2nd year / GIT block Med teams 431 2012

PATHOLOGY
TEAM

D one by:

Abdulrahman Aljadoa & Manar Aljebreen

 DIARREAHA

Objectives:
1. Define diarrhea
2. Describe the pathogenesis of different types
of diarrhea
3. List the causes of chronic diarrhea

Physiology of Fluid and small intestine:

DEFINITION
•  World Health Organization:
 3 or more loose or liquid stools per day

•  Abnormally high fluid content of stool

> 200-300 gm/day

Why important?
• The loss of fluids through diarrhea can cause dehydration and electrolyte imbalances
• Easy to treat but if untreated, may lead to death especially in children.
• More than 70 % of almost 11 million child deaths every year are attributable to 6 causes:
1. Diarrhea
2. Malaria
3. neonatal infection
4. Pneumonia
5. preterm delivery
6. lack of oxygen at birth.

CLASSIFICATION acute Persistent Chronic

• if 2 weeks (less • if 2 to 4 weeks • if 4 weeks in

than 2 weeks) duration (more
than 4 weeks)
Pathophysiology:

Categories of diarrhea
1. Secretory Each category will be
2. Osmotic explained below
3. Exudative (inflammatory )
4. Motility-related

Fecal osmolarity:
•  As stool leaves the colon, fecal osmolality is equal to the serum osmolality i.e. 290 mosm/kg.
•  Under normal circumstances, the major osmoles are Na+, K+, Cl–, and HCO3–.

Fecal osmotic gap is calculation performed to

distinguish among different causes of diarrhea

=  290  −  2  *  (stool Na + stool K)

Osmotic:
•  Excess amount of poorly absorbed substances that exert  osmotic  effect………water  is  drawn  
into the bowels……diarrhea    
Osmotic diarrhea is characterized by hypotonic
•  Stool output is usually not massive
stool due to presence of osmotically active solutes
•  Fasting improve the condition.
drawing more water than electrolytes out of the
•  Stool osmotic gap is high, > 125 mOsm/kg enterocytes . (from USMLE)
Can be the result of
1. Malabsorption in which the nutrients are left in the lumen to pull in water e.g. lactose
intolerance.
2. osmotic laxatives. Laxatives: are foods, compounds or drugs taken to loosen the stool.

Sufficiently high doses of laxatives may cause diarrhea.

Secretory: Bacterial infections that

•  There is an increase in the active secretion of water. are not associated with
•  High stool output invasion of the mucosa
•  Lack of response to fasting only producing toxins
•  Stool osmotic gap < 100 mOsm/kg
•  The most common cause of this type of diarrhea is a bacterial toxin ( E. coli , cholera) that
stimulates the secretion of anions.
•  Other causes: The stool is isotonic
– Enteropathogenic virus e.g. rotavirus and norwalk virus
– Also seen in neuroendocrine tumours ( carcinoid tumor, gastrinomas)
Exudative (inflammatory):
•  Results from the outpouring of blood protein, or mucus from an inflamed or ulcerated
mucosa.
•  Presence of blood and pus in the stool.
•  Persists on fasting
•  Occurs with inflammatory bowel diseases, and invasive infections e.g. E. coli,
Clostridium difficile and Shigella
E.coli can be 1)invasive and
causing exudative diarrhea
2)toxins producing and causing
secretory diarrhea.
Motility-related
•  Caused by the rapid movement of food through the intestines (hypermotility).
•  Irritable bowel syndrome (IBS) – a motor disorder that causes abdominal pain and
altered bowel habits with diarrhea predominating.
Occurs with stress and neurological disorders and diagnosed by exclusion of bacterial , viral
infections and malabsorption.

Aetiology:
Acute diarrhea: (less than 2 weeks)
•  Approximately 80% of acute diarrheas are due to infections (viruses, bacteria, helminths,
and protozoa).
•  Viral gastroenteritis (viral infection of the stomach and the small intestine) is the
most common cause of acute diarrhea worldwide.
Rotavirus the cause of nearly 40% of hospitalizations from diarrhea in children under 5 years.
(most common cause of diarrhea in children)
•  Food  poisoning
•  Drugs  
•  Others    
Chronic diarrhea:
1. Infection e.g. Giardia lamblia . AIDS often have chronic infections of their intestines
that cause diarrhea. Gardia covers the mucosa of the small intestine
and interfere with absorption and lead to
malabsorption , can be seen in the stool and in
mucosal biopsy.

2. Post-infectious Following acute viral, bacterial or parasitic infections

3. Malabsorption investigations for malabsorptions are applied mainly in chronic diarrhea
*to differentiate between the villus atrophy produced by celiac disease and post
infections :By the location in celiac disease the atrophy is in the proximal part of
the intestine while in post infection it involves the entire intestine.
4. Inflammatory bowel disease (IBD)
5. Endocrine diseases
6. Colon cancer
7. Irritable bowel syndrome

Antibiotic-Associated Diarrheas
•  Diarrhea  occurs  in  20%  of  patients  receiving broad-spectrum antibiotics; about 20%
of these diarrheas are due to Clostridium difficile
•  Leading  to  pseudomembranous  colitis  

Complications:
1.  Fluids  ………………Dehydration  
2.  Electrolytes  ……………..  Electrolytes  imbalance  
3. Sodium  bicarbonate…….  Metabolic  acidosis    
4.    If  persistent  ……Malnutrition  
 Summary

 Diarrhea is one of the most common causes of death in children all over the world; it
causes dehydration, electrolyte imbalance and death if not treated.
 The diarrhea is divided according to the pathophysiology into:
a. Secretory: caused by bacterial toxin and endocrine tumors with normal osmotic
gap.
b. Osmotic: result from malabsorbtion and osmotic laxatives with high osmotic
gap
c. Exudative: caused by invasive infection(ex. Shigella and salmonella) and
inflammatory bowel disease with present of pus and blood in stool.
d. Motility-related: Irritable bowel syndrome (IBS)

 Diarrhea is divided according to the aetiology into:

Acute diarrhea (2 weeks): most common caused by viral gastroenteritis.
Chronic diarrhea: it results from many causes like e.g.Giardia lamblia, and AIDS.
 1- Which type of diarrhea is associated lactose intolerance:
a) Secretory
b) Osmotic
c) Exudative (inflammatory )
d) Motility-related
Answer: b

2- all of the following are causes of acute diarrhea except:

a) Viral gastroenteritis
b) Food poisoning
c) Inflammatory bowel disease
d) Antibiotic-Associated Diarrheas
Answer: c

3- A 10-month-old, previously healthy male infant develops a severe, watery diarrhea 2 days after visiting the
pediatrician for a routine checkup. The most likely diagnosis is :
a) Rotavirus infection
b) Enterotoxigenic E. coli infection
c) Entamoeba histolytica infection
d) Lactase deficiency
e) Ulcerative colitis
Answer : a

Rotavirus accounts for estimated 130 million cases and 0.9 million deaths worldwide per year, and
constitute about 60% of children enterocolitis in the United States. The affected population is children 6
to 24 months of age; spread is by fecal-oral contamination. The prodrome of development of diarrhea
after infection is 2 days, and the disease last 3 to 5 days. (from Robbbins)