History

Fact Explanation
Loose, mushy or watery stools The symptom of loose, mushy or watery stools was the most frequent symptom of functional diarrhea. In fact, most people apply the term diarrhea to loose or watery stools. It was indicated that stool form, not frequency, defined diarrhea, and how often a symptom must occur to be significant depends on its troublesomeness.[1].
Frequent bowel movements without abdominal pain More than three bowel movements a day can be identified.Functional diarrhea was defined in accordance with the Rome II criteria as loose, mushy, or watery stools, present more than three quarters of the time and no abdominal pain in the last 3 months.[1].
Having to rush to the toilet Having to rush to the toilet to have a bowel movement is one of the most common symptom of functional diarrhea.[1].
Feeling of Incomplete emptying Feeling of incomplete emptying after a bowel movement is another reported symptom.[1].
Abdominal fullness Another presenting symptom of functional diarrhea.[1].
Bloating or swelling Functional diarrhea may also present with bloating and swelling. But not a frequent complaint.[1].
Food intolerance Food intolerance, especially to wheat, corn, and dairy products, seems to be a common cause of functional diarrhea in some patients.[2].
History of male sex and high BMI Some studies showed that the prevalence of functional diarrhea was slightly higher in men than in women.It might be that men had a faster colonic transit time than women, and women had delayed gastric emptying of liquids and solids compared to that in men. Studies also found that BMI was positively associated with functional diarrhea.This may be that BMI is correlated inversely with colonic transit time and overweight/obese patients have more severe symptoms of urgency, loose stools and more stools per day.[1].
Family history of gastrointestinal diseases Some studies found that functional diarrhea was significantly associated with a family history of gastrointestinal diseases. Common demographic risk factors and a genetic predisposition may play a role in this relationship.[1].
References
  1. ZHAO YAN-FANG, GUO XIAO-JING, ZHANG ZHAN-SAI, MA XIU-QIANG, WANG RUI, YAN XIAO-YAN, HE JIA, KIRK MARTYN. Epidemiology of Functional Diarrhea and Comparison with Diarrhea-Predominant Irritable Bowel Syndrome: A Population-Based Survey in China. PLoS ONE [online] 2012 August [viewed 05 September 2014] Available from: doi:10.1371/journal.pone.0043749
  2. HEATON KW. Functional diarrhoea: the acid test. Br Med J (Clin Res Ed) [online] 1985 May 4, 290(6478):1298-1299 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1415544

Examination

Fact Explanation
Mucus containing stool Passing mucus (slime) during a bowel movement also observed in patients with functional diarrhea.[1].
Features of dehydration Have to look for the features of dehydration. If there is no dehydration, but diarrhea,It is corresponds to <5% loss of total body weight. In moderate dehydration patient feels thirsty, dry mouth/tongue, no tears, sunken eyes, skin pinch slow to retract and it is corresponds to 5%–10% loss of total body weight. In severe dehydration,patient is unconscious, lethargic or floppy, weak pulse, unable to drink and corresponds to >10% loss of total body weight. Those patients who are hemodinamically unstable, may need immediate fluid resuscitation.[2].
Abdominal examination findings Even functional diarrhea itself not produced any specific abdominal finding, abdominal examination is performed to exclude other associated pathologies such as colorectal cancers that sometimes give rise to palpable masses.[3].
Pallor Right sided colorectal tumors were associated with anemia. So that examination of pallor should be performed to detect clinical presence of anemia.[3].
DRE findings Digital rectal examtion can perform, not in all cases but in suspected cases of malignancy such as colorectal cancer in elderly patients. It has the ability to identify low rectal cancers but not high rectal cancers.[4].
Gynecological examination for women In women, gynecological causes (endometriosis, adnexitis, ovarian cysts, ovarian carcinoma) should be ruled out through an examination by a gynecologist.[5].
References
  1. ZHAO YAN-FANG, GUO XIAO-JING, ZHANG ZHAN-SAI, MA XIU-QIANG, WANG RUI, YAN XIAO-YAN, HE JIA, KIRK MARTYN. Epidemiology of Functional Diarrhea and Comparison with Diarrhea-Predominant Irritable Bowel Syndrome: A Population-Based Survey in China. PLoS ONE [online] 2012 August [viewed 05 September 2014] Available from: doi:10.1371/journal.pone.0043749
  2. CHOWDHURY F, KHAN AI, FARUQUE AS, RYAN ET. Severe, Acute Watery Diarrhea in an Adult PLoS Negl Trop Dis [online] , 4(11):e898 [viewed 08 September 2014] Available from: doi:10.1371/journal.pntd.0000898
  3. KOO HY, PARK KJ, OH JH, KANG SB, OH ST, LEE WY. Investigation of Clinical Manifestations in Korean Colorectal Cancer Patients Ann Coloproctol [online] 2013 Aug, 29(4):139-143 [viewed 16 September 2014] Available from: doi:10.3393/ac.2013.29.4.139
  4. BROWN G, DAVIES S, WILLIAMS GT, BOURNE MW, NEWCOMBE RG, RADCLIFFE AG, BLETHYN J, DALLIMORE NS, REES BI, PHILLIPS CJ, MAUGHAN TS. Effectiveness of preoperative staging in rectal cancer: digital rectal examination, endoluminal ultrasound or magnetic resonance imaging? Br J Cancer [online] 2004 Jul 5, 91(1):23-29 [viewed 16 September 2014] Available from: doi:10.1038/sj.bjc.6601871
  5. HäUSER W, LAYER P, HENNINGSEN P, KRUIS W. Functional Bowel Disorders in Adults Dtsch Arztebl Int [online] 2012 Feb, 109(5):83-94 [viewed 06 September 2014] Available from: doi:10.3238/arztebl.2012.0083

Differential Diagnoses

Fact Explanation
Irritable bowel syndrome Irritable bowel syndrome (IBS) is a functional condition of the bowel.It is diagnosed by clinically rather than investigations. Affected individuals may experience symptoms such as abdominal pain and altered bowel habit. It can be either predominantly diarrhea (IBS-D), constipation (IBS-C), or both (IBS-M).[1]. Diagnostic criteria of IBS include duration of at least 12 weeks but need not be consecutive, in the preceding 12 months of abdominal discomfort or pain with two of three features of followings. (1) Relieved with defecation; and/or(2) Onset associated with a change in frequency of stool; and/or (3) Onset associated with a change in appearance of stool. [2]. However clinicians frequently use other clinical findings such as bloating and psychological stress to assist in diagnosing IBS and do not adhere to the above criteria.[1].
Crohns disease Crohns disease is a gastrointestinal disorder in which any part of the alimentary tract may become inflamed, from the mouth to the anus. The disease is characterized by following signs and symptoms, the most common of which are abdominal pain, diarrhea, fever, and weight loss.There are several extraintestinal features, such as arthritis, iritis, and mucocutaneous lesions. Some of the more common lesions include erythema nodosum, pyoderma gangrenosum, Sweet syndrome, epidermolysis bullosa acquista and clubbing .Oral lesions can also be present.Nonspecific lesions, such as aphthous ulcers, labial and facial edema and gingival erythema and edema may also seen.[3].
Bile acid malabsorption It is a known cause of chronic diarrhea. Although bile acids are absorbed both actively and passively,symptomatic bile acid malabsorption results from failure of the active transport of bile acids in the terminal one meter of the ileum. Three types of bile acid malabsorption are recognized. They are Type 1 that occurs following ileal resection or bypass of the terminal ileum.Type 2 caused by primary idiopathic malabsorption. Type 3 is associated with surgeries such as cholecystectomy, chronic pancreatitis, peptic ulcer surgery and coeliac disease.[4].
Lactose intolerance Approximately about 75% of the people loses this ability of lactose digestion in some part of their lives. Colonic microflora ferment undigested lactose in the intestinal lumen. It will lead to production of short-chain fatty acids, hydrogen, methane and carbon dioxide. These byproducts cause bloating, flatulence, and abdominal pain. Undigested lactose acidifies the colon and increases the osmotic load leads to loose stools and diarrhea. Those stools are foamy, voluminous, and aqueous. However affected individuals usually do not lose weight. Some patients found to have constipation due to decreased intestinal motility.[5].
Colorectal cancer (CRC) The presenting symptoms may be rectal bleeding, altered bowel habit such as constipation or diarrhea, weight loss, abdominal pain, palpable mass and anemia.Right-sided tumors commonly associated with anemia and the left-sided tumors were associated with visible blood in stools and altered bowel habits. It is common in patients older than 60 years. CRC patients with bleeding tended to be present in an early stageof the disase where the CRC patients with constipation tended to present with a more advanced stage.[6].
References
  1. CANAVAN C, WEST J, CARD T. The epidemiology of irritable bowel syndrome Clin Epidemiol [online] :71-80 [viewed 06 September 2014] Available from: doi:10.2147/CLEP.S40245
  2. THOMPSON W G, LONGSTRETH G F, DROSSMAN D A, HEATON K W, IRVINE E J, MULLER-LISSNER S A. Functional bowel disorders and functional abdominal pain. Gut [online] 1999 September, 45(Supplement 2):ii43-ii47 [viewed 06 September 2014] Available from: doi:10.1136/gut.45.2008.ii43
  3. SIDIROPOULOS M, SKUY B. Crohn's disease presenting with atypical mucocutaneous lesions in an 11 year old boy Mcgill J Med [online] 2011 Jun, 13(1):28 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277335
  4. WILLIAMS AJ, MERRICK MV, EASTWOOD MA. Idiopathic bile acid malabsorption--a review of clinical presentation, diagnosis, and response to treatment. Gut [online] 1991 Sep, 32(9):1004-1006 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1379038
  5. MATTAR R, DE CAMPOS MAZO DF, CARRILHO FJ. Lactose intolerance: diagnosis, genetic, and clinical factors Clin Exp Gastroenterol [online] :113-121 [viewed 06 September 2014] Available from: doi:10.2147/CEG.S32368
  6. KOO HY, PARK KJ, OH JH, KANG SB, OH ST, LEE WY. Investigation of Clinical Manifestations in Korean Colorectal Cancer Patients Ann Coloproctol [online] 2013 Aug, 29(4):139-143 [viewed 16 September 2014] Available from: doi:10.3393/ac.2013.29.4.139

Investigations - for Diagnosis

Fact Explanation
Complete blood count FBC is suggested to look for anemia and signs of inflammation. They were taken as red flag signs.The absence of red flags, a normal physical examination, and the presence of yellow flags support the diagnosis of a functional bowel disorder.[1].
Erythrocyte sedimentation rate (ESR) Carried out to rule out other inflammatory causes.[1].
C-reactive protein (CRP) Also carried out to rule out other inflammatory causes.[1].
Urinalysis Also perform as a basic investigation to exclude other pathological conditions.[1].
Abdominal ultrasonography Ultrasonography is part of the basic diagnostic assessment of abdominal symptoms. Carried out in functional diarrhea to exclude other abdominal pathology.[1]. Endoluminal ultrasound can used to identify intraluminal tumour masses in rectum.[4]. Transabdominal ultrasound also can detect bowel wall thickening, enlarged lymph nodes, abdominal tuberculosis, , pneumatosis and complications such as amoebic liver abscesses.[5].
Sigmoidoscopy with biopsy/ Ileocolonoscopy Chronic diarrhea without pain is caused by many diseases. So that to rule out other serious pathology sigmoidoscopy with biopsy is performed.[3].No investigations except sigmoidoscopy and rectal biopsy are needed when the patient is under 40, has had diarrhea off and on for many years, when his symptoms are closely related to stress and anxiety, and when his weight is steady and his stool is free of occult blood. [2]. Ileocolonoscopy can be carried out in individual basis, for patients over age 50, for patients over age 45 with a family history of colon cancer, and for patients of any age with elevated levels of calprotectin A / lactoferrin in the stool).[1].
Stool tests Basic evaluation of functional diarrhea includes routine blood and stool tests plus sigmoidoscopy with biopsy.[3]. Calprotectin A / lactoferrin in the stool can be performed for further evaluation on individual basis.[1].
Selenium-75-homotaurocholic acid test (SEHCAT) A special diagnostic test, that performed depending on the main symptoms.[1]. SEHCAT, a radiolabelled bile acid analogue which emits gamma rays and so can be counted easily with little or no handling of stools.SEHCAT can be use to confirm bile acid malabsorption in patients with chronic diarrhoea.[2].
References
  1. HäUSER W, LAYER P, HENNINGSEN P, KRUIS W. Functional Bowel Disorders in Adults Dtsch Arztebl Int [online] 2012 Feb, 109(5):83-94 [viewed 06 September 2014] Available from: doi:10.3238/arztebl.2012.0083
  2. HEATON KW. Functional diarrhoea: the acid test. Br Med J (Clin Res Ed) [online] 1985 May 4, 290(6478):1298-1299 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1415544
  3. THOMPSON W G, LONGSTRETH G F, DROSSMAN D A, HEATON K W, IRVINE E J, MULLER-LISSNER S A. Functional bowel disorders and functional abdominal pain. Gut [online] 1999 September, 45(Supplement 2):ii43-ii47 [viewed 06 September 2014] Available from: doi:10.1136/gut.45.2008.ii43
  4. BROWN G, DAVIES S, WILLIAMS GT, BOURNE MW, NEWCOMBE RG, RADCLIFFE AG, BLETHYN J, DALLIMORE NS, REES BI, PHILLIPS CJ, MAUGHAN TS. Effectiveness of preoperative staging in rectal cancer: digital rectal examination, endoluminal ultrasound or magnetic resonance imaging? Br J Cancer [online] 2004 Jul 5, 91(1):23-29 [viewed 16 September 2014] Available from: doi:10.1038/sj.bjc.6601871
  5. CASBURN-JONES AC, FARTHING MJ. Management of infectious diarrhoea Gut [online] 2004 Feb, 53(2):296-305 [viewed 16 September 2014] Available from: doi:10.1136/gut.2003.022103

Investigations - Fitness for Management

Fact Explanation
Blood urea and serum creatinine Acute renal failure a common manifestation secondary to diarrheal diseases due to dehydration.[3]. So to detect those conditions these test are performed.[4].
Serum electrolytes Use for Further diagnostic evaluation.It is important to inform the patient that these tests are very unlikely to reveal a serious illness, and that they are simply being performed to rule such illnesses out.[1].Usually Patients with functional diarrhoea do not get dehydrated or hypokalaemic.[2].
References
  1. HäUSER W, LAYER P, HENNINGSEN P, KRUIS W. Functional Bowel Disorders in Adults Dtsch Arztebl Int [online] 2012 Feb, 109(5):83-94 [viewed 06 September 2014] Available from: doi:10.3238/arztebl.2012.0083
  2. HEATON KW. Functional diarrhoea: the acid test. Br Med J (Clin Res Ed) [online] 1985 May 4, 290(6478):1298-1299 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1415544
  3. KAM TAO LI P, BURDMANN EA, MEHTA RL, FOR THE WORLD KIDNEY DAY STEERING COMMITTEE 2013. Acute kidney injury: Global health alert J Nephropathol [online] 2013 Apr, 2(2):90-97 [viewed 16 September 2014] Available from: doi:10.12860/JNP.2013.15
  4. THOMAS P, FORBES A, GREEN J, HOWDLE P, LONG R, PLAYFORD R, SHERIDAN M, STEVENS R, VALORI R, WALTERS J, ADDISON G, HILL P, BRYDON G. Guidelines for the investigation of chronic diarrhoea, 2nd edition Gut [online] 2003 Jul, 52(Suppl 5):v1-v15 [viewed 16 September 2014] Available from: doi:10.1136/gut.52.suppl_5.v1

Investigations - Screening/Staging

Fact Explanation
Psychosocial screening Functional diarrhea itself can cause psychological disturbances. And on the other hand psycosocial factors as well as somatic factors also contribute for this.Impairment can be assess by asking few questions. The affect to the day today life can assess by asking “How do the symptoms affect your everyday life/your performance?” and emotional state can be assess by asking“Have you often felt depressed in the past month? Have you often felt anxious or nervous in the past month?” like questions. Symptoms get worse when disease get progressed.[1].
References
  1. HäUSER W, LAYER P, HENNINGSEN P, KRUIS W. Functional Bowel Disorders in Adults Dtsch Arztebl Int [online] 2012 Feb, 109(5):83-94 [viewed 06 September 2014] Available from: doi:10.3238/arztebl.2012.0083

Management - General Measures

Fact Explanation
Symptom explanation, and reassurance Discussion should be include disease symptoms and signs, contributory factors including psychological factors and reassurance of the patient.[2]. They should be assure that they have normal life expectancy. Explain them about stress or vicious-circle model of the disease. Then asked them to do regular physical exercise, engage in their hobbies and social contact to overcome the stress.Educate them that those measures will cause improvement of the disease but not fully curative.[1].
Dietary measures Restriction of foods seems to be help.[2].If the clinical history suggest that the symptoms related to a certain food, these measures can be taken. The patient should asked to keep a diary of food intake and symptoms for a limited period of time. Those measures can be continue only if they clearly improved the patient’s symptoms.[1].
References
  1. HäUSER W, LAYER P, HENNINGSEN P, KRUIS W. Functional Bowel Disorders in Adults Dtsch Arztebl Int [online] 2012 Feb, 109(5):83-94 [viewed 06 September 2014] Available from: doi:10.3238/arztebl.2012.0083
  2. THOMPSON W G, LONGSTRETH G F, DROSSMAN D A, HEATON K W, IRVINE E J, MULLER-LISSNER S A. Functional bowel disorders and functional abdominal pain. Gut [online] 1999 September, 45(Supplement 2):ii43-ii47 [viewed 06 September 2014] Available from: doi:10.1136/gut.45.2008.ii43

Management - Specific Treatments

Fact Explanation
Loperamide and diphenoxylate Diphenoxylate or loperimide like empiric antidiarrheal therapy found to be effective. Specially if taken those drugs prophylactically, before meals .[1]. Loperamide and a diphenoxylate-atropine combination act by increasing intestinal transit time and enhancing the potential for reabsorption of fluid and electrolytes. They have some effect on reducing faecal losses and loperamide also found to have some antisecretory activity .[3]. Loperamide can be used over long term because it is not systemically bioavailable. Treatment causes improvement of quality of life and improvement of symptoms but not elimination.[2]. Loperamide found to be efficacious even in low doses such as 0.1–0.25 mg/kg/day. So that the lowest efficacious dose should be used reduce the risk of overdose.[4].
Cholestyramine The occasional patient responds to cholestyramine.[1].Colestyramine is an anion exchange resin. It forms complexes with organic anions such as bile acids with high affinity.It is mainly helpful to control bile acid diarrhea. This drug is generally well tolerated but has an unpleasant taste. Constipation is the main side effect of the drug. Other Side effects include nausea, , flatulence, bloating, borborygmi and abdominal pain.[5].
References
  1. THOMPSON W G, LONGSTRETH G F, DROSSMAN D A, HEATON K W, IRVINE E J, MULLER-LISSNER S A. Functional bowel disorders and functional abdominal pain. Gut [online] 1999 September, 45(Supplement 2):ii43-ii47 [viewed 06 September 2014] Available from: doi:10.1136/gut.45.2008.ii43
  2. HäUSER W, LAYER P, HENNINGSEN P, KRUIS W. Functional Bowel Disorders in Adults Dtsch Arztebl Int [online] 2012 Feb, 109(5):83-94 [viewed 06 September 2014] Available from: doi:10.3238/arztebl.2012.0083
  3. CASBURN-JONES AC, FARTHING MJ. Management of infectious diarrhoea Gut [online] 2004 Feb, 53(2):296-305 [viewed 16 September 2014] Available from: doi:10.1136/gut.2003.022103
  4. LI SU‐TING T., GROSSMAN DAVID C., CUMMINGS PETER. Loperamide Therapy for Acute Diarrhea in Children: Systematic Review and Meta-Analysis. Plos Med [online] 2007 December [viewed 16 September 2014] Available from: doi:10.1371/journal.pmed.0040098
  5. PATTNI S., WALTERS J. R. F.. Recent advances in the understanding of bile acid malabsorption. British Medical Bulletin [online] December, 92(1):79-93 [viewed 17 September 2014] Available from: doi:10.1093/bmb/ldp032