交通大学医学院附属交通大学医学院附属仁济医院消化科仁济医院消化科上海市消化疾病研究所上海市消化疾病研究所范范竹萍竹萍DiarrheaDefinitionincrease in the frequency of bowel movements increase in stool liquidityin some cases increase in daily stool weight (200g/d)Pathophysiological mechanismssecretory diarrhea (increased intestinal secretion)Osmotic diarrheaDecreased intestinal surface area and/or intestinal absorptionInflammatary diarrheaRapid transit of intestinal contents (shortened transit time)Pathophysiological mechanismssecretory diarrhea (increased intestinal secretion)v infections (cholera toxin, E-col, salmonella, staphylococcal)v Hormonal (Gut Hormones, ZES, VIP), cancer (calcitonin, Prostaglandins)v miscellaneous (laxatives abuse, villous adenoma of the rectum)agentsAdenylate cyclasecAMP systemsecretory diarrheaactivateNaCl secretory diarrhoeainfectioncholerahormonal Verner-Morrison syndrome (VIP associated) carcinoid syndrome gastrinoma medullary thyroid cancerphenolphthalein abuse bile salt malabsorptionCholera: the simplified versionVerner-Morrison syndrome (VIP associated)a profuse, watery diarrhoea that results in massive intestinal loss of water, potassium, sodium and bicarbonate, leading to hypovolaemia, hypokalaemia and reduced total body potassium, and achlorhydria (metabolic acidosis).carcinoid syndromeparoxysmal flushing - for example, following coffee, alcohol, certain foods and drugs bronchoconstrictive episodes, similar to asthma right-sided heart failure episodes of explosive watery diarrhoea abdominal pain pellagra-like lesions of the skin and oral mucosagastrinoma The Zollinger-Ellison syndrome describes the association of:gastrin-producing tumours gastric hypersecretion severe peptic ulcer diseasegastrinomahigh fasting plasma gastrin high gastric acid secretion diminished response to pentagastrin demonstrable pancreatic or gastrointestinal tumour - by CT or venous sampling for gastrin more than 90% of gastrinomas have somatostatin receptors, and somatostatin receptor scintigraphy has been reported to be a especially sensitive method to image gastrinomasPathophysiological mechanismsOsmotic diarrheaIt caused by accumulation of the followings in the gut lumen watersalts poorly absorble solutes maldigestion of ingested food failure to transport an osmotically active dietary nonelectrolyte (E: glucose)intestinal Lumenbeing osmotically activediarrheaosmotic diarrhoeadisaccharidase deficiencyprimarily lactase deficiencylaxative abuse(about 20% of patients Causes of diarrhea in enteral nutritionCalculation of osmotic gapPathophysiological mechanismsDecreased intestinal surface area and/or intestinal absorptionE: surgical removal; malabsorption syndromePathophysiological mechanismsRapid transit of intestinal contents (shortened transit time) E: irritable bowel syndrome Functional diarrhea laxatives abuse post vagotomy diarrhea post gastrectomy dumbing syndromestoolvolumeliquiditycontact time increasesmall bowel mucosa contentsincrease in intestinal motility (intestinal hurry)reduceEtiologyAcute DiarrheainfectionFood poisoningSystematic diseases (influenza, sepsis, etc)MiscellanousEtiologyAcute Diarrheainfection1.viral 2. bacterialcampylobacteriaShigellaE. ColiSalmoneilaetc3.fungal4.parasitic (amebic Trophozoites, Giardia)Acute DiarrheaFood poisoningbacterial, plants, chemical poison(arsenic,.)Systematic diseases (influenza, sepsis, measle, etc)MiscellanousAllergic diseases Allergic purpura, enteropathy.endocronic diseases (ZES, etc.)Drugs: laxatives, 5-Fu, etc.food poisoningbacterial intrinsically poisonous food, for example deadly nightshade, red kidney beans parasites in the meat, for example Taenia, Trichinella chemicalsheavy metals, e.g. mercury, zinc pesticides, e.g. rodenticides, insecticidesallergies paralytic shell fish poisoning scombrotoxin histamine intoxication viral food poisonining chinese restaurant syndrome - monosodium glutamatechinese restaurant syndromeExcess ingestion of monosodium glutamate results in a syndrome that includes a burning sensation over the neck, chest and arms, with tightness over the face and chest. There may also be headache, flushing, weakness, nausea and abdominal cramps.EtiologyChronic DiarrheaIntestinalGastric(chronic gastritis,subtotal gastrectomy , etc.)Pancreatic (Chronic Pancreatitis, Pancreatic Cancer, etc.)Hepatobiliary(liver cirrhosis, obstructive jaundice)functional causesEndocronic (Hyperthyroids crisis, ZES, Carcinoids) Drugs (Reserpin, Ismelin, Laxatives, etc.)Others (uremia, hypogammaglobulemia, etc.)Chronic DiarrheaIntestinalinfections(T.B., Chronic bacteria dysentery, etc.)parasitics (Amebia dysentery, Giardiasis, etc.)IBD (ulcerative colitis, Chrons, etc.)malabsorption synd. (lactase deficiency, etc.)tumorsEndoscopic image: infectious colitis in 7-year-old girllower small bowel diseaseCrohns disease tuberculosis Yersinia enterocoliticaComplications of lower small bowel disease causing diarrhoea include:B12 deficiency bile acid wastingupper small bowel diseasecoeliac disease Giardiasis Whipples diseaseThere may be steatorrhoea or a watery stool.Other complications include:iron deficiency folate deficiency calcium deficiencylarge intestine causesdysentery worms inflammatory bowel disease colonic carcinoma irritable bowel syndrome faecal impaction with overflow radiation enteritis diverticular disease mesenteric ischaemiagastric causespost gastrectomy post vagotomy gastrocolic fistulapancreatic causescystic fibrosis chronic pancreatitis pancreatic carcinomaendocrine relateduraemia thyrotoxicosis carcinoid syndrome Zollinger-Ellison syndrome medullary carcinoma of the thyroid hypoparathyroidism diabetes mellitus, which may cause autonomic diabetic neuropathy, presenting with nocturnal diarrhoea Verner-Morrison syndromefunctional causes irritable bowel syndromemore than three motions per day less than three motions per week hard or lumpy stools loose or watery stools straining during a bowel movement urgency feeling of incomplete emptying passing mucus during a bowel movementabdominal fullness, bloating or swellingclassification of diarrhoeal disease by time-courseacute chronic SymptomsAcute diarrhea duration less than 2 weeksonset: Abrupt frequent, small fecal discharge Cramping abdominal pain, tenesmusestool: increased Routin Exsevere cases: dehydration, electrolyte disturbances, metabolic acidosis, collapse hypovolumia, tetany.Acute diarrhea Symptomsvolumeliquidityflecks of blood, mucusWBC, RBC, pus, destroyed epitheliumSymptoms Chronic diarrhea duration more than 2 monthsChronic diarrhea SymptomsOnset:gradual/insidiousDiarrhea of variable severityDiarrhea alternate with constipationColicky abdominal pain, distentionintestinal causesin small bowel pathology: abdominal pain, when present, is periumbilical or right iliac fossa the frequency of defecation is often reduced the stool may be well formed but it is bulky, offensive, and may be pale in colour there may be signs and symptoms of malabsorptionintestinal causesin large bowel pathology: there is often a defect in the reabsorption of water from the faeces stools may be profuse and watery and/or mixed with blood and mucus there may be lower abdominal pain with tenesmus and urgencystoolwatery, bloody, steatorrheacontains:inflammatory cells/mucus/pus/indigested foodsevere/long-standing cases: weight loss, malnutrition, edema, multy vits deficiency, malabsorption, wasting, edema, bone painAccompanied Symptomssevere dehydration (cholera, pancreatic cholera-WDHA, etc.)fever (Acute bacillery dysentery, Typhoid, TB enteritis, etc.)tenesmus (Acute dysentery, proctitis, etc.)markedly weight loss (cancer of gut, malabsorption, etc.)Arthralgia/Arthritis (IBD, connective tissue diseases, etc.)masses (malignant cancer of GI, TB, peritonitis, etc.) Diagnostic ProceduresInformationP.E. Findings fever, dehydration, malnutrion, anemia, ulticaria, jaundice, arthralgia, abdominal masses, Tenesmus, digital rectal examination.Lab findingsDiagnostic Proceduresinformationin epidemics (Dysentery, v. Cholerae, Typhoid, food poisonning, enteritis)food allergypast illness(antibiotic related diarrhea, etc.)medication take(corticosteroids, laxatives, etc.)predisposing conditions (surgical resection, parasitic infection, etc.) Lab findingsBloodUrineStoolMicroscopyTolerance testsBreath tests Culture of Jejunal aspirates5 HIAA (urinary excretion)Vit B12 absorption testX-ray BariumEndoscopySuction biopsy technique (Jejunal mucosa histologyinvestigations of diarrhoeadigital rectal examination, to exclude overflow diarrhoea due to constipation and a low rectal carcinomablood tests includefull blood count, ESR creatinine and electrolytes, glucose C reactive protein clotting screen B12 and folate TIBC thyroxine immunoglobulins fasting gut hormones - if other tests(-)Lab findingsUrineoProteinocastStooloappearance(watery, bloody, bulky, sticky, malodorous, steaterrhea, foul-smelling)Lab findingsMicroscopyRBC, WBC polymorphonuclear (PMN):Shigella, solmonella, E colimononuclear (M)motile amebic trophozoitesGrams stain (+) staphylococcal enteritisCulture: salmonolla, shigella, v. choleraFat determinationinvestigations of diarrhoearadiologyespecially important when the abdomen is distended or tender a plain abdominal film may reveal fluid levels, gas- filled loops or loss of gas in parts where the loops are inflamed barium enemasigmoidoscopy +/- biopsycolonoscopy +/- biopsystool microbiology, including microscopy, culture and antibiotic sensitivitydeterminestool for faecal fat estimation to exclude steatorrhoeaLab findingsTolerance tests (d-xylose; Glucose/lactose/sucrose)Breath tests 14C Glycine-cholate, xyloseCulture of Jejunal aspirates (Bacterial overgrowth)(increased Bile and deconjugation)5 HIAA (urinary excretion)Vit B12 absorption testdifferential diagnosis of diarrhoeacopious watery diarrhoea suggests an organic aetiology nocturnal diarrhoea suggests an organic aetiology - patient wakes up in the night needing to open bowels frequent passage of small amounts of faeces suggests functional bowel disease, e.g. irritable bowel syndrome bloody diarrhoea implies colonic disease, often inflammatory bowel disease or carcinoma, or an invasive infective diarrhoea, e.g. Campylobacter jejuni acute diarrhoea often has an infective aetiologyCASE REPORT女性,28岁反复腹泻10年大便检查:常规,脂肪,D-木糖试验生化:低白蛋白,低钙,贫血特殊检查:胃,结肠,小肠,腹腔小肠病变:胶囊内镜,上下小肠镜+活检治疗:激素有效