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Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis
Open accessAbstract
Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the B ristol S tool F orm S cale 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.
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TL;DR
This working party report reviews definitions, classification, and diagnostic evaluation of chronic diarrhea, concluding that a 4-week duration cutoff is arbitrary and that careful history plus targeted testing remains central. It surveys classification by pathophysiology and stool characteristics and assesses stool, serologic, breath, bile acid, pancreatic, imaging, endoscopic, and biopsy tests, highlighting gaps and limited utility of many tests.
Key findings
- Chronic diarrhea is less frequent than acute diarrhea; 3–5% of the population may have diarrhea lasting more than 1 month in any given year. Normal stool output averages approximately 100 g/day, with an upper 95% confidence limit of roughly 200 g/day, though up to 300 g may be normal on a high-fiber diet; about 20% of patients referred to one tertiary center for chronic diarrhea had normal stool weight.
- IBS and functional diarrhea are the most common causes of chronic diarrhea in Western populations. IBS onset averaged 38 ± 14 years in one large study, while microscopic colitis averaged 57 ± 13 years; IBS shows a female predominance with a sex ratio of 3:1 in primary care consulters. Microscopic colitis accounted for 10% of chronic diarrhea cases in patients over 70 years in Sweden.
- Fecal osmotic gap helps classify watery diarrhea: a gap < 50 mOsm/kg is characteristic of secretory diarrhea, and a gap > 75 mOsm/kg is characteristic of osmotic diarrhea.
- Breath test performance is variable: glucose hydrogen breath tests for small intestinal bacterial overgrowth had reported sensitivity 27–93% and specificity 30–86%, while lactulose hydrogen breath tests had sensitivity 17–89% and specificity 44–100%. Capsule endoscopy retention occurred in 1.3% of patients in one retrospective Swedish study and may be as high as 13% in known Crohn’s disease.
Methods
- Design: Working party report/consensus review from the Gastro 2013 APDW/WCOG Shanghai Working Party, proposed by the American College of Gastroenterology to the World Gastroenterology Organisation, to examine definitions, classification, and diagnosis of chronic diarrhea.
- Data and analysis: Narrative synthesis of existing literature and expert consensus; no primary data collection, systematic search strategy, or formal meta-analysis is reported. The report assesses diagnostic tests and highlights knowledge gaps and research opportunities.
Limitations
- Stated: the definition of chronic diarrhea remains debated, with loose stool form, increased frequency, stool weight, and duration criteria all at best arbitrary; most studies used to define the 4-week cutoff were done in industrialized countries, and information from less developed regions is needed.
- Stated: classification schemes need to be judged by their utility in individual patients who may not fit distinct categories; no simple diagnostic algorithm is currently possible because of the number of possible diagnoses, limited appreciation of pretest probabilities that depend on geography and patient specifics, variable test availability and performance, and costs.
- Evident from the text: as a narrative working party report, it does not provide a systematic review, formal evidence grading, or prospective validation of the proposed definitions and diagnostic approaches.
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“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.”
§ Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis > Abstract
plainstates a cause- Asserted: passes — The authors put it forward as true.
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“Patients with higher stool weights tended to have both loose stools and increased frequency.”
§ Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis > Definition of chronic diarrhea
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“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.”
§ Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis > Abstract
plainstates a cause- Asserted: passes — The authors put it forward as true.
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“Most patients consider loose stools-more than frequency-as the key characteristic of diarrhea.4”
§ Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis > Definition of chronic diarrhea
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“Patients may report diarrhea as being present when stools are looser than normal (i.e.liquid or unformed), even when stool frequency is not increased.”
§ Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis > Definition of chronic diarrhea
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Metadata
- Authors
- Schiller, L. R., Pardi, D. S., Spiller, R., Semrad, C. E., Surawicz, C. M., Giannella, R. A., Krejs, G. J., Farthing, M. J. G., & Sellin, J. H.
- Affiliations
- Baylor University Medical Center (US)
- Mayo Clinic (US)
- Nottingham Digestive Diseases Centre Queens Medical Centre Nottingham UK
- University of Chicago (US)
- University of Washington (US)
- University of Cincinnati (US)
- Medical University of Graz (AT)
- University of Sussex (GB)
- Baylor College of Medicine (US)
- Corresponding author
- Schiller, Lawrence R
- Venue
- Journal of Gastroenterology and Hepatology
- Publisher
- Wiley
- Published
- 2013-12-19
- Volume
- 29
- Issue
- 1
- Pages
- 6-25
- ISSN
- 0815-9319 (ISSN-L)
- 1440-1746
- OpenAlex
- W1521766620
- Cited by
- 95
- References
- 175
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 6 · 2023: 11 · 2022: 5 · 2021: 11 · 2020: 10 · 2019: 12 · 2018: 7 · 2017: 7 · 2016: 11 · 2015: 4
- FWCI
- 3.72
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Gastroenterology and Hepatology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
- Health Sciences › Medicine › Gastroenterology › Microscopic Colitis
- Health Sciences › Medicine › Gastroenterology › Digestive system and related health
- Keywords
- chronic diarrhea, differential diagnosis, Bristol Stool Form Scale, stool consistency, small bowel biopsy, endomicroscopy, gut microbiota, autoimmune enteropathy, inflammatory bowel disease, endocrine tumors, carbohydrate malabsorption, small intestinal bacterial overgrowth, intestinal transit, bile acid malabsorption, bile acid sequestrants, breath test
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Bile Acids and Salts, Breath Tests, China, Chronic Disease, Diarrhea, Feces, Female, Humans, Intestine, Small, Magnetic Resonance Imaging, Male, Middle Aged, Pancreatic Function Tests, Serologic Tests, Tomography, X-Ray Computed, Endoscopy, Gastrointestinal, Peptide Hormones, Steatorrhea, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-11-14, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-11-14 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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Data sources
Bibliographic data: Semantic Scholar, OpenAlex, Crossref.
Contains information from the Semantic Scholar Academic Graph Datasets, made available under the ODC Attribution License (ODC-BY 1.0).
Semantic Scholar’s data is described in: Kinney, R., et al. (2023). The Semantic Scholar Open Data Platform. arXiv:2301.10140.
