Maldigestion (loss of digestive function) Whipple disease ( Tropheryma whippelii infection) Small bowel bacterial overgrowth (> 10 5 bacteria per mL) Noninvasive small bowel parasite (e.g., Giardia) Lymphatic damage (e.g., congestive heart failure, some lymphomas) Malabsorption syndrome (damage to or loss of absorptive ability)Ĭarbohydrate malabsorption (e.g., lactose intolerance)Ĭeliac sprue (gluten enteropathy)–various clinical presentations Sugar alcohols (e.g., mannitol, sorbitol, xylitol)įunctional (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting)įatty (bloating and steatorrhea in many, but not all cases) Osmotic laxatives and antacids (e.g., magnesium, phosphate, sulfate) Secretory (often nocturnal unrelated to food intake fecal osmotic gap 125 mOsm per kg *)Ĭarbohydrate malabsorption syndromes (e.g., lactose, fructose) Empiric therapy is justified when a specific diagnosis is strongly suspected and follow-up is available. ![]() This narrows the list of diagnostic possibilities and reduces unnecessary testing. Still, the most practical diagnostic approach is to attempt to categorize the diarrhea by type before testing and treating. Not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories overlap. Infections caused by Clostridium difficile subsequent to antibiotic use have become increasingly common and virulent. Invasive bacteria and parasites also produce inflammation. Inflammatory diarrhea, such as ulcerative colitis or Crohn disease, is characterized by blood and pus in the stool and an elevated fecal calprotectin level. Celiac disease (gluten-sensitive enteropathy) is also malabsorptive, and typically results in weight loss and iron deficiency anemia. Malabsorptive diarrhea is characterized by excess gas, steatorrhea, or weight loss giardiasis is a classic infectious example. Laxative-induced diarrhea is often osmotic. Another example of watery diarrhea is microscopic colitis, which is a secretory diarrhea affecting older persons. Watery diarrhea includes irritable bowel syndrome, which is the most common cause of functional diarrhea. Watery diarrhea may be subdivided into osmotic, secretory, and functional types. ![]() It can be divided into three basic categories: watery, fatty (malabsorption), and inflammatory. Chronic diarrhea, defined as a decrease in stool consistency for more than four weeks, is a common but challenging clinical scenario.
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