Chronic Diarrhea

Fahmi Indrarti
Division of Gastroenterohepatology
Department of Internal Medicine
Faculty of Medicine, University of Gadjah Mada
Yogyakarta
Definition of diarrhea

Generally accepted definition

a volume of stool of > 200 ml per day, or

frequency of > 3 x per day

Simpler and less arbitrary definition

a decrease in consistency or

increase of liquidity of stool,

widely accepted in clinical practice & accords well with what patients understand by
diarrhoea

Chronic > 15 days

Clinical features of diarrhea

A detailed history is essential
Onset, duration, frequency, and volume of stool should be estimated.
Bloody diarrhoea with pus or mucus
Inflammatory process
Bulky, greasy, foul smelling stool
Steatorrhoea
Urgency to defecate, blood or pus per rectum
Proctitis
Nocturnal symptoms, continuous symptoms, a duration of over 3 months and significant weight
loss
Organic rather than functional process
Associated symptoms: abdominal pain, bloating, nausea & vomiting
Past medical history of HIV disease or other immunosuppressant states
Radiotherapy to the abdomen or pelvis or previous bowel surgery
bacterial overgrowth
Anal intercourse HSV or gonococcal proctitis
Diabetic patients are prone to dysmotility or bacterial overgrowth
The drug history

 Many commonly prescribed medications can cause diarrhoea

Recent antibiotic use predisposes to C. difficile infection
Longstanding alcohol excess
pancreatic abnormality
Family history of inflammatory bowel disease (IBD) or gastrointestinal malignancy
Physical examination
General examination
jaundice, hepatomegaly, cachexia or extra-luminal signs of GI disease clues to the cause
of the diarrhoea
A palpable mass
malignancy or Crohns disease
Dehydration, sepsis, peritonism or shock should be recognized and treated promptly

Investigations
Chronic diarrhoea is guided by the history and likely underlying diagnosis
Further blood tests: LED, CRP, albumin, amoebic serology, thyroid function tests (TFTs), iron
studies, folate and B12 levels
Patients over the age of 45 with persistent diarrhoea
colonoscopy to exclude colonic neoplasm disease
Younger patients with typical features of functional bowel disease, normal examination and
blood screen
no further investigation is necessary.
Patients with suspected Crohns disease
small bowel follow-through

Irritable Bowel Syndrome

Benign, chronic symptom complex of altered bowel habits and abdominal pain
No organic or structural cause can be detected to explain its symptoms
The most common functional disorder of the gastrointestinal (GI) tract functional
prevalence of patients in the general population
10 - 20 %,
only 10 - 30 % of those patients seek medical care.
At 5 y follow-up of IBS patients,
5 % - complete recovery
up to 30 % - partial recovery

Patophysiology

Management

Dietary recommendations
Psycotherapy
yakinkan penyakit ini adalah penyakit yang dapat diobati dan tidak membahayakan
kehidupan
Pharmacotherapy

Inflammatory Bowel Disease

Ulcerative colitis and Crohn disease
Similarities:
chronic remitting and relapsing course
inflammatory nature
unknown causes
Distinct clinicopathologic features:
different locations within the gastrointestinal tract,
diverse histologic patterns of inflammation
various disease-specific complications
IBD pathophysiology
Classical paradigms: dysregulated response of the mucosal immune system toward intraluminal
antigens of bacterial origin in genetically predisposed persons

Both genetic and environmental factors play important roles in disease pathogenesis.
New hypotheses implicate the innate immune system and the intestinal epithelium in the
pathogenesis of the disease.
Lymphocytes, cytokines, and adhesion molecules are dysregulated and have been targeted for
therapeutic intervention.

Based on a new understanding of the complicated mechanisms that underlie the disease process,
combination therapies are currently being pursued.
A better understanding of the pathophysiologic mechanisms will aid in prevention and more
effective maintenance of

Gambaran klinik

Diare kronik, dengan atau tanpa darah

Nyeri perut kronikih seragam
Distribusi anatomik saluran cerna yang terlibat pada KU adalah kolon
Pada PC: lebih bervariasi, dapat melibatkan atau tejadi pada semua segmen saluran
cerna, mulai mulut sampai anorectal
Sifat perjalanan klinik : kronik-eksaserbasi-remisi
Diagnostic features

Alur diagnosis
Anamnesis yang akurat
Gambaran klinik yang sesuai
Data lab menyingkirkan penyebab inflamasi lain (tdk ada parameter lab yang spesifik untuk IBD)
Temuan endoskopik yang karakteristik dan didukung konfirmasi histopatologik
Pemantauan perjakanan penyakit pasien : akut-remisi- eksaserbasi kronik
Management
Nutrition
Intraluminal dan ekstraluminal manifestation
maintenance of remission
Psychosocial support
Education
Complication
ocal : fistula, fissura dan strictura 10%
massive bleeding > 3%
fulminant colitis 15 %
Toxic megacolon colectomi.
Colorectal malignancy
8% CD after onset 22 y
7% UC after onset 20 y