss 124
Clinical Manifestations 127
Diseases Associated with Protein Losing Gastroenteropathy: Without Mucosal Erosions or Ulcerations 127
Diseases Associated with Protein Losing Gastroenteropathy: with Mucosal Erosions or Ulcerations 130
Diseases Associated with Protein Losing Gastroenteropathy: Altered Lymphatic Drainage 131
Diagnosis In Protein-Losing Gastroenteropathies 132
Treatment 136
Summary Points And Recommendations 139
References 139
8 Radiation Enterocolitis 145
Introduction 146
Classification 146
Risk Factors For Radiation-Induced Gut Injury 148
Incidence And Clinical Presentation 148
Diagnostic Workup 150
Radiologic Tests 150
Endoscopic Procedures 151
Other Tests 151
Prevention 152
Medical Therapy 154
Diet 154
Caloric Supplements 155
Antidiarrheal Drugs 155
Antibiotics and Probiotics 155
Prednisone and 5-ASA Drugs 156
Hyperbaric Oxygen 156
Octreotide 156
Cholestyramine 156
Parenteral Nutrition 157
Surgery 157
Conclusion 158
References 158
9 Congenital Disorders of Digestion and Absorption 162
Disorders Of Carbohydrate Assimilation 165
Congenital Lactase Deficiency 165
Adult-Type Hypolactasia 166
Sucrase--Isomaltase Deficiency 167
Glucose--Galactose Malabsorption 168
Fructose Malabsorption 169
Fanconi--Bickel Syndrome 169
Disorders Of Protein Assimilation 170
Enterokinase and Trypsinogen Deficiency 171
Lysinuric Protein Intolerance 171
Disorders Of Lipid Assimilation 172
Abetalipoproteinemia 172
Hypobetalipoproteinemia 173
Chylomicron Retention Disease 174
Primary Bile Acid Malabsorption 174
Disorders Leading To Generalized Malabsorption 174
Enteric Anendocrinosis 175
Disorders of Mixed Secretory and Osmotic Diarrhea 175
References 176
10 Pancreatic Exocrine Insufficiency 179
Introduction 180
How Does Cck Stimulate Pancreatic Secretion? 180
Physiologic Control And Regulation Of Exocrine Pancreatic Secretion 181
Mechanism for CCK-Mediated Pancreatic Secretion in Animals 181
Mechanisms for Exocrine Pancreatic Secretion in Humans 181
The Role Of Secretin In Pancreatic Ductal Cell Secretion 182
Non-Cck-Dependent Factors Which Affect Pancreatic Secretion 182
Physiology And Definition Of Pancreatic Exocrine Insufficiency 183
When Should Treatment Begin And What Are The Goals Of Enzyme Therapy? 183
Which Enzyme Preparation Should Be Used? 185
Treatment Goals And Expected Response To Pancreatic Enzyme Therapy 186
Potential Complications Of Therapy 187
Future Research 187
Conclusion 188
References 188
11 Bacterial Overgrowth 191
Introduction 192
Definition 194
Mechanisms 194
Symptoms 195
Disease Associations 196
Short Bowel Syndrome 196
Irritable Bowel Syndrome 196
Gastroesophageal Reflux 197
Inflammatory Bowel Disease 197
Diagnosis 197
Treatment 200
Antibiotics 200
Dietary Support 203
Mechanical Methods 204
Conclusion 204
References 205
12 Celiac Disease 210
Introduction 211
Epidemiology 211
Pathophysiology 212
Immunology 212
adaptive immunity 212
innate immunity 213
Pathology 213
Clinical Presentation 213
''Typical'' Celiac Disease: Gastrointestinal Manifestations 215
''Atypical'' Celiac Disease: Extraintestinal Manifestations 216
Associated Diseases 218
Diagnosis 219
The Role of Serology in the Diagnosis of Celiac Disease 220
Treatment 221
Complications 222
Refractory Celiac Disease 222
Increased Mortality Rate 223
References 223
13 Whipple Disease 226
Introduction 227
Epidemiology 227
Etiology And Pathogenesis 227
Pathology 228
Clinical Features 229
Diagnosis 231
Treatment And Prognosis 232
References 233
14 Surgical Conditions Presenting with Diarrhea 238
Introduction 239
Pediatric Surgical Disorders Presenting With Diarrhea 239
Necrotizing Enterocolitis 239
Intussusception 242
Malrotation with Midgut Volvulus 243
Perforated Appendicitis 244
Chronic Diarrheal Disorders In Pediatrics 246
Short Bowel Syndrome 246
Inflammatory Bowel Disease: Crohn's Disease and Ulcerative Colitis 248
Tumors 248
Verotoxigenic Escherichia coli and Post-diarrheal Hemolytic Uremic Syndrome 249
Post-transplant Lymphoproliferative Disease 250
Colocutaneous Fistula After Percutaneous Endoscopic Gastrostomy Tube Placement 251
Juvenile Polyposis Coli 252
Surgical Disorders Presenting With Diarrhea In Adults 252
Intestinal Ischemia 252
Acute Mesenteric Ischemia (AMI) 254
Chronic Mesenteric Ischemia (CMI) 254
Mesenteric Venous Thrombosis (MVT) 255
Ischemic Colitis 255
Clostridium difficile Colitis 257
Chronic Diarrheal Disorders In Adults 258
Tumors 258
Carcinoid/Carcinoid Syndrome 258
Gastrinomas/Zollinger--Ellison Syndrome 259
Vasoactive Intestinal Peptide Tumor (VIPoma) 259
Somatostatinoma 260
Medullary Thyroid Cancer 260
Chronic Pancreatitis 260
References 260
15 Chronic Diarrheal Disorders due to Endocrine Neoplasms 265
Introduction 266
Gastrinomas 266
Clinical Presentation 266
Diagnosis 267
Treatment 268
Carcinoid 269
Clinical Presentation 269
Diagnosis 270
Treatment 270
Vipomas 272
Clinical Presentation 272
Diagnosis 272
Treatment 273
Somatostatinomas 273
Glucagonomas 275
Systemic Mastocytosis And Other Rare Causes Of Neuroendocrine Tumors Resulting In Diarrhea 275
References 277
16 Diarrhea from Enterotoxins 280
Introduction 281
Increasing Cl Secretion 283
Reducing Cl Absorption 287
Decreasing Na+ Absorption 287
Impairment Of Water Intestinal Transport 288
Therapeutic Strategies 288
References 294
17 Factitious Diarrhea 298
Introduction 299
Epidemiology 300
Clinical Presentation 300
Diagnostic Evaluation 300
Stool Studies 301
Laxative Screens 303
Colonoscopy 304
Room Searches 304
Stool Characteristics Of Factitious Diarrhea 305
Osmotic Diarrhea 305
Non-gap Diarrhea 306
Dilutional Diarrhea 307
Management 307
Conclusions 308
References 308
18 Chronic Idiopathic Diarrhea 310
Introduction 311
What Is The Definition Of Diarrhea? 312
What Constitutes Chronic Diarrhea? 313
Differential Diagnosis 313
Available Tests 316
What Conditions Should Be Considered In The Differential Diagnosis Of Diarrhea Of Obscure Etiology? 316
What Is The Characteristic History And Course Of Sporadic Chronic Idiopathic Secretory Diarrhea? 319
Brainerd Diarrhea 320
Potential Etiologies 321
Management Of Chronic Idiopathic Secretory Diarrhea 321
References 322
19 Irritable Bowel Syndrome 324
Introduction 325
Clinical Manifestations 325
Chronic Abdominal Pain 325
Altered Bowel Habits 326
Diarrhea 326
Constipation 326
Other Gastrointestinal Symptoms 326
Diagnostic Criteria 326
Diagnostic Approach 328
Initial Diagnostic Studies 329
Other Diagnostic Studies 330
Treatment 330
General Principles 330
Therapeutic Relationship 330
Patient Education 331
Dietary Modification 331
Medications 332
Antispasmodic Agents 332
Antidepressants 333
Antidiarrheal Agents 334
Benzodiazepines 334
5-Hydroxytryptamine (Serotonin) 3 Receptor Antagonists 334
Antibiotics 335
Psychosocial Therapies 335
Alternative Therapies 335
Summary And Recommendations 335
Mild Symptoms 335
Moderate Symptoms 336
Intractable Symptoms 336
References 336
20 Functional Diarrhea (Non-specific Chronic Diarrhea, Toddler Diarrhea) 339
Introduction 340
Terminology 340
Definition According To The Rome III Criteria 341
Epidemiology 341
Clinical Evaluation 341
Differential Diagnosis 342
Pathophysiology 343
Motility 344
Gastric Motility 344
Small Bowel Motility 345
Infection 345
Bacterial Overgrowth 346
Prostaglandins 346
Bile Acid Malabsorption 346
Fecal Microbiota 347
Role of Nutrition: Carbohydrate Consumption and Malabsorption 348
Psychosocial and Parental Factors 348
Therapy 349
Dietary Intervention 349
Pharmacological Treatment 350
Enzymes 350
Probiotics 350
Anticholinergic Agents 350
Binding Resins 351
Conclusion 351
References 351
21 Diarrhea Related to Non-neoplastic Endocrine Diseases 355
Introduction 356
Diabetic Diarrhea 356
Definition of Diabetic Diarrhea 357
Causes of Diarrhea in Diabetes Mellitus 357
Related or Associated with Diabetes Mellitus 357
Associated with Autonomic Neuropathy 360
Approach to the Diabetic Patient with Chronic Diarrhea 362
Treatment of Diabetic Diarrhea 363
Diarrhea Related To Hyper- And Hypo-Function Of The Thyroid Gland 366
Diarrhea in Thyrotoxicosis 366
Mechanisms of Diarrhea 366
Diarrhea in Hypothyroidism 368
Treatment of Thyroid Gland-Related Diarrhea 368
Diarrhea Related To Adrenal Gland 368
Addison's Disease 368
Diarrhea Related to Autoimmune Polyglandular Syndromes 369
Autoimmune Polyendocrine Syndrome (APS) Type I 369
Autoimmune Polyglandular Syndrome Type II 370
Diarrhea Related To Immune Dysfunction, Polyendocrinopathy, Enteropathy, X-Linked Syndrome (IPEX) 371
References 372
22 Alcohol-Related Diarrhea 377
Introduction 378
Classification 378
Absorption And Metabolism Of Alcohol In The Gut 379
Etiopathogenesis Of Diarrhea 379
Clinical Presentation 379
Treatment 384
Acute Alcohol-Related Diarrhea 384
Chronic Alcohol-Related Diarrhea 384
References 385
23 Drug-Induced Diarrhea 391
Introduction 392
Mechanisms Of Drug-Induced Diarrhea 393
Watery Diarrhea 395
Osmotic diarrhea 395
Secretory Diarrhea 395
Inflammatory Diarrhea 396
Fatty Diarrhea 396
Complex Diarrheas 397
Diet 398
Laxatives 400
Cholinergics, Seritonergics, And Other Neuromodulators 401
Gastroenterology Medications 403
Diabetes Medications 405
Endocrine Medicines 406
Chemotherapy And Immunomodulators 407
Antibiotics 410
Nsaids 411
HIV Medications 412
Cardiac Medications 413
Miscellaneous Drugs 414
Conclusion 414
References 415
24 Runners Diarrhea 422
Introduction 423
Incidence 423
Exercise Effects On Gastrointestinal Physiology 423
Clinical Management 424
Race Management 425
Training Implications 425
Conclusion 426
References 426
25 Evaluation of Patients with Diarrhea and Timing of Referral 428
Introduction 429
Evaluation Of Patient With Diarrhea 430
History 430
Physical Examination 432
Evaluation By Primary Care Physicians 432
Evaluation by gastroenterologists 436
Role Of Endoscopy 436
Evaluation For Bile Acid Malabsorption 437
Evaluation For Small Intestinal Bacterial Overgrowth (SIBO) 438
References 439
26 Empiric Treatment of Chronic Diarrhea 440
Introduction 441
Oral Rehydration Solutions 441
Dietary Modifications 443
Treatments Based On A Clinical Setting Or After A Specific Diagnosis Is Obtained 443
Antibiotic Therapy 444
Anti-diarrheal Agents 444
Agents Used as Empiric or Specific Treatment of Chronic Diarrhea 444
References 452
27 Probiotics for Diarrheal Diseases 456
Introduction 457
Clinical Trials In The Prevention And/Or Treatment Of Acute Diarrhea 458
Prevention Of Diarrhea 459
Community Acquired 459
Day-Care Acquired 459
Hospital Acquired 461
Traveler's Diarrhea 461
Prevention Of Antibiotic-Associated Diarrhea 462
Treatment Of Acute Diarrhea 462
Treatment Of Persistent Diarrhea 464
Prevention Of Necrotizing Enterocolitis In The Newborn 464
Use Of Probiotics In Inflammatory Bowel Diseases 465
Crohn's Disease 465
Ulcerative Colitis 468
Conclusions 468
References 468
Subject Index 472