![]() 79 The problem of detecting drug-induced diarrhea is more difficult in patients with surreptitious laxative abuse these patients deliberately conceal vital information about the cause of their problem (see later). Olmesartan can cause a sprue-like enteropathy (see Chapter 107). ![]() A diverse group of drugs (e.g., aspirin, mycophenolate mofetil, gold) can incite an inflammatory process in the intestine that may cause diarrhea. Chemotherapeutic agents are associated with a high frequency of diarrhea, which may result from disruption of the delicate balance between enterocyte proliferation and apoptosis, leading to what has been termed an apoptotic enteropathy (see Chapter 36). Some drugs (e.g., cocaine) may interfere with blood flow to the intestine. Other antibiotics may alter the bacterial flora in the colon and lead to impaired colonic salvage of malabsorbed carbohydrate or overgrowth of toxin-producing Clostridioides difficile. Some drugs may activate specific receptors and transporters for example, caffeine, like theophylline, may increase intracellular cAMP activity and fluid secretion, as can be seen clinically in cases of what has been called “Starbucks diarrhea.” Erythromycin interacts with the motilin receptor, thereby stimulating propulsive motor activity in the GI tract. The pathophysiology of drug-induced diarrhea is complex and has not been well studied. 75-79 Identifying drugs as the cause of diarrhea depends on recognizing that the initiation of drug ingestion and the onset of diarrhea occurred coincidentally, but such a temporal correlation is not always easy to identify and requires a detailed and carefully taken history. Diarrhea in such cases is mediated by secretion of cytokines and other inflammatory mediators (see Chapter 128).Ĭhronic watery diarrhea can also be caused by ingestion of drugs or poisons ( Box 16.4). By contrast, chronic secretory diarrhea, in which electrolyte malabsorption leads to fluid retention within the lumen, is associated with many clinical conditions (see Box 16.2).Īlthough IBD typically produces diarrhea characterized by the presence of blood and pus, other inflammatory diseases without ulceration (e.g., microscopic colitis) may cause diarrhea with the characteristics of chronic secretory diarrhea. Ingestion of any of a limited number of osmotic agents, such as magnesium, phosphate, and sulfate laxatives or poorly absorbed carbohydrates, causes osmotic diarrhea. Diseases that lead to chronic diarrhea may present with an acute onset and therefore must be considered when acute diarrhea becomes persistent.Ĭhronic watery diarrhea may be caused by ingestion of poorly absorbed, osmotically active substances (osmotic diarrhea) or, more commonly, conditions that cause secretory diarrhea. ![]() Acute diarrhea also can be caused by food poisoning, food allergies, and medications. 73 The usual cause is infection by bacteria, viruses, protozoa, or multicellular parasites ( Box 16.3). To facilitate the differential diagnosis, the clinician first should divide diarrheal diseases into acute and chronic, and then subdivide chronic diarrhea by stool characteristics-watery, inflammatory, and fatty ( Box 16.2).Īcute diarrhea is defined as lasting less than 4 weeks, although many cases last fewer than 4 days. Many GI and systemic diseases can present with diarrhea. Mark Feldman MD, in Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 2021 Differential Diagnosis
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