Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis

 

Am Fam Physician. 2020 Apr 15;101(8):472-480.

  Patient information: See related handout on chronic diarrhea, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Chronic diarrhea is defined as a predominantly loose stool lasting longer than four weeks. A patient history and physical examination with a complete blood count, C-reactive protein, anti-tissue transglutaminase immunoglobulin A (IgA), total IgA, and a basic metabolic panel are useful to evaluate for pathologies such as celiac disease or inflammatory bowel disease. More targeted testing should be based on the differential diagnosis. When the differential diagnosis is broad, stool studies should be used to categorize diarrhea as watery, fatty, or inflammatory. Some disorders can cause more than one type of diarrhea. Watery diarrhea includes secretory, osmotic, and functional types. Functional disorders such as irritable bowel syndrome and functional diarrhea are common causes of chronic diarrhea. Secretory diarrhea can be caused by bile acid malabsorption, microscopic colitis, endocrine disorders, and some postsurgical states. Osmotic diarrhea can present with carbohydrate malabsorption syndromes and laxative abuse. Fatty diarrhea can be caused by malabsorption or maldigestion and includes disorders such as celiac disease, giardiasis, and pancreatic exocrine insufficiency. Inflammatory diarrhea warrants further evaluation and can be caused by disorders such as inflammatory bowel disease, Clostridioides difficile, colitis, and colorectal cancer.

Chronic diarrhea is defined as a predominantly decreased stool consistency lasting longer than four weeks.1,2 The prevalence is estimated to be 1% to 5% of the adult population.1 Common causes include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), celiac disease, and microscopic colitis. The differential diagnosis for chronic diarrhea is broad; however, a thorough history and physical examination can narrow the diagnostic evaluation. The British Society of Gastroenterology published guidelines for the evaluation of chronic diarrhea, and other authors suggest similar diagnostic approaches, but supporting evidence is weak.1,2 The recommendations in this article are based on the evidence available and published guidelines for the evaluation of causes of chronic diarrhea. Figure 1 is an algorithm for the diagnosis of chronic diarrhea.14

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

A normal C-reactive protein or fecal calprotectin level effectively rules out inflammatory bowel disease for patients who meet Rome IV diagnostic criteria for irritable bowel syndrome without alarm features.1,3,13,30

A

Good-quality meta-analysis and clinical guidelines

Serologic testing should be performed for celiac disease in all patients presenting with chronic diarrhea.1,3,8

C

Evidence-based guidelines, consistent retrospective evidence

Clinicians testing for Clostridioides difficile infection should examine only diarrheal stools.21

C

Evidence-based guidelines, consistent observational evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

A normal C-reactive protein or fecal calprotectin level effectively rules out inflammatory bowel disease for patients who meet Rome IV diagnostic criteria for irritable bowel syndrome without alarm features.1,3,13,30

A

Good-quality meta-analysis and clinical guidelines

Serologic testing should be performed for celiac disease in all patients presenting with chronic diarrhea.1,3,8

C

Evidence-based guidelines, consistent retrospective evidence

Clinicians testing for Clostridioides difficile infection should examine only diarrheal stools.21

C

Evidence-based guidelines, consistent observational evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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FIGURE 1.

Algorithm for the diagnosis of chronic diarrhea.

Information from references 14.


FIGURE 1.

Algorithm for the diagnosis of chronic diarrhea.

Information from references 14.

History

Most patients use the word diarrhea to describe loose stools3; however, some patients may use it to describe fecal urgency, frequency, or incontinence.2 The Bristol Stool Scale (https://www.aafp.org/afp/2011/0801/p299.html#afp20110801p299-f1) is helpful in distin

The Authors

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KRISTINA BURGERS, MD, FAAFP, was an associate program director at Womack Army Medical Center Family Medicine Residency Program, Fort Bragg, N.C., at the time this article was written....

BRIANA LINDBERG, MD, was chief resident in the Womack Army Medical Center Family Medicine Residency Program at the time this article was written.

ZACHARY J. BEVIS, MD, is a faculty physician at the Womack Army Medical Center Family Medicine Residency Program, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

Address correspondence to Kristina Burgers, MD, Womack Army Medical Center, 2817 Reilly Rd., Fort Bragg, NC 28310 (email: kristina.g.burgers.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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