An accurate clinical history should collect information on the stool form and the presence of urgency or incontinence. The chronic diarrhea of diabetes is generally watery, paroxysmal, and includes nocturnal episodes. Presence of blood per rectum, relationship of diarrhea to dietary factors including sor-bitol-containing dietetic foods, and features suggestive of fecal incontinence should be sought in history. Oral medications used for glycemic control, such as metformin (Avandemet) and acarbose (Precose), are often associated with bloating, diarrhea, and other gastrointestinal side effects. Other medications may cause diarrhea, including laxatives and proki-netics. The clinical examination should include a thorough neurological evaluation, with the search for signs suggesting autonomic neuropathy (such as orthostatic hypotension, lack of pupillary response to light, response of pulse and blood pressure to the Valsalva maneuver and absence of sweating), or malabsorption, such as anemia, edema, and clubbing.
The presence of an abdominal mass or tenderness suggests the presence of concomitant conditions causing diarrhea, such as inflammatory bowel disease (IBD) or a neoplasm. Since up to 20% of tertiary referral patients with diabetes may experience fecal incontinence, an anorectal examination should be performed (Camilleri, 1996). The anorectal examination includes inspection of the external anal area for the presence of rectal prolapse, digital assessment of the sphincter tone at rest and during squeeze, and assessment of alterations in sensation (eg, pinprick around anal verge).
A routine hematological and biochemical screening, serum tissue transglutaminase assay, and analysis of stool for blood, leukocytes, ova, and parasites should be performed; a flexible sigmoidoscopy or colonoscopy will exclude specific causes of chronic diarrhea, such as IBD.
These screening tests will indicate whether the patient needs correction of water and electrolytes imbalance in the initial management. Adequate glycemic control and nutritional support is necessary. In patients with dehydration, oral solutions containing glucose, rice powder, or glycine can be safely administered without significant fluctuation in blood glucose levels. Rarely, IV hyperalimentation or fluid replacement may be administered over a longer period to restore nutrition and hydration.
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