今日の臨床サポート

慢性下痢

著者: 鎌田一宏 福島県立医科大学 会津医療センター 総合内科

監修: 山中克郎 福島県立医科大学会津医療センター総合内科

著者校正済:2021/11/24
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 器質的疾患と機能的疾患を鑑別するうえで、重度の体重減少・夜間の下痢・しぶり腹の欠如は器質的な疾患を示唆する(O)。
  1. 過敏性腸症候群は女性に多く、青年や成人の10~20%程度の有病率であり、慢性下痢症の原因として多い機能的疾患である。器質的疾患が除外されたうえでローマIII基準に基づいて診断される(S)。
  1. 高齢外来患者の下痢では抗菌薬・プロトンポンプ阻害薬(PPI)・アロプリノール・精神抑制薬・選択的セロトニン再取り込み阻害薬(SSRI)・アンジオテンシンII受容体拮抗薬(ARB)などが原因となり得る(S)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
鎌田一宏 : 未申告[2021年]
監修:山中克郎 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行い、疫学・病態・注意事項、および問診・診察のポイントについて要点の修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 慢性下痢症は、回数にかかわらず4週間以上続く軟便(ブリストルスケール)と定義され[1]、先進国における有病率は約3~5%とされる[2]
  1. 原因疾患は血管性、医原性、感染性、毒素性、アレルギー性、内分泌性、炎症性、腫瘍性、その他多岐にわたるが、先進国では非感染性のものが多く、頻度が高いものとして過敏性腸症候群や乳糖不耐症などが挙げられる。
  1. 原因疾患を考えるうえで、注意深い病歴聴取や身体診察が、診断の手がかりを得るために必要である。
  1. 分泌性下痢・浸透圧性下痢・炎症性下痢・脂肪便に分けて考えると考えやすい。
  1. うつ病の患者は非うつ病患者に比べ下痢が多いと言われている。
 
慢性下痢症に対する英国消化器学会のガイドライン[3]
  1. 臨床評価:
  1. 詳細な病歴聴取を推奨する(エビデンスレベル1、強い推奨)。
  1. 貧血、セリアック病の除外のために血液検査及び炎症に関する便検査のスクリーニングを推奨する(エビデンスレベル1、強い推奨)。
  1. 基本的な血液検査および便スクリーニング検査後に過敏性腸症候群(IBS)の陽性診断を行うことを推奨する(エビデンスレベル2、強い推奨)。
  1. 癌や炎症性疾患について:
  1. 排便習慣の変化や直腸出血のある患者では大腸内視鏡検査による大腸癌の除外を推奨する(エビデンスレベル1、強い推奨)。
  1. 慢性下痢といった下部消化管症状を呈するが直腸出血を伴わない患者に対して除外目的及び初期評価として便免疫学的検査による便潜血検査を行うことを推奨する(エビデンスレベル2、弱い推奨)。
  1. 糞便カルプロテクチンは、過敏性腸症候群が疑われる40歳未満の患者で大腸の炎症性疾患を除外するために推奨する(エビデンスレベル1、強い推奨)。
  1. 二次臨床評価:
  1. 通常ファーストラインの検査および治療にもかかわらず症状が持続する場合は、さらなる精査のための専門医への紹介が推奨される(エビデンスレベル5、強い推奨)。
  1. 吸収不良症候群や一般的な感染症(特に免疫不全患者や高齢者において)を除外するために血液検査や便検査を推奨する(エビデンスレベル2、強い推奨)。
  1. 一般的な疾患:
  1. 機能的問題または過敏性腸症候群における下痢患者では、75 SeHCAT試験または血清胆汁酸前駆体検査(7α-ヒドロキシ-4-コレステン-3-1)のいずれかによる胆汁酸性下痢の積極的な診断を下すべきである(エビデンスレベル1、強い推奨)。
  1. 胆汁酸性下痢症の診断をするよりも経験的治療を行うことを推奨する十分なエビデンスはない(エビデンスレベル5、強い推奨)。
  1. 顕微鏡的大腸炎を除外するためには直腸ではなく上行及び下行結腸の生検を推奨する(エビデンスレベル1、強い推奨)。
  1. 吸収不良:
  1. 乳糖不耐症が疑われる場合は、可能であれば水素呼気検査または乳糖/炭水化物の摂取中止を推奨する(エビデンスレベル3、弱い推奨)。
  1. 可能であれば小腸評価目的にMR enterographyが推奨される(エビデンスレベル1、強い推奨)。
  1. 可能であれば小腸評価目的にビデオカプセル内視鏡検査が推奨される(エビデンスレベル1、強い推奨)。
  1. 感度と特異度が低いため小腸評価目的の小腸バリウム造影検査は推奨しない(エビデンスレベル5、強い推奨)。
  1. 小腸内視鏡検査は慢性下痢診断のためではなく、MR enterographyやビデオカプセル内視鏡検査によって特定された標的病変を認める場合にのみ推奨する(エビデンスレベル4、強い推奨)。
  1. 脂肪吸収不良が疑われる場合は便中エラスターゼ検査を推奨する。PABA検査は推奨しない(エビデンスレベル1、強い推奨)。
  1. 慢性膵炎の疑いがある場合に膵臓の構造異常を評価するには、CTよりMRIが推奨される(エビデンスレベル2、強い推奨)。
  1. 小腸内細菌過増殖が疑われる場合は、水素またはメタン呼気検査を推奨する十分なエビデンスがないため、抗菌薬による試験的治療を推奨する(エビデンスレベル3、強い推奨)。
  1. 外科的および解剖学的障害:
  1. 他の局所的な病変が除外され保守治療に反応がない場合にのみ、直腸肛門内圧測定および肛門内超音波の使用を推奨する(エビデンスレベル3、強い推奨)。
  1. 瘻孔評価のために造影剤を使用したMRIまたはCT等の画像検査を推奨する(エビデンスレベル3、強い推奨)。
  1. まれな原因:
  1. ホルモン分泌腫瘍による下痢はまれであるため、下痢の他の原因が除外されている場合にのみ検査を行うことを推奨する(エビデンスレベル4、強い推奨)。
推奨度:
  1. 強い推奨:提案が満場一致で一致した場合
  1. 中等度/弱い推奨:提案が多数決により決定した場合
エビデンスレベル:EBMに基づいたオックスフォード医療センターに従って、レベル1~5に基づいてエビデンスを評価
  1. レベル1a~c:均質性のある系統的レビュー、個々のランダム化比較試験(RCT)
  1. レベル2a~c:コホート研究、質の低いRCTおよびアウトカム研究の系統的レビュー
  1. レベル3a~b:均質性のない系統的レビューや個別の症例対照研究
  1. レベル4:質の悪いコホートまたはケースシリーズ
  1. レベル5:批判的な評価はない専門家の意見
問診・診察のポイント  
 
 
  1. 先進国における慢性下痢症の原因として多いのは過敏性腸症候群、炎症性腸疾患、吸収不良症候群、薬剤性下痢、慢性感染症、特発性分泌性下痢である。一方発展途上国における慢性下痢症の原因として多いのは細菌感染症、マイコバクテリウム感染症、寄生虫感染症であり、炎症性腸疾患、吸収不良症候群などもある(O)。(参考文献:[4][5][6][7][8]
  1. さまざまな検査でも診断に至らなかった重度慢性下痢症27例を専門家が検討したところ、器質的疾患が13例あり、うち薬剤性が9例、潰瘍性大腸炎が2例、アレルギーが1例、小腸細菌異常増殖が1例であった。残りの14例では、8例が過敏性腸症候群を示唆する所見を認め、2例が肛門括約筋機能障害、4例が原因不明(3例が分泌性下痢、1例が浸透圧性下痢)であった[9]
 
  1. うつ病患者における慢性下痢症の頻度(G)(参考文献:[10]
  1. 成人のうつ病患者495例と非うつ病患者4709例の便通を後ろ向きに検討した研究。

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文献 

著者: M R Blake, J M Raker, K Whelan
雑誌名: Aliment Pharmacol Ther. 2016 Oct;44(7):693-703. doi: 10.1111/apt.13746. Epub 2016 Aug 5.
Abstract/Text BACKGROUND: The Bristol Stool Form Scale (BSFS) is a 7-point scale used extensively in clinical practice and research for stool form measurement, which has undergone limited validity and reliability testing.
AIM: To determine the validity and reliability of the BSFS in measuring stool form in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome (IBS-D).
METHODS: One hundred and sixty-nine healthy volunteers provided a stool sample and used the BSFS to classify stool form, which was compared with measured stool water content and with values from 19 patients with IBS-D. Eighty-six volunteers used the BSFS to classify 26 stool models to determine accuracy and reliability.
RESULTS: Volunteers' classifications of stool type correlated with stool water (Spearman's rho = 0.491, P < 0.001), which increased in hard (Types 1-2), normal (Types 3-5) and loose stools (Types 6-7) (P < 0.001). The BSFS detected differences in stool form between healthy volunteers (mean 3.7, s.d. 1.5) and IBS-D patients (mean 5.0, s.d. 1.2) (P < 0.001). Overall, 977/1204 (81%) stool models were correctly classified (substantial accuracy, κ = 0.78), although <80% of Types 2, 3, 5 and 6 were classified correctly. On 852/1118 (76%) occasions, volunteers classified covert duplicate models to the same stool type (substantial reliability, κ = 0.72), but with only moderate reliability for Types 2 (63%, κ = 0.57) and 3 (62%, κ = 0.55).
CONCLUSIONS: The BSFS demonstrated substantial validity and reliability, although difficulties arose around clinical decision points (Types 2, 3, 5, 6) that warrant investigation in larger clinical populations. Potential for improving validity and reliability through modifications to the BSFS or training in its use should be explored.

© 2016 John Wiley & Sons Ltd.
PMID 27492648  Aliment Pharmacol Ther. 2016 Oct;44(7):693-703. doi: 10・・・
著者: Lawrence R Schiller, Darrell S Pardi, Robin Spiller, Carol E Semrad, Christina M Surawicz, Ralph A Giannella, Guenter J Krejs, Michael J G Farthing, Joseph H Sellin
雑誌名: J Gastroenterol Hepatol. 2014 Jan;29(1):6-25. doi: 10.1111/jgh.12392.
Abstract/Text Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.

© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.
PMID 24117999  J Gastroenterol Hepatol. 2014 Jan;29(1):6-25. doi: 10.1・・・
著者: Ramesh P Arasaradnam, Steven Brown, Alastair Forbes, Mark R Fox, Pali Hungin, Lawrence Kelman, Giles Major, Michelle O'Connor, Dave S Sanders, Rakesh Sinha, Stephen Charles Smith, Paul Thomas, Julian R F Walters
雑誌名: Gut. 2018 Aug;67(8):1380-1399. doi: 10.1136/gutjnl-2017-315909. Epub 2018 Apr 13.
Abstract/Text Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
PMID 29653941  Gut. 2018 Aug;67(8):1380-1399. doi: 10.1136/gutjnl-2017・・・
著者: T M Bayless
雑誌名: Hosp Pract (Off Ed). 1989 Jan 15;24(1):117-22, 124-6, 131-2 passim.
Abstract/Text
PMID 2492029  Hosp Pract (Off Ed). 1989 Jan 15;24(1):117-22, 124-6, 1・・・
著者: P Bytzer, M Stokholm, I Andersen, B Lund-Hansen, O B Schaffalitzky de Muckadell
雑誌名: Scand J Gastroenterol. 1990 Jun;25(6):572-8.
Abstract/Text All patients referred for diarrhoea over a 2-year period were studied to determine the relative frequency of organic diarrhoea and functional disorder. One hundred and nine patients had diarrhoea of established aetiology at admission. Two hundred and one patients with diarrhoea of unestablished aetiology at admission were interviewed about symptoms, and faecal output was measured. An organic or other explanation was eventually found in 78 patients (39%), whereas the bowel symptoms were categorized as functional or transient in 58%. Chronic diarrhoea of unknown origin was seen in 3%. Only 40% of the patients referred for diarrhoea had faecal output greater than 200 g/day. A reliable differentiation between organic and functional diarrhoea based solely on history and a physical examination at admission was not possible, as the initial diagnostic guess was only confirmed in 42% of the patients. More sensitive and specific indicators of functional diarrhoea are needed before the patients can be safely classified without the need for thorough diagnostic study.

PMID 2359988  Scand J Gastroenterol. 1990 Jun;25(6):572-8.
著者: M U Ahmed, N C Sarker, E Haque, M A Hasan
雑誌名: Bangladesh Med Res Counc Bull. 1976 Jun;2(1):8-11.
Abstract/Text The relationship of chronic diarrhoeal diseases in adults on socio-economic condition, parasitic infestation and degree of anaemia have been investigated. The disease was more prevalent in poor socio-economic group of people. Most of the patients had mixed parasitic infestations. Anaemia was present in all the cases. Difference in the degree of anaemia was not significant amongst the patients having either Ascaris or hookworm infestation.

PMID 1037200  Bangladesh Med Res Counc Bull. 1976 Jun;2(1):8-11.
著者: M R Kotwal, H A Durrani, S N Shah
雑誌名: J Indian Med Assoc. 1978 Feb 16;70(4):77-80.
Abstract/Text
PMID 670749  J Indian Med Assoc. 1978 Feb 16;70(4):77-80.
著者: S Manatsathit, S Israsena, N Kladcharoen, P Sithicharoenchai, S Roenprayoon, P Suwanakul
雑誌名: Southeast Asian J Trop Med Public Health. 1985 Sep;16(3):447-52.
Abstract/Text Fifty-five Thai patients with chronic diarrhoea were prospectively studied to find out the underlying causes. The aetiology was identified in 38.2%, uncertain in 29.1%, and unknown in 32.7% of the patients. In the group with a definitive aetiologic diagnosis, parasitic and infective causes were commoner than non-infective causes. Amoebiasis and giardiasis were more frequent than expected, such that empirical therapeutic trial with an antiprotozoal may be justified if initial routine investigations fail to uncover the cause of the diarrhoea. No significant clinical features were noted between the infective and the non-infective groups. Overall, repeated stool microscopy using the concentration technique was the most useful single investigation in approaching the chronic diarrhoea problem.

PMID 4095610  Southeast Asian J Trop Med Public Health. 1985 Sep;16(3・・・
著者: N W Read, G J Krejs, M G Read, C A Santa Ana, S G Morawski, J S Fordtran
雑誌名: Gastroenterology. 1980 Feb;78(2):264-71.
Abstract/Text We studied 27 patients with severe chronic diarrhea for which extensive investigations carried out at other institutions had failed to reveal a diagnosis. They were studied by standard diagnostic methods as well as by careful fecal analysis and intestinal perfusion. If they were incontinent of feces, anal sphincter function tests were performed. Although many were suspected of having pancreatic cholera syndrome, this diagnosis could not be established in a single patient. The most common diagnosis that could be established was surreptitious ingestion of drugs (laxatives in 7 patients and diuretics in 2). Other specific diagnoses included ulcerative colitis in 2 patients, allergy to beef in 1, and bacterial overgrowth of the small intestine in 1. Thus, we were able to establish a specific diagnosis in 13 patients. Of the remaining 14 patients, 8 had findings suggestive of irritable bowel syndrome, and 2 others had anal sphincter dysfunction as the major cause of their disability. The other 4 undiagnosed patients had severe secretory (3 patients) or osmotic (1 patient) diarrhea. Follow-up interviews at 6 mo-6 yr failed to reveal evidence of a cause for diarrhea that had been overlooked during our studies. The diagnostic approach to patients with unexplained diarrhea is discussed. The importance of a search for surreptitious drug ingestion and accurate measurement of bowel movement frequency and stool weight is emphasized.

PMID 7350049  Gastroenterology. 1980 Feb;78(2):264-71.
著者: Sarah Ballou, Jesse Katon, Prashant Singh, Vikram Rangan, Ha Neul Lee, Courtney McMahon, Johanna Iturrino, Anthony Lembo, Judy Nee
雑誌名: Clin Gastroenterol Hepatol. 2019 Apr 4;. doi: 10.1016/j.cgh.2019.03.046. Epub 2019 Apr 4.
Abstract/Text BACKGROUND AND AIMS: Depression is a major health issue in the United States and is highly comorbid with gastrointestinal conditions. We collected data from the National Health and Nutrition Examination Survey (NHANES), a representative sample of the US population, to study the relationship between depression and bowel habits.
METHODS: Using data from the NHANES (2009-2010), we identified 495 depressed and 4709 non-depressed adults who filled out the Bowel Health Questionnaire. Depression was defined according to a validated questionnaire. We used multivariable analysis, controlling for clinical and demographic variables, to evaluate the relationship between mood and bowel habits.
RESULTS: In our weighed sample, 24.6% of depressed individuals and 12.6% of non-depressed individuals reported disordered bowel habits. Chronic diarrhea was significantly more prevalent in depressed individuals (15.53%; 95% CI, 11.34%-20.90%) than non-depressed individuals (6.05%; 95% CI, 5.24%-6.98%; P = .0001). Chronic constipation was also more common in depressed individuals (9.10%; 95% CI, 7.02%-11.69%) than non-depressed individuals (6.55%; 95% CI, 5.55%-7.70% CI; P = .003). Mean depression scores in patients with chronic diarrhea (4.9 ± 5.8) and with chronic constipation (4.4 ± 4.93) were significantly higher than mean depression scores for individuals with normal bowel habits (3.2 ± 4.6) (P < .001). Moderate and severe depression were significantly associated with chronic diarrhea but not chronic constipation. Only mild depression was significantly associated with chronic constipation.
CONCLUSIONS: In an analysis of the NHANES database, we found a higher proportion of depressed individuals to have chronic diarrhea and constipation than non-depressed individuals; chronic diarrhea was more strongly associated with depression. Our findings provide support for the relationship between mood and specific bowel habits, accounting for multiple co-variables in a large sample of the general US population.

Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 30954714  Clin Gastroenterol Hepatol. 2019 Apr 4;. doi: 10.1016/j・・・
著者: K D Fine, L R Schiller
雑誌名: Gastroenterology. 1999 Jun;116(6):1464-86.
Abstract/Text This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.

PMID 10348832  Gastroenterology. 1999 Jun;116(6):1464-86.
著者:
雑誌名: Gastroenterology. 1999 Jun;116(6):1461-3.
Abstract/Text This document presents the official recommendations of the American Gastroenterological Association (AGA) on the Evaluation and Management of Chronic Diarrhea. It was approved by the Clinical Practice and Practice Economics Committee on September 27, 1998, and by the AGA Governing Board on November 8, 1998.

PMID 10348831  Gastroenterology. 1999 Jun;116(6):1461-3.
著者: Alberto Pilotto, Marilisa Franceschi, Dino Vitale, Augusto Zaninelli, Francesco Di Mario, Davide Seripa, Franco Rengo, FIRI (Fondazione Italiana Ricerca sull'Invecchiamento), SOFIA Project Investigators
雑誌名: Am J Gastroenterol. 2008 Nov;103(11):2816-23. doi: 10.1111/j.1572-0241.2008.02107.x. Epub 2008 Aug 21.
Abstract/Text OBJECTIVES: To evaluate the prevalence of diarrhea and its association with drug use in elderly outpatients.
METHODS: The study was carried out by 133 general practitioners (GPs) who referred to 24 geriatric units in Italy. The demographic data, disability, gastrointestinal symptoms, and current medications were evaluated using a structured interview, including the evaluation of the activities of daily living (ADL), the instrumental activities of daily living (IADL), and the gastrointestinal symptoms rating scale (GSRS).
RESULTS: The study included 5,387 elderly subjects who regularly completed the structured interview. In total, 488 patients (9.1% of the whole population, 210 men and 278 women, mean age 75.6 +/- 6.2 yr, range 65-100 yr) reported diarrhea, that is, items 11 and 12 of the GSRS, during the 7-day period before the interview. The prevalence of diarrhea significantly increased with older age (P = 0.025), the severity of ADL (P < 0.0001) and IADL disability (P < 0.0001), and the number of drugs taken (P = 0.0002). A multivariate analysis demonstrated that the presence of diarrhea was significantly associated with the use of antibiotics (odds ratio [OR] 4.58, 95% confidence interval [CI] 1.95-10.73), proton pump inhibitors (OR 2.97, 95% CI 2.03-4.35), allopurinol (OR 2.19, 95% CI 1.26-3.81), psycholeptics (OR 1.82, 95% CI 1.26-2.61), selective serotonin reuptake inhibitors (OR 1.71, 95% CI 1.01-2.89), and angiotensin II receptor blockers (OR 1.46, 95% CI 1.08-1.99), also accounting for sex, age, and the use of antidiarrheal agents and drugs for functional gastrointestinal disorders.
CONCLUSION: Diarrhea is a common problem in elderly outpatients. Its prevalence increases with old age, the severity of disability, and the number of drugs. Monitoring the presence of diarrhea and its complications in elderly patients who need treatments with drugs significantly associated with diarrhea may be clinically useful.

PMID 18721240  Am J Gastroenterol. 2008 Nov;103(11):2816-23. doi: 10.1・・・
著者: George F Longstreth, W Grant Thompson, William D Chey, Lesley A Houghton, Fermin Mearin, Robin C Spiller
雑誌名: Gastroenterology. 2006 Apr;130(5):1480-91. doi: 10.1053/j.gastro.2005.11.061.
Abstract/Text Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onset > or =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.

PMID 16678561  Gastroenterology. 2006 Apr;130(5):1480-91. doi: 10.1053・・・
著者: Matthew J H Shale, Julian R F Walters, David Westaby
雑誌名: Gastrointest Endosc. 2011 Apr;73(4):757-64. doi: 10.1016/j.gie.2010.11.037. Epub 2011 Feb 2.
Abstract/Text BACKGROUND: The optimal endoscopic investigation of diarrhea in patients under age 50 without specific features of right-sided colonic/ileal disease is inadequately defined.
OBJECTIVE: To assess the potential additional yield of colonoscopy over flexible sigmoidoscopy (FS) in this group.
DESIGN: Retrospective cohort study.
SETTING: Two teaching hospital endoscopy units.
PATIENTS: This study involved all patients under age 50 who had a colonoscopy between 1997 and 2007 to investigate diarrhea, without high-risk features of right-sided colonic/ileal disease, inflammatory bowel disease (IBD), or rectal bleeding.
INTERVENTION: Colonoscopy and biopsy.
MAIN OUTCOME MEASUREMENTS: Diagnostic yield of colonoscopy over FS with biopsy.
RESULTS: Colonoscopic appearances were abnormal in 126 of 625 eligible patients (20%); 72% of abnormalities were within reach of FS. The most common endoscopic abnormality was suspected inflammation in 60 patients (10% overall), reportedly confined to the proximal colon or ileum in 22 patients (37% of this group). Histology from areas of suspected inflammation revealed features of IBD in 68% of patients, but results were normal in the remainder. In the 22 patients with suspected isolated proximal disease, 8 patients (36%) had normal histology results, and a further 6 had left-side colon biopsies demonstrating IBD. In patients with macroscopically normal colons, histological evidence of IBD or microscopic colitis occurred in 14 and 12 patients, respectively, with changes in the left side of the colon in 93% of patients. In this patient group, 85% of IBD or microscopic colitis could have been detected by FS and biopsy. The negative predictive value of FS with biopsy was 98% for IBD and 99% for microscopic colitis.
LIMITATIONS: Retrospective study.
CONCLUSION: FS is adequate for the investigation of diarrhea in patients under age 50 who lack other features, but its yield depends on biopsy of the left side of the colon.

Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.
PMID 21288510  Gastrointest Endosc. 2011 Apr;73(4):757-64. doi: 10.101・・・
著者: A Bertomeu, E Ros, V Barragán, L Sachje, S Navarro
雑誌名: J Clin Gastroenterol. 1991 Oct;13(5):531-6.
Abstract/Text To investigate whether the clinical history and basic laboratory test results can differentiate between an organic or functional cause of chronic diarrhea and thus avoid unnecessary hospital admissions and invasive procedures, we reviewed the charts of 58 adult patients admitted during 6 years because of chronic diarrhea who had normal stool and colonic examinations. The final diagnoses were irritable bowel syndrome in 34 patients, organic diarrhea in 21, and unknown cause in three. The following clinical data did not help in the differential diagnosis: age, sex, duration of diarrhea, presence of continuous diarrhea, abdominal pain, stool frequency or volume, and presence of stool mucus. Significant weight loss, nocturnal diarrhea, and the absence of tenesmus were associated with an organic cause. One or more laboratory alterations (increased erythrocyte sedimentation rate, anemia, hypokalemia, and low serum albumin level) were found in 62% of patients with organic diarrhea but in only 3% of those with functional disease; p less than 0.001. In 20 of 21 patients with organic diarrhea, an syndromic diagnosis (fat malabsorption, n = 13; inflammatory bowel disease, n = 4; and secretory diarrhea, n = 3) could be obtained with three simple tests (stool fat, rectal biopsy, and fecal water osmolality and electrolyte determination, respectively). Our study confirms that a detailed history and a few simple laboratory data can help to distinguish between functional and organic diarrhea and so avoid extensive investigation. The syndromic diagnosis of organic diarrhea can also be approximated with relatively easy tests.

PMID 1744388  J Clin Gastroenterol. 1991 Oct;13(5):531-6.
著者: K R Palmer, C L Corbett, C D Holdsworth
雑誌名: Gastroenterology. 1980 Dec;79(6):1272-5.
Abstract/Text As no adequate comparison of these widely used drugs has been made, we have performed a double-blind cross-over trial in 30 individuals with chronic diarrhea. Each underwent three randomized treatment periods of 4 wk duration. Patients were instructed to increase the daily dose gradually until control was achieved or side effects became intolerable. Stool frequency, consistency, urgency, and incontinence were then compared when a stable dose was reached. Though 2.3 capsules (4.6 mg) of loperamide, 2.3 capsules (103.5 mg) of codeine and 2.5 capsulses (12.5 mg) of diphenoxylate all reduced stool frequency to the same extent, diphenoxylate was significantly less effective in producing a solid stool. Before treatment 95% of patients experienced urgency, sometimes associated with fecal incontinence, often as their major diability. Loperamide and codeine were more effective in relieving this than was diphenoxylate. Side effects, particularly central nervous effects, were greatest with diphenoxylate and least with loperamide. Approximately equal numbers discontinued each preparation; poor control and central-nervous-system side effects were the usual reasons for stopping diphenoxylate and codeine, and abdominal pain and constipation for stopping loperamide. We conclude that both loperamide and codeine phosphate are superior to diphenoxylate in the symptomatic treatment of chronic diarrhea.

PMID 7002706  Gastroenterology. 1980 Dec;79(6):1272-5.
著者: T Pastrana, W Meißner
雑誌名: Schmerz. 2013 Apr;27(2):182-9. doi: 10.1007/s00482-013-1296-z.
Abstract/Text Diarrhea is a distressing symptom which limits the quality of life in patients receiving palliative care and is associated with high morbidity and mortality. In patients with AIDS, it is a more common problem than for other entities (e.g., cancer). Loperamide is considered the first choice medication for the symptomatic treatment of diarrhea. This literature review examines the efficacy of loperamide in the symptomatic treatment of diarrhea in palliative care. Two databases (Medline and Embase) were searched through June 2012. A total of 286 studies were identified, but only 7 met the inclusion criteria (1 cohort and 6 experimental studies) in which loperamide (alone or in combination) was tested. There is a lack of significant studies which investigate the efficacy of loperamide in the symptomatic treatment of diarrhea. Two trials indicated superiority of loperamide over placebo. In comparison with octreotide, the results were contradictory. The combination of acetorphan with loperamide was more effective than acetorphan alone, but the combination of loperamide with diphenoxylate was inferior to octreotide. The identified studies revealed methodical problems. A definite recommendation for administration of loperamide can, therefore, not be derived from this work.The English full-text version of this article is available at SpringerLink (under "Supplemental").

PMID 23475156  Schmerz. 2013 Apr;27(2):182-9. doi: 10.1007/s00482-013-・・・

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