Approach to the adult with chronic diarrhea in resource-rich settings
- Peter A L Bonis, MD
Peter A L Bonis, MD
- Chief Medical Officer of Clinical Effectiveness (UpToDate, Clinical Drug Information, and Emmi Solutions)
- Deputy Editor — Gastroenterology/Hepatology
- Adjunct Professor of Medicine
- Tufts University School of Medicine
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease; Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
Diarrhea, derived from the Greek "to flow through," is a common manifestation of gastrointestinal disease. Its definition has traditionally been based upon the frequency, volume, and consistency of stools. However, the relationship between these features and patients' perception of diarrhea is variable. As a result, a consensus statement issued by the American Gastroenterological Association suggests that chronic diarrhea should be defined as three or more loose or watery stools daily lasting for four or more weeks.
This topic review will provide an overview of the evaluation and treatment of chronic diarrhea. Individual disorders associated with chronic diarrhea, a discussion regarding diarrhea in HIV-infected patients, and an approach to patients with acute diarrhea are presented separately. (See "Evaluation of the HIV-infected patient with diarrhea" and "Approach to the adult with acute diarrhea in resource-rich settings".)
The prevalence of chronic diarrhea in the general population in developed nations has not been well established. The variable rates observed in several studies reflect differences in study design, definitions, and characteristics of populations that have been sampled [1-4]. Based upon a commonly used definition (ie, the presence of excessive stool frequency) a reasonable approximation is that chronic diarrhea affects approximately 5 percent of the population.
Economic impact — The economic impact of chronic diarrhea has not been well quantified, particularly when considering societal costs. One estimate based upon limited data is that chronic diarrhea costs more than $350,000,000 annually from work loss alone [5,6].
Effect on quality of life — Chronic diarrhea can decrease quality of life. However, accurate assessment of the degree to which this occurs has not been established. One explanation is that a well-validated, disease-specific quality-of-life instrument has not yet been developed. Furthermore, no studies have attempted to measure quality of life in large groups of patients. Chronic diarrhea was an independent predictor of decreased quality of life in HIV-infected patients [7,8].
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- Economic impact
- Effect on quality of life
- Irritable bowel syndrome and other functional bowel disorders
- Inflammatory bowel disease
- - Crohn disease
- - Ulcerative colitis
- Microscopic colitis
- Malabsorption syndromes
- Post-cholecystectomy diarrhea
- Chronic infections
- Timing of referral
- Physical examination
- Specific testing
- - Secretory diarrhea
- Inflammatory or infectious diarrhea
- - Fecal leukocytes
- - Fecal calprotectin
- - Fecal lactoferrin
- Fatty diarrhea
- Colonoscopy versus sigmoidoscopy
- Bowel imaging
- Role of empiric therapy
- Symptomatic therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS