Clinical Information

The concentration of electrolytes in fecal water and their rate of excretion are dependent upon 3 factors:

-Normal daily dietary intake of electrolytes

-Passive transport from serum and other vascular spaces to equilibrate fecal osmotic pressure with vascular osmotic pressure

-Electrolyte transport into fecal water due to exogenous substances and rare toxins (eg, cholera toxin)

Fecal osmolality is normally in equilibrium with vascular osmolality, and sodium is the major effector of this equilibrium. Fecal osmolality is normally 2 x (sodium + potassium) unless there are exogenous factors inducing a change in composition, such as the presence of other osmotic agents (magnesium sulfate, saccharides) or drugs inducing secretions, such as phenolphthalein or bisacodyl. Osmotic diarrhea is caused by ingestion of poorly absorbed ions or sugars.(1) There are multiple potential causes of osmotic diarrhea. Measurement of phosphate and/or magnesium in liquid stool can assist in identifying intentional or inadvertent use of magnesium and/or phosphate-containing laxatives as the cause.(2-4) The other causes of osmotic diarrhea include ingestion of osmotic agents such as sorbitol or polyethylene glycol laxatives, or carbohydrate malabsorption due most commonly to lactose intolerance. Carbohydrate malabsorption can be differentiated from other osmotic causes by a low stool pH (<6).(5,6)

Non-osmotic causes of diarrhea include bile acid malabsorption, inflammatory bowel disease, endocrine tumors, and neoplasia.(1) Secretory diarrhea is classified as non-osmotic and is caused by disruption of epithelial electrolyte transport when secretory agents such as anthraquinones, phenolphthalein, bisacodyl, or cholera toxin are present. The fecal fluid usually has elevated electrolytes (primarily sodium and chloride) and a low osmotic gap (<50 mOsm/kg). Infection is a common secretory process; however, it does not typically cause chronic diarrhea (defined as symptoms >4 weeks).