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Rectal/lower colonic impaction of scybala (hard, rounded stools) stimulates an increase in mucus production. Impaction with overflow – ‘spurious’ (non-genuine) diarrhoea.
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Fear and anxiety may cause diarrhoea (Metcalf, 2007 Norton and Chelvanayagam, 2004) and stress may precipitate a relapse of IBS and IBD (Bell, 2004). Factitious diarrhoea – either from laxative abuse or from adding urine or water to stool specimens – accounts for 20% of referrals to tertiary care for diarrhoea of undetermined origin (Thomas et al, 2003). Diarrhoea may result from laxative abuse in eating disorders or for other reasons, including malingering (where there is a primary gain, for example missing work), Munchausen’s syndrome and Munchausen’s syndrome by proxy (Kumar et al, 2007 Bell, 2004). Patients frequently have diarrhoea attributed to chronic infection, bacterial overgrowth and lactose intolerance (Bell, 2004). Diarrhoea occurs when the secretion exceeds the absorption capacity of the gut or where there is inhibition of ion transportation and therefore absorption of water from the colon (Metcalf, 2007 Bell, 2004 Thomas et al, 2003 Ganong, 1995). This is associated with rare tumours that cause the overproduction of vasoactive intestinal peptide, a hormone that stimulates secretion of electrolytes and hence water from intestinal glands. Diarrhoea may result from radiation enteritis (Bell, 2004). This occurs where large amounts of non-absorbable material, for example, magnesium sulphate (Epsom salts) draws water into the gut (Bell, 2004 Thomas et al, 2003). Symptoms of diarrhoea improve with appropriate dietary exclusions. This includes sensitivity to gluten (coeliac disease) and lactose intolerance. Bacterial overgrowth in the small bowel (where the bacterial count is usually low) can occur as a result of diabetes mellitus type 2 (Wigg et al, 2001), autonomic neuropathy and some types of gastric surgery, and this can cause diarrhoea (Bell, 2004 Thomas et al, 2003). Diarrhoea can occur as a result of systemic sclerosis, thyrotoxicosis, and parathyroid and adrenal disease. Alcohol misuse affects the digestion of sugars, electrolyte and water absorption, and decreases gut transit times (Metcalf, 2007 Bell, 2004 Thomas et al, 2003 McArdle, 2000 Chambers and Harris, 1993 Ganong, 1995). Reduced pancreatic function associated with alcohol misuse, chronic pancreatitis or the blocking of the pancreatic duct with thick mucus in cystic fibrosis can lead to maldigestion and malabsorption, because of a lack of pancreatic enzymes to digest fat and protein. Malabsorption of bile acid after cholecystectomy can also lead to loose stools (Bell, 2004 Emmanuel, 2004 Thomas et al, 2003 McArdle, 2000 Ganong, 1995). Following shorter resections involving the terminal ileum, diarrhoea can occur after meals as a result of bile salts entering the colon and causing more intestinal secretions.
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The depletion of fat absorption leads to steatorrhoea, where the stools are characteristically offensive, greasy and float in the toilet. Extensive resection of the ileum and right colon causes malabsorption of fat, carbohydrate and bile acid and can lead to diarrhoea. The right colon acts as a reservoir, allowing water absorption from faecal matter resection in this area can decrease intestinal transit time and reduce the absorptive surfaces, leading to watery stools. In IBD, diarrhoea is an indicator of active inflammation, which interferes with the absorption of fluid from the bowel contents. Inflammatory bowel disease (IBD) such as Crohn’s disease and ulcerative colitis, colorectal cancer, irritable bowel syndrome and diverticular disease are all associated with diarrhoea. Causes of chronic diarrhoeaĬhronic diarrhoea is one of the most common reasons for referral to gastroenterology clinics (Thomas et al, 2003). It is defined as the abnormal passage of loose or liquid stools more than three times, and/or of a volume of stool greater than 200g, in 24 hours (Thomas et al, 2003). Diarrhoea may be either acute or chronic in nature and can be due to more than one cause (Bell, 2004).