Chair consists of 60-90% water. In the Western world the stool volume is 100-200 g / day in healthy adults and children 10 g / kg / day, depending on the content of non-resorbable components of the diet (mainly carbohydrates). Diarrhea is defined as stool weight> 200 g / day. However, many people refer to any form of more fluid stool as diarrhea. On the other hand, many people make the fiber, a massive but shaped chair, which they do not regard as diarrhea.
(Overview malabsorption and overview of inflammatory Darmerkrankheiten. Diarrhea in children is discussed elsewhere.) The chair is made of 60-90% water. In the Western world the stool volume is 100-200 g / day in healthy adults and children 10 g / kg / day, depending on the content of non-resorbable components of the diet (mainly carbohydrates). Diarrhea is defined as stool weight> 200 g / day. However, many people refer to any form of more fluid stool as diarrhea. On the other hand, many people make the fiber, a massive but shaped chair, which they do not regard as diarrhea. Complications can arise from diarrhea of ??any etiology. It can (sodium, potassium, magnesium, chloride), and even circulatory collapse occur with fluid loss following dehydration, electrolyte loss. Such a collapse can develop very quickly in patients who have severe diarrhea (eg., Patients with cholera), or in very young, very old or debilitated patients. A loss of bicarbonate may cause metabolic acidosis. Hypokalemia may occur when patients have severe or chronic diarrhea or when the chair excessively contains mucus. Hypomagnesemia after long standing diarrhea can cause tetany. Normally etiology resorb small intestine and colon 99% of the liquid that comes from oral intake and gastrointestinal secretions – total liquid amount of about 9-10 liter per day. Thus, even small reductions (d. E. 1%) in the absorption of water in the intestine or an increase in the secretion increase the water content sufficient to cause diarrhea. There are a number of causes of diarrhea (see Table: Some causes of diarrhea *). Several fundamental mechanisms are responsible for most clinically significant diarrhea: increased osmotic stress, increased secretion and decreased contact time / area. In many diseases more than one mechanism is active. Diarrhea in inflammatory bowel diseases as a result of the inflammation of the mucosa, the exudation into the lumen and a plurality of secretagogues substances and bacterial toxins that affect the Enterozytenfunktion. Osmotic stress A diarrhea whenever non-resorbable, water-soluble, has passed into solution components remain in the intestine and retain water is produced. Such soluble components consisting of polyethylene glycol, magnesium salts (hydroxide and sulfate), and sodium phosphate, which are used as laxatives. An osmotic diarrhea occurs (eg., Lactose intolerance caused by lactase deficiency) for sugar intolerance. The ingestion of large amounts of hexitol (eg., Sorbitol, mannitol, xylitol) or corn syrup high fructose contained in sugar substitutes, in candies, chewing gum and fruit juices, causing an osmotic diarrhea because hexitol is hardly absorbed. Lactulose, which is used as a laxative, diarrhea caused by a similar mechanism. Overconsumption of certain foods (see table: Some causes of diarrhea *), an osmotic diarrhea verursachen.Erhöhte secretion a diarrhea occurs when the intestine secretes more electrolytes and water than it can absorb. Causes increased secretion include infection, unabsorbed fats, certain medications and various intrinsic and extrinsic secretagogues substances. Infections (z. B. gastroenteritis) are the most common cause of secretory diarrhea. Infections in combination with food poisoning are the most common cause of acute diarrhea (<4 days duration). Most enterotoxins block the sodium-potassium exchange, which is an important driving force for the liquid absorption in the small intestine and colon. Nichtresorbiertes dietary fat and bile acids (such as malabsorption syndromes and after ileal resection) may stimulate intestinal secretion and cause diarrhea. Drugs can stimulate the intestinal secretion directly (eg., Quinidine, quinine, colchicine, anthraquinone laxative, castor oil, prostaglandins) or indirectly by affecting fat absorption (eg. As orlistat). Various endocrine tumors produce secretion-stimulating substances, incl. Vipomas (vasoactive intestinal peptide), gastrinomas (gastrin), mastocytosis (histamine), medullary carcinoma of the thyroid (calcitonin and prostaglandins) and carcinoid tumors (histamine, serotonin, and polypeptides). Some of these mediators (eg. As prostaglandins, serotonin, related compounds) also accelerate the intestinal transit time, the intestinal transit or both. Impaired absorption of bile salts, which may occur with several disorders, can cause diarrhea by water and electrolyte secretion is stimulated. The stools have a green or orange Farbe.Reduzierte contact time / Surface Rapid intestinal transit and reduced surface affect the fluid intake and cause diarrhea. Common causes include a small intestine or large bowel resection or bypass, a gastric resection and inflammatory bowel disease. Other causes are microscopic colitis (collagenous or lymphocytic colitis) and celiac disease. The stimulation of intestinal smooth muscle by medicines (eg. As magnesium-containing antacids, laxatives, cholinesterase inhibitors, SSRI) or humoral substances (eg. As prostaglandins, serotonin) can also speed up the passage. Some causes of diarrhea * Type Examples Acute Viral Infektione norovirus, rotavirus Bacterial infection Salmonella, Campylobacter, or Shigella sp .; Escherichia coli, Clostridium difficile Parasitic infection Giardia sp, Entamoeba histolytica, Cryptosporidiasp.. Food poisoning staphylococci, Bacillus cereus, Clostridium perfringens drug laxatives, magnesium-containing antacids, caffeine, cytostatics, many antibiotics, colchicine, quinine / quinidine, prostaglandin, adjuvants (eg., Lactose) in elixirs Chronic drug See acute Conveniently, irritable bowel syndrome dietary factors Dietary factors that may aggravate diarrhea Inflammatory Bowel Disease Ulcerative colitis, Crohn's disease Surgical procedures intestinal or gastric bypass or resection malabsorption syndromes celiac disease, pancreatic insufficiency carbohydrate intolerance (especially lactose intolerance) tumors colon carcinoma, lymphoma, villous colon adenoma Endocrine tumors VIPoma, Gastrinoma, carcinoid, mastocytosis, medullary carcinoma of the thyroid Endocrine hyperthyroidism diabetes (multifactorial accompanying celiac disease, pancreatic insufficiency, autonomic neuropathy) * There are numerous causes. Some not mentioned herein may be the possible causes in certain subgroups. Diet factors that can aggravate diarrhea diet factor Source caffeine coffee, tea, cola, OTC headache remedy fructose (in quantities that exceed the resorptive capacity of the intestine) apple juice, pear juice, grapes, honey, dates, nuts, figs, soft drinks (especially fruit-flavored ), plums hexitol, sorbitol and mannitol sugar-free chewing gum, peppermint, sweet cherries, plums Lactose milk, ice cream, frozen yogurt, yogurt, soft cheese magnesium-containing antacids magnesium Olestra Certain fat-free potato chips or fat-free ice cream Modified from Bayless T: Chronic diarrhea. Hospital Practice January 15, 1989, p 131; by kind. Approval. Clarification of history, the history of the currently existing disease should determine the duration and severity of diarrhea, the circumstances surrounding its manifestation (incl. Recently of past travel, type of ingested food, drinking water quality), drug use (eg., Antibiotics during the previous 3 months) , abdominal pain or vomiting, frequency and time of onset of bowel movements, changes in stool consistency (e.g., admixtures of blood, pus or mucus;. changes in the color and consistency; occurrence of steatorrhea), changes of body weight, or appetite, urge to defecate, or tenesmus. The simultaneous occurrence of diarrhea in close contacts should be detected. A review of organ systems should for symptoms were looking for, suggesting the possible causes, including joint pain (inflammatory bowel disease, celiac disease), skin redness (carcinoid, Vipom, mastocytosis), chronic abdominal pain (irritable bowel syndrome, inflammatory bowel disease, gastrinoma) and gastrointestinal bleeding (ulcerative colitis, tumor ). The personal history should try to identify the known risk factors for diarrhea, incl. Inflammatory bowel disease, irritable bowel syndrome, HIV infection and earlier surgical procedures (eg. As intestinal or gastric bypass or resection, pancreatic resection). Family and social history should the simultaneous occurrence of diarrhea in close contacts erfragen.Körperliche investigation should the hydration condition of the patient to be assessed. In the whole-body examination especially the abdomen is inspected, including a rectal examination to assess the functioning of the sphincter. a test for the detection of occult blood is wichtig.Warnhinweise Certain findings substantiate the suspicion of an organic or serious etiology of diarrhea: blood or pus Fever signs of dehydration Chronic diarrhea weight loss interpretation of the findings Acute, watery diarrhea in an otherwise healthy person is likely infectious etiology, especially when traveling, possibly tainted food or a point source of the outbreak are the cause. Acute bloody diarrhea with or without hemodynamic instability in an otherwise healthy person suggests a enteroinvasive infection. Diverticular bleeding and ischemic colitis also manifested by acute bloody diarrhea. Recurring bouts of bloody diarrhea in a younger person suggest the suspicion of a chronic inflammatory bowel disease. If there is no use of laxatives large-volume diarrhea (z. B. daily stool volume> 1 l / day) strongly suspected in patients with normal gastrointestinal anatomy to endocrine cause. Oil droplets in the chair in the history suggest malabsorption, especially when so weight loss is associated. Diarrhea, consistently after intake of certain foods (eg. As fats) occurs due to suspected food intolerance. The recent use of antibiotics should always let think of an antibiotic-associated diarrhea, including Clostridium difficile colitis. Diatthö with green or orange chair suggests an impaired absorption of bile salts. These symptoms may be helpful in identifying the intestinal segment affected. In general, the chair is voluminous in diseases of the small intestine, aqueous or oily. In diseases of the colon, the bowel movements are common, eg. T. only in small amounts and possibly accompanied by blood, mucus, pus, or abdominal pain. In an irritable bowel syndrome (IBS) improve the abdominal complaints by defecation associated with thin or frequent chairs or both. However, these symptoms alone are not suitable, irritable bowel syndrome from other diseases (eg. As inflammatory bowel disease) to distinguish. Patients with irritable bowel syndrome or involvement of the rectal mucosa often show strong urinary urgency, tenesmus and small, frequent stools (irritable bowel syndrome (IBS) symptoms and complaints). Potentially important etiologic clues can provide Extraabdominal findings, incl. Skin lesions or appearance of Flush (mastocytosis), nodes in the thyroid (medullary thyroid cancer), heart sounds on the right side (carcinoid), enlargement of lymph nodes (lymphoma, AIDS) and arthritis (inflammatory bowel disease, celiac disease) .Testsverfahren in acute diarrhea (<4 days), no studies are usually required. Exceptions are patients with signs of dehydration, bloody stool, fever, severe pain, hypotension, or toxic symptoms - especially those who are very young or very old. In these patients, blood count, electrolytes, Harnstickstoffwerte and creatinine should be monitored. Stool samples should be collected for microscopy, cultures, fecal Leukozytenbestimmung and if a recent antibiotics were used for a C. difficile toxin assay. Chronic diarrhea (> 4 weeks) requires a thorough evaluation, as well as a shorter episode of diarrhea (1-3 weeks) in immunocompromised and seriously ill appearing patient. The initial examination of the stool should cultures, fecal Leukozytenbestimmung (by smear or determination of fecal lactoferrin) and microscopic examination for ova and parasites, pH determination (bacterial digestion of unabsorbed carbohydrates reduces the stool pH to <6.0), grease proof (Sudan staining) and electrolyte determination include (sodium and potassium). If no common pathogens are found, specific tests for Giardia antigen, for Aeromonas, Plesiomonas, coccidia and microsporidia are required. As a consequence, a Sigmoido- or colonoscopy should be performed with biopsy to rule out inflammatory causes. Chronic diarrhea develop in 10% of patients after an acute intestinal infection (post-infectious irritable bowel syndrome). If no obvious diagnosis is available and the Sudan staining gives a positive fat evidence that fecal fat amount should be determined; Moreover, radiographic small bowel and a CT Enterographie (structural disease) and a biopsy of the small intestine (the presence of mucosal diseases) are recommended. If these results do not lead to the goal, should be considered in patients with steatorrhea unknown origin the investigation of the structure and function of the pancreas into consideration (Acute Pancreatitis: Laboratory Tests). Rarely can reveal lesions capsule endoscopy, mainly Crohn's disease or NSAID enteropathy, which can not be identified by other methods. The osmotic gap in the stool, with 290 - is calculated 2 × (chair-chair-sodium + potassium), indicates whether it is a secretory or osmotic diarrhea. An osmotic gap <50 mEq / l suggests a secretory diarrhea, a larger gap is suspect of an osmotic diarrhea. In patients with osmotic diarrhea covert intake can magnesium-containing laxatives (detectable by magnesium values ??in the chair) (diagnosed by hydrogen breath test, lactase assay and diet protocol) or a carbohydrate malabsorption present. A hitherto serene secretory diarrhea requires an investigation on endocrine-related causes (eg. B. Plasmagastrin, calcitonin, VIP levels, histamine, and 5-hydroxy-acetoacetic acid [5-HIAA] in the urine). In addition, studies on a possible thyroid disease or a failure of the adrenal glands are required. Secret laxative abuse must be taken into consideration, it can be excluded by a fecal Laxanzienbestimmung. Treatment fluid and electrolytes against dehydration may Antidiarrheals in bloodless diarrhea in patients without systemic toxicity Severe diarrhea requires fluid and electrolyte replacement to correct fluid loss, electrolyte imbalance and acidosis. The parenteral administration of sodium chloride, potassium chloride and glucose-containing solutions is required. Salts, which counteract acidification (sodium lactate, acetate, bicarbonate) are indicated when the serum HCO3 = <15 mmol / l. An oral glucose-electrolyte solution can be given if the diarrhea is not serious and nausea and vomiting are scarce (Oral Rehydration Solutions). The simultaneous oral and parenteral administration of liquid is required in heavy water and electrolyte disorders (eg. As in cholera). Diarrhea is a symptom. If possible, the underlying disease should be treated, but symptomatic treatment is often necessary. Diarrhea can be reduced by oral administration of loperamide 2-4 mg 3 to 4 times daily (preferably 30 min before the meals), diphenoxylate 2.5-5 mg (tablets or liquid) 3 to 4 times daily, codeine phosphate 15-30 mg 2 to 3 times daily or elixir Paregoricum (containing camphor term tincture of opium) 5-10 ml, 1 to 4 times daily. Because medicines for diarrhea, a C. difficile colitis worsen or increase the probability of occurrence of a hemolytic uremic syndrome in the Shiga toxin-producing Escherichia coli infection, they should not be applied to bloody diarrhea of ??unknown cause. Their use should be limited to patients with aqueous diarrhea and lack of signs of general toxicity rather. However, there is little evidence for earlier concerns that anti-diarrheal agents protract the elimination of bacterial pathogens. Psyllium and methylcellulose compounds increase the intestinal contents. Although they are generally prescribed for constipation, these substances can also reduce the liquid content of watery stools in small doses. Kaolin and pectin absorb liquid. Osmotically active food ingredients (see table: Diet factors that can aggravate diarrhea) and stimulatory drugs should be avoided. Key Points For patients with acute diarrhea is a stool test (culture, ova and parasites, C. difficile cytotoxin) required only for those who have prolonged symptoms (i. E.> 1 week) or suspicious findings have. one should be careful in the use of anti-diarrheal agents when a C. difficile colitis, a Salmonella infection or shigellosis is possible. After an acute infectious enteritis, a post-infectious irritable bowel syndrome developed in 10% of patients.