At this point, we will then categorize our diarrhea.
This is important table for you to able to properly organize your thoughts.
The category of the type of diarrhea, clinical conditions
and the important comments of each one of these.
Osmotic diarrhea: As we get older, our need and requirement for calcium starts dropping.
This becomes quite evident to us because as we get older
and if we were to consume the same amount of dairy that may be perhaps did,
once upon a time when we were young,
there´s a possibility that this is going to be rapidly evacuated from the colon
due to the fact that as we get older naturally speaking
and physiologically speaking, lactase, in fact, becomes more and more scarce.
Or you can have a patient who is actually lactase deficient.
What does that mean to you? Remember that if you are reabsorbing
your glucose from your intestinal lumen,
you have to have it in the form of monosaccharide.
The type of monosaccharide that becomes the most important to you physiologically
and then here pathologically will be glucose. Others include galactose as well.
The combination of glucose and galactose gives you an interesting disaccharide
and that being the lactose. The lactose, of course, being the major carbohydrate
that is contained in dairy. The reason that we're able to metabolize our lactose
so very well is because of this very enzyme that we´re seeing, lactase.
Quickly, physiologically and biochemistry, as we consume our carbohydrate or dairy,
we have amylase within our mouth salivary,
begins the digestion but obviously does not complete the full digestion.
In the stomach further, we have acid and such
which then further breaks down the carbohydrate.
By the time we get in to our duodenum, first and second part
which is highly, highly concentrated with finger-like projections called microvilli
which then you can refer to as being your brush border.
Literally, the finger-like projections are like your brush borders.
This brush border then contains a type of disaccharidase,
another name for your lactase will be the enzyme that breaks down disaccharide.
Be smart about how your approach of material.
Therefore, a lactase is called a disaccharidase which it does exactly
as to what the name implies which is to break down your disaccharide.
Which one is it when we consume milk or dairy? Lactose.
What if your patient is lactase deficient?
Then, you´ve left behind lactose and disaccharide back in your intestinal lumen.
You´ve now created an osmotic force which is then diffusing water out
from your tissue or from the ECF and coming into the intestinal lumen.
Literally drawing water in and take a look at how much volume you´re losing.
It´s going to be a lower amounts of volume and here you have osmolar gap
at being greater than 40. Stops with fasting and here you might find the pH to be less than 6.
Welcome to an osmotic diarrhea lactose intolerance.
The second type is secretory type of diarrhea.
The ones that you should be quite familiar with or those that are peptide-like.
For example, the one type of tumor that produces too much serotonin and company
would be carcinoid and whenever you think about carcinoid tumor,
you should be thinking about residing within the intestines.
That´s where the carcinoid tumor begins.
Therefore the type of stool that you are going to examine
and which you are examining in the stool would be for your 5-hydroxyindoleacetic acid (5-HIAA).
One type of secretory, VIPoma, the important acronym here that you will know
or should know is WDHA and WD stands for watery diarrhea.
With all that diarrhea, your potassium levels drop like crazy,
the H stands for hypokalemia and then finally, the A stands for achlorhydria
but this would be a secretory type of diarrhea.
Now a far from tumors and including a gastrinoma here,
a far from tumors that also produce your secretory diarrhea.
You can have certain organisms. For example, say that you drink contaminated water
that contains the organism, the bacteria, vibrio cholera.
A Vibrio cholera then works upon your intestinal cell.
In other base, a lot of membrane cause what's known as ADP-ribosylation
if you remember from biochemistry.
That ADP-ribosylation is then going to insert or open up these chloride channels
and lumina membrane and what is it going to do? You've heard of rice water stools.
This is a secretory type of diarrhea. E. coli, there´s something called 'ETEC'.
Remember from micro, E. coli could also result in a secretory type of diarrhea.
You also have laxatives such as Senna and all these may result in secretory.
Now, here, yes, it´s also large volume stool,
however the osmolar gap is not going to be as significant as to what you find with osmotic diarrhea.
That is important for you to pay attention too and even though your patient might be fasting,
it doesn´t matter because this is a secretory biochemical activation.
Just because you stop eating doesn´t mean the diarrhea stops.
That is very dangerous 'cause what´s your next step of management.
That´s a lot of fluid loss that the patient is experiencing
so you need to make sure that you do supportive therapy with IV fluids and company.
Next, we have abnormal motility and here, you should be thinking about
dumping syndrome that we have discussed earlier.
For example during surgery there is every possibility that the pyloric sphincter might be compromised.
There is an increase of dumping of this chyme into the intestine.
We´ve talked about the symptoms where there might be things like hypoglycemia
and the fact that there is going to be flushing and sweating and tachycardia and company.
With all those dumping taking place with abnormal motility,
you can only imagine that there is going to be a diarrhea. In fact, thyroid issues, increase motility.
Thyroid issues, hyperthyroidism would cause more or less diarrhea
where as you see here in the paragraph, decreased motility, diabetes mellitus
which slows things down because you might be suffering from diabetic neuropathy.
In addition, what else may then decrease motility? What if you had Scl-70 in fibrosis?
We´ve talked about scelorodermal so occurring up in the esophagus.
The scleroderma, if it´s a visceral type and it´s systemic
may also cause fibrosis all over the place including intestine, decreased motility,
along with this hypothyroidism. For example, if you have Hashimoto, it´s primary hypothyroidism.
The patient maybe suffering from constipation.
The diarrhea due to bacterial overgrowth and syndrome of/and decreased motility.
Exudative. Example for this, inflammatory bowel disease such as ulcerative colitis.
Infection. Diverticulitis, is exudative. Diverticulitis, we´ve talked about diverticular disease.
So we'll begins by looking at it by referring to diverticuli
and then we'll go into diverticulosis and some point with diverticuli with fecalith accumulating in there.
My goodness, just a matter of time before your patient goes into state of diverticulitis
and as for the inflammatory, that's pretty exudative by the time the stool then comes out.
Here once again, variable quantity and with exudative
think of once again ulcerative colitis which almost always begins in the rectum.
With all that ulceration taking place and in your stool, then you might be looking for blood.
Anorectal dysfunction. Neurologic disease post-surgically. Here, it´s small stool volume.