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What is the definition of diarrhea?



>200 grams of stool or 200mL of stool in a 24 hour period


However, a high-fiber diet can easily produce more than 300g


What are the two varieties of diarrhea?



Malabsorptive vs Exudative


Which type of diarrhea fits the following description?

  1. Etiology is inflammation
  2. Relieved by fasting
  3. Due to nutrient absorption problems
  4. Bloody Stools
  5. Watery Stools
  6. Continues during fasting

  1. Exudative
  2. Malabsorptive
  3. Malabsorptive
  4. Exudative
  5. Malabsorptive
  6. Exudative


What can cause malabsorptive diarrhea?

  1. Failure of intraluminal digestion
  2. Failure of terminal digestion 
  3. Failure of transepithelial transport
  4. Failure of lymphatics transport


What is a "normal" amount of bowel movements?


What is diarrhea?

Patient's baseline; ranges from 1x every 3 days to 3x/day


More than 3 watery/loose stools per day OR a clear increase in the baseline 


What clues on history can indicate real diarrhea?

  • Consistency 
  • Urgency
  • Incontinence
  • Nocturnal BMs
  • Flatuphobia


What volume of fluid enters the stomach each day?


What volume is eliminated in the stool?


Where is water absorbed?



0.1 L


6L in the jejunum

2.5L in the ileum

1.4L in the colon


What are some indications that the diarrhea is caused by problems in the small intestine?

  • Large, infrequent, watery stools
  • Cramping, bloating, gas 
  • Fever unlikely
  • Blood or WBC in stool unlikely


What are some indications that the diarrhea is caused by problems in the large bowel?

  • Frequent, small stools
  • Tenesmus (rectal dry heaving)
  • Painful BM
  • Bloody, mucus-y stools
  • WBCs in stool common


What is osmotic diarrhea?


What is the cause?

Watery, loose stools


Caused by a problem absorbing nutrients in the intestines; the intestines can not maintain an osmotic gradient


Mannitol, sorbitol

disaccharide deficiency

magnesium, phosphate, sulfate


What is secretory diarrhea?


What causes it?


How can secretory diarrhea be distinguished from osmotic diarrhea?

water loose stool


excretion of chloride or blocked sodium absorbtion, typically caused by infection or enterotoxins


Electrolyte profile and osmotic gap will be different.


What are the most likely causes of acute diarrhea?


What are the most likely causes of chronic diarrhea?

Infections, Food poisoning, Medications


Food allergies, Autoimmune, Anatomic problems, Cancer




What should you do when a patient comes in complaining of diarrhea?

  • Assess fluid state
  • Try to determine consistency/frequency
  • Ask about associated symptoms:
    • Tenesmus
    • Abdominal pain
    • Nocturnal Waking
    • Blood in stool
    • Incontinence
    • Flatuphobia
  • Ask about recent travel
  • Changes in diet, medications


What are the most likely causes of diarrhea with fever?

  • Invasive Bacteria
  • Enteric Viruses
  • Ischemia
  • IBD


What things should you look for on physical exam when a patient comes in with diarrhea?

  • Diabetic Herpetiformis
    • Celiac Disease
  • Erythema Nodosum
    • IBD
  • Arthritis
    • IBD
  • Fistulas
    • Crohn's Disease
  • Abdominal Mass
    • Cancer


How sensitive are the tests for cryptosporidium and giardia?


How specific are the tests?



almost 100%