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 and 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].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Talley NJ, O'Keefe EA, Zinsmeister AR, Melton LJ 3rd. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology 1992; 102:895.
- Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology 1991; 101:927.
- Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ 3rd. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders. Am J Epidemiol 1992; 136:165.
- Sandler RS, Stewart WF, Liberman JN, et al. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci 2000; 45:1166.
- Fine KD, Schiller LR. AGA technical review on the evaluation and management of chronic diarrhea. Gastroenterology 1999; 116:1464.
- Everhart JE (Ed). Digestive Disease in the United States: Epidemiology and impact. NIH Publ 94-1447. Bethesda, MD: National Instiutues of Health, 1994.
- Lubeck DP, Bennett CL, Mazonson PD, et al. Quality of life and health service use among HIV-infected patients with chronic diarrhea. J Acquir Immune Defic Syndr 1993; 6:478.
- Watson A, Samore MH, Wanke CA. Diarrhea and quality of life in ambulatory HIV-infected patients. Dig Dis Sci 1996; 41:1794.
- Schmulson MJ, Drossman DA. What Is New in Rome IV. J Neurogastroenterol Motil 2017; 23:151.
- Philip NA, Ahmed N, Pitchumoni CS. Spectrum of Drug-induced Chronic Diarrhea. J Clin Gastroenterol 2017; 51:111.
- Burbure N, Lebwohl B, Arguelles-Grande C, et al. Olmesartan-associated sprue-like enteropathy: a systematic review with emphasis on histopathology. Hum Pathol 2016; 50:127.
- Kroschinsky F, Stölzel F, von Bonin S, et al. New drugs, new toxicities: severe side effects of modern targeted and immunotherapy of cancer and their management. Crit Care 2017; 21:89.
- Sauter GH, Moussavian AC, Meyer G, et al. Bowel habits and bile acid malabsorption in the months after cholecystectomy. Am J Gastroenterol 2002; 97:1732.
- Fort JM, Azpiroz F, Casellas F, et al. Bowel habit after cholecystectomy: physiological changes and clinical implications. Gastroenterology 1996; 111:617.
- Ros E, Zambon D. Postcholecystectomy symptoms. A prospective study of gall stone patients before and two years after surgery. Gut 1987; 28:1500.
- Wilson RG, Macintyre IM. Symptomatic outcome after laparoscopic cholecystectomy. Br J Surg 1993; 80:439.
- Arlow FL, Dekovich AA, Priest RJ, Beher WT. Bile acid-mediated postcholecystectomy diarrhea. Arch Intern Med 1987; 147:1327.
- Breuer NF, Jaekel S, Dommes P, Goebell H. Fecal bile acid excretion pattern in cholecystectomized patients. Dig Dis Sci 1986; 31:953.
- Schiller LR. Chronic Diarrhea. Curr Treat Options Gastroenterol 2005; 8:259.
- Bryant DA, Mintz ED, Puhr ND, et al. Colonic epithelial lymphocytosis associated with an epidemic of chronic diarrhea. Am J Surg Pathol 1996; 20:1102.
- Janda RC, Conklin JL, Mitros FA, Parsonnet J. Multifocal colitis associated with an epidemic of chronic diarrhea. Gastroenterology 1991; 100:458.
- Mintz ED, Weber JT, Guris D, et al. An outbreak of Brainerd diarrhea among travelers to the Galapagos Islands. J Infect Dis 1998; 177:1041.
- Osterholm MT, MacDonald KL, White KE, et al. An outbreak of a newly recognized chronic diarrhea syndrome associated with raw milk consumption. JAMA 1986; 256:484.
- Vugia DJ, Abbott S, Mintz ED, et al. A restaurant-associated outbreak of Brainerd diarrhea in California. Clin Infect Dis 2006; 43:62.
- Kimura AC, Mead P, Walsh B, et al. A large outbreak of Brainerd diarrhea associated with a restaurant in the Red River Valley, Texas. Clin Infect Dis 2006; 43:55.
- Hellmig S, Ott S, Musfeldt M, et al. Life-threatening chronic enteritis due to colonization of the small bowel with Stenotrophomonas maltophilia. Gastroenterology 2005; 129:706.
- Friedman M, Ramsay DB, Borum ML. An unusual case report of small bowel Candida overgrowth as a cause of diarrhea and review of the literature. Dig Dis Sci 2007; 52:679.
- Eherer AJ, Fordtran JS. Fecal osmotic gap and pH in experimental diarrhea of various causes. Gastroenterology 1992; 103:545.
- Habba SF. Chronic diarrhea: identifying a new syndrome. Am J Gastroenterol 2000; 95:2140.
- Schoepfer AM, Trummler M, Seeholzer P, et al. Accuracy of four fecal assays in the diagnosis of colitis. Dis Colon Rectum 2007; 50:1697.
- Chitkara YK, McCasland KA, Kenefic L. Development and implementation of cost-effective guidelines in the laboratory investigation of diarrhea in a community hospital. Arch Intern Med 1996; 156:1445.
- Stoll BJ, Glass RI, Banu H, et al. Value of stool examination in patients with diarrhoea. Br Med J (Clin Res Ed) 1983; 286:2037.
- Siegel D, Cohen PT, Neighbor M, et al. Predictive value of stool examination in acute diarrhea. Arch Pathol Lab Med 1987; 111:715.
- Huicho L, Sanchez D, Contreras M, et al. Occult blood and fecal leukocytes as screening tests in childhood infectious diarrhea: an old problem revisited. Pediatr Infect Dis J 1993; 12:474.
- Poullis A, Foster R, Mendall MA, Fagerhol MK. Emerging role of calprotectin in gastroenterology. J Gastroenterol Hepatol 2003; 18:756.
- Holtman GA, Lisman-van Leeuwen Y, Reitsma JB, Berger MY. Noninvasive Tests for Inflammatory Bowel Disease: A Meta-analysis. Pediatrics 2016; 137.
- Mosli MH, Zou G, Garg SK, et al. C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2015; 110:802.
- van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ 2010; 341:c3369.
- Kristinsson J, Nygaard K, Aadland E, et al. Screening of first degree relatives of patients operated for colorectal cancer: evaluation of fecal calprotectin vs. hemoccult II. Digestion 2001; 64:104.
- Kristinsson J, Armbruster CH, Ugstad M, et al. Fecal excretion of calprotectin in colorectal cancer: relationship to tumor characteristics. Scand J Gastroenterol 2001; 36:202.
- Limburg PJ, Devens ME, Harrington JJ, et al. Prospective evaluation of fecal calprotectin as a screening biomarker for colorectal neoplasia. Am J Gastroenterol 2003; 98:2299.
- Bunn SK, Bisset WM, Main MJ, et al. Fecal calprotectin: validation as a noninvasive measure of bowel inflammation in childhood inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2001; 33:14.
- Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol 2003; 98:1309.
- ASGE Standards of Practice Committee, Shen B, Khan K, et al. The role of endoscopy in the management of patients with diarrhea. Gastrointest Endosc 2010; 71:887.
- Levin TR, Conell C, Shapiro JA, et al. Complications of screening flexible sigmoidoscopy. Gastroenterology 2002; 123:1786.
- Korman LY, Overholt BF, Box T, Winker CK. Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003; 58:554.
- Fine KD, Seidel RH, Do K. The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea. Gastrointest Endosc 2000; 51:318.
- Shale MJ, Walters JR, Westaby D. Adequacy of flexible sigmoidoscopy with biopsy for diarrhea in patients under age 50 without features of proximal disease. Gastrointest Endosc 2011; 73:757.
- Tanaka M, Mazzoleni G, Riddell RH. Distribution of collagenous colitis: utility of flexible sigmoidoscopy. Gut 1992; 33:65.
- Zins BJ, Tremaine WJ, Carpenter HA. Collagenous colitis: mucosal biopsies and association with fecal leukocytes. Mayo Clin Proc 1995; 70:430.
- 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