Chronic diarrhea

Rationale

Chronic diarrhea is defined as a disturbance of stool frequency and/or consistency for greater than four weeks’ duration.

Causal Conditions

(list not exhaustive)

1. Steatorrhea
   1. Luminal
      1. Pancreatic insufficiency
      2. Cholestasis
      3. Ileal disease or resection
      4. Bacterial overgrowth
   2. Mucosal
      1. Lactase deficiency
      2. Celiac disease
2. Large bowel
   1. Secretory diarrhea (e.g., villous adenoma)
   2. Inflammatory diarrhea
      1. Inflammatory bowel disease
      2. Infection
      3. Other (e.g., radiation, ischemic colitis)
   3. Motility disorders (e.g., irritable bowel syndrome)
3. Small bowel
   1. Osmotic diarrhea
   2. Secretory diarrhea
      1. Tumours
         1. Neuroendocrine (e.g., carcinoid)
         2. Neoplasia (e.g., lymphoma)
      2. Mucosal
   3. Motility disorders (e.g., diabetic neuropathy)

Key Objectives

Given a patient with chronic diarrhea, the candidate will diagnose the cause, severity, and complications, and will initiate an appropriate management plan. In particular, the history should focus on contrasting small and large bowel diarrhea.

Enabling Objectives

Given a patient with chronic diarrhea, the candidate will

1. list and interpret clinical findings, including those derived from an appropriate history and physical examination aimed at
   1. differentiating pancreatic and biliary causes from small bowel and large bowel causes of diarrhea;
   2. differentiating osmotic from secretory diarrhea;
   3. differentiating maldigestion from malabsorption; and
   4. diagnosing irritable bowel syndrome based on history and the appropriate exclusion of other causes;
2. list and interpret critical investigations, including
   1. investigations for malabsorption and specific underlying causes; and
   2. investigations for other causes of chronic diarrhea; and
3. construct an effective initial management plan, including
   1. prevent, recognize, and treat related complications (e.g., other manifestations of inflammatory bowel disease, celiac disease, or other chronic conditions);
   2. determine whether the patient requires specialized care or consultation; and
   3. conduct education and counseling in case of malabsorption, inflammatory bowel disease, and other chronic conditions.